Penetrated Eyelid Trauma
Penetrated Eyelid Trauma
I’m Ed Smith, a Sacramento Eye Injury Lawyer. Management of the patient with penetrating eyelid trauma is facilitated by knowing the mechanisms of wound healing. Healing of full thickness eyelid injuries has not been extensively studied but clinical observations suggest that the fundamental series of events is probably similar to other types of wounds. Cutaneous wound repair might be primary or secondary.
Primary wound healing occurs when the wound edges are opposed; it is characterized by a sequence of events involving the epithelial and connective tissue components of the wound. Downward migration of the epithelium along the edges of the wound is noted in the first 24-48 hours after the injury. During the next 5-8 days, epithelial hyperplasia and spur formation occur across the base of the defect. This is followed by thinning of the epithelial layer, a phase that can last from 25 days to several years after the wound is closed.
There are several phases of connective tissue healing. In the first four days, there is vasoconstriction followed by vasodilatation and migration of leukocytes and macrophages into a wound bed that has new blood vessels and platelet clots. The second phase is identified as the fibroblastic phase, in which there is fibroblastic proliferation and elaboration of collagen into the matrix. This is the phase when the most strength of the wound occurs and lasts about four weeks. A decreased rate of collagen synthesis in the wound bed are seen in the maturational phase of healing, beginning about four weeks after the injury. Collagen remodeling and wound maturation may occur for 6-12 months later.
Secondary wound healing occurs when the wound edges are not apposed. This is accomplished by contraction of the wound and by the formulation of granulation tissue composed of new blood vessels, fibroblasts, collagen, reticulin, and elastin fibers into the wound. Although this is effective in closing the wound, the contraction may extend to around the eye, causing functional and cosmetically unacceptable displacement of the eyelids.
Factors that affect wound healing include the following:
- The presence of infection
- The vascular supply
- Mechanical stress on the wound
- Radiation exposure
- Suture material used
- Surgical technique used
- Hypoxia (low oxygen levels)
- Kidney dysfunction
- The presence of cancer
- Liver dysfunction
- Drug therapy used
After a complete eye examination, attention may be turned to the evaluation of the eyelids and adnexa. Abnormalities of the eye and the position of the canthi are noted. Alterations of the eye and the canthal position may reflect underlying bony injury. Eyelid position is evaluated by measuring the distance between the upper and lower lids and the distance between the pupillary light reflex and the upper eyelid margin. If the eye is shaped abnormally, this should be drawn into the chart.
Examination of the eyelids continues with evaluation of the integrity of the eyelid skin surface. Cutaneous injuries may involve an abrasion or a laceration. Lacerations may be simple or beveled. IN simple injuries, the wound edges are perpendicular to the skin surface, whereas in beveled injuries, the plane of laceration is oblique to the skin. Avulsion-type injuries can result in a loss of eyelid skin or deeper tissues. Special attention must be paid to medial lacerations, which can mean that the tear ducts are involved or that the medial canthal tendon is involved. Lacerations of the lateral part of the eye may mean that the lateral canthal tendon is involved or that the lacrimal gland is involved.
Medical and Surgical Repair
Surgery to the eyelid may take place by a plastic surgeon, eye surgeon, otolaryngologist, neurosurgeon or an oral and maxillofacial surgeon, as appropriate. X-ray studies, ultrasound, or CT scan of the eye may be indicated prior to surgery.
A tetanus shot should be given along with immune globulin if the patient’s tetanus status is not current. Antibiotic therapy may be started, depending on the nature of the injury. If there is a delay of more than three hours before surgery or a deeply contaminated wound, systemic antibiotic therapy may be required. Local and systemic factors predisposing the person to relative immunocompromise of the wound bed may also mean the patient needs systemic antibiotic therapy.
The antibiotics chosen should protect the individual against Staph aureus and streptococcal species, which are the most common causes of infection of the eyelid. This means using first generation cephalosporins or penicillinase-resistant penicillins. There should be high antibiotic tissue levels at the time of closure of the wound. For this reason, IV antibiotics may be recommended. This is followed by IV or oral antibiotics for an additional 5-7 days.
If there is a suspicion of a ruptured globe, there should be limited manipulation of the eyelid before surgery. Because irrigating the wound may be uncomfortable for the patient, it may be deferred until the patient is in the operating room. Removal of foreign bodies should be deferred until the patient is in surgery. A protective shield should be placed over the eye if it has not been determined that the globe is ruptured. If the globe is intact, topical antibiotic ointment can be applied over the eyelid wound. Iced compresses may be used to reduce bleeding and bruising.
Facial wounds should be repaired within 24 hours following the trauma. Satisfactory results have been obtained if there happened to be a delay in surgery for up to four days after the injury. Regardless of the interval from injury to repair, the wound should be assessed immediately before closure. If there is infection or gross contamination of the wound, then the surgery should be delayed until the wound can be cleaned and antibiotics given. Then the wound can be closed primarily or allowed to heal secondarily.
Local or general anesthesia may be used to repair eyelid injuries. General anesthesia may be required in children who can’t cooperate with the surgery or examination. Evaluation of the tear ducts and other tissues may also best be done under general anesthesia. Indications for general anesthesia include the following:
- Associated neurosurgical trauma
- Uncertainty about the extent of the injuries
- Associated ENT trauma
- Bony orbital trauma
- Lacrimal outflow system injury
- Extensive trauma
- Uncooperative patient
Local anesthesia can be given as long as it doesn’t distort the anatomy of the eyelid. Sometimes regional anesthesia can be used by making use of sensory nerve blocks.
Sutures can be absorbable or nonabsorbable. Absorbable sutures lose their strength after sixty days, while nonabsorbable sutures can last longer than sixty days. Nonabsorbable sutures can include natural materials, such as silk and cotton, or synthetic materials, such as nylon or Dacron. Silk is preferred because it slowly absorbs into the eyelid, losing its strength after 2 years. Nylon retains about 75 percent of its strength during this period of time.
Various kinds of suture techniques can be used, including interrupted sutures, running sutures, and buried subcutaneous sutures. In buried subcutaneous sutures, the knot is buried, leaving a better aesthetic to the wound. Surgical tapes can also be used. This is especially helpful in people who are likely to form keloid scars.
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