Lid cracked open

aka Ophthalmology Befuddler 034

A 3 year-old boy is brought to the emergency department by his father after coming second best in a ‘head versus chair’ collision.

EYE trauma eyelid laceration
Photo by Tom Carmony

Questions

Q1. What is shown?
Answer and interpretation

Right Upper Eyelid laceration


Q2. What are aspects of history and examination should be included in the assessment of this injury?
Answer and interpretation

Assume a lid injury is a penetrating eye injury until proven otherwise.

History:

  • mechanism, e.g. bite, foreign body, etc
  • symptoms, e.g. pain, tearing, altered vision

Examination:

  • visual acuity
  • assess superficial structures looking for conjunctival penetration or laceration. Ideally use a slit lamp, or simply a magnifying glass.
  • rule out serious eye injury before wound closure — this may require detailed fundoscopic examination depending on the history and mechanism.
  • explore the wound fully to assess depth and rule out foreign bodies — lid lacerations may appear deceptively superficial.
  • Damage to the nasolacrimal drainage system should be suspected if a laceration is present nasal to the upper or lower eyelid punctum. Punctal dilation and irrigation of the canalicular system may be required.

Anatomy of the lacrimul punctum (RootAtlas)


Q3. Describe the management of this injury.
Answer and interpretation

Superficial lacerations can be managed in the ED:

  • univeral precautions, antisepsis, irrigation, local anesthesia (e.g. 2% lignocaine with adrenaline), debridement and removal of foreign bodies, closure with 6/0 non-absorbable sutures.
  • avoid deep sutures and never suture the orbital septum, which will cause eyelid tethering.
  • tetanus prophylaxis
  • Antibiotics are not usually indicated — consider in contaminated wounds or following bites.

Is there more to the injury than just a lid laceration?

  • Consider the need for C-spine clearance and CT head in the case of head trauma.
  • Orbital XR or CT may be necessary to rule out foreign body or orbital fracture.

Q4. Which eyelid wounds require ophthalmological referral?
Answer and interpretation

Refer to an ophthalmologist if any of the following are present:

  • laceration involving the lid margin
  • possible damage to the nasolacrimal duct system (i.e. punctum, canaliculus, common duct, or lacrimal sac) — a laceration that is nasal to either the upper or lower eyelid punctum.
  • full thickness lid laceration
  • extensive tissue loss or distortion of anatomy
  • medial canthal tendon avulsion (suspect when there is displacement, excessive rounding, or abnormal laxity of the medial canthus)
  • involvement of the levator aponeurosis of the upper eyelid (producing ptosis) or the superior rectus muscle
  • visible orbital fat in an eyelid laceration, indicating penetration of the orbital septum. Such patients require CT imaging and careful assessment of levator and extraocular muscle function.
  • associated ocular trauma requiring surgery (e.g. ruptured globe, intraorbital foreign body)

References

Ophthalmology Befuddler 700

CLINICAL CASES

Ophthalmology Befuddler

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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