The structures surrounding the eye and eyelids are very delicate; they are cosmetically and functionally important. Depending on the mechanism of injury, a high degree of suspicion for injury to these structures must be maintained. The emergency physician should have a low threshold for referring lacerations in this area to an ophthalmologist or oculoplastic specialist for definitive treatment.

The eyelids are very thin and do not offer any protection from penetrating injuries to the globe. A complete exam of the eye's structure and function and a search for the presence of foreign bodies must be completed before local wound care can be attempted. Once the integrity of the globe and muscular structures is verified, the lid should be examined for involvement of the canthi, the lacrimal system, or penetration through the tarsal plate or lid margin. The following wounds should be referred to an ophthalmologist or oculoplastic specialist: (1) those involving the inner surface of the lid, (2) those involving the lid margins, (3) those involving the lacrimal duct, (4) those associated with ptosis, and (5) those that extend into the tarsal plate. Poor approximation of the lid margins leads to a notched appearance (ectropion). Failure to recognize and properly repair the lacrimal system can result in chronic tearing (epiphora) or dacrocystitis. In general, wounds that are superficial and especially those parallel to the lid margins may be carefully repaired by the emergency physician ( Fig 38-4)17

FIG. 38-4. Eyelid anatomy. A. External landmark. B. Simple closure of a superficial laceration of the upper lid.

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