Lid Lacerations

Full-thickness lid lacerations should be repaired by an ophthalmologist, if at all possible, within 24 h. Proper alignment of the lid margin during repair under magnification (loupes or microscope) is essential to preserve proper lid function and even corneal wetting with each blink. Improper lid closure can result in notching of the lid and create a functional deformity. If there is no opportunity for the patient to see an ophthalmologist, repair should be performed as in Fig.: 230-12. One 6-0

silk vertical mattress suture, using the meibomian gland orifices as a landmark, or two 6-0 silk sutures (one approximating the anterior and the other the posterior lamella) are used to repair the lid margin. The ends of the silk sutures should be left long enough to tuck under the more distal skin sutures to avoid corneal irritation.

The tarsus should be repaired with 5-0 Vicryl from the external side so as to approximate the wound without the need for sutures on the conjunctival side of the lid (which would abrade the cornea with each blink). Skin closure can be performed with 6-0 or 7-0 monofilament or silk suture. Deep lacerations medial to the punctum can potentially transect the canalicular system. These patients need to be seen by an ophthalmologist for evaluation of the nasolacrimal duct system's integrity. If a canalicular laceration is discovered, the patient will need to go to the operating room within 24 to 36 h for repair and Silastic tube stenting ( Fig...230-13, Plate 14).

Because a meticulous repair by an experienced eye surgery team is preferable, it is not unreasonable for the ophthalmologist to discharge a patient seen late in the evening or on the weekend with arrangements for surgical repair to take place within the next 36 h. Patients discharged pending repair should be placed on oral and topical antibiotics and told to use cold compresses. Oral cephalexin (Keflex) 500 mg bid or qid and topical erythromycin ophthalmic ointment qid are reasonable choices.

FIG. 230-12. Full-thickness lid repair. 6-0 silk used for lid margin. 5-0 Vicryl used to approximate tarsal plate. The Vicryl sutures should not pass through the conjunctiva on the inside of the eyelid to avoid mechanical abrasion of the cornea during blinking. 7-0 nylon is used for skin closure, and the lid margin silk suture tail can be incorporated into these sutures to avoid corneal irritation.

FIG. 230-13. (Plate, , ..14). Traumatic canalicular laceration repair requires microsurgical stenting to reestablish patency.

Partial-thickness lid lacerations can usually be repaired in the ED with referral for ophthalmologic evaluation in 2 to 3 days. It is important to have the suture ends closest to the cornea tucked under more distal sutures to avoid corneal irritation (see Fig. 230-12).

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