NONGLOBE INJURIES

Eyelid trauma has been a part of human history since ancient times. Sharp sticks, flint knives, and animal bites have commonly led to substantial eyelid trauma.

Phillip of Macedonia, the father of Alexander the Great, suffered extensive eyelid wounds yet lived long enough to launch his son. Archaeological evidence suggests, however, that eyelid wounds could signal fatal trauma. Harold of England suffered eyelid trauma during the Battle of Hastings. The Bayeux tapestry and legend claim that he was killed by an arrow, which entered his skull through his eyelid.

Repair of eyelid wounds is documented in ancient Egyptian and Greek writings. Bandages and sutures were available when words were first written to describe surgical techniques.

In modern times trauma is still common because of sharp objects, animal bites, fighting, and burns; in addition newer sources such as high-speed missiles, and MVCs have also emerged. This chapter reviews the current management concepts in treating patients with trauma to the eyelids and lacrimal system.

EPIDEMIOLOGY (USEIR DATA)

Rate of lid and lacrimal system involvement among all serious injuries: 5%; breakdown:

•lacrimal laceration: 81%;

•periocular laceration: 70%;

•lid erythema: 19%;

•lacrimal obstruction: 6 1%.;

•lid deformity: 6 1%.

Age (years):

•range: 0–90;

•average: 23;

•rate of 0- to 9-year-olds among the total: 23%;

•rate of 10to 19-year-olds among the total: 18%;

•rate of 60-year-olds among the total: 6%.

Sex: 77% male.

Place of injury:

•home: 37%;

•street and highway: 21%;

•recreation and sport: 11%;

•industrial premises: 8%;

•public building: 5%;

•school: 3%.

Source of injury:

•various blunt objects: 28%;

•various sharp objects: 16%.

•MVC: 14%;

•fall: 8%

•gunshot: 6%;

•fireworks: 4%;

•BB/pellet gun: 3%;

Globe involvement among the total: 61%.

Rate of animal bites among the total: 9%.

374 • SECTION V NONGLOBE INJURIES

PREVENTION

Through history and into modern times, clever devices have been developed to provide protection for the eyelids and eyeballs. From the hoplite helmet to shatterproof windshield glass, technology has continued to improve eye safety. In the 20th century, laws and regulations at the workplace have been very helpful; this tendency is not apparent in the home (see Chapter 4).

EYELID LACERATIONS

Pathophysiology

Eyelid trauma can be quite dramatic, and the evaluation of eyelid trauma requires a thorough understanding of the anatomy of the eyelid and the adjacent structures. The eyelid’s primary function is to provide protection to the eyeballs.

PEARL... Because globe injury and eyelid trauma commonly occur concurrently, any investigation of eyelid trauma must include to a detailed examination of the eyeballs.

PEARL... When orbital fat is present in the wound, an orbital injury has occurred.

The eyelid margin is in contact with both the tear film and the outside environment. The mucoepithelial junction is an important anatomic landmark.

The eyelid is also an important part of the tear pump. The action of the lid margin pushes tears toward the punctum for removal. Disruption of the eyelid margin may lead to an impaired tear pump. This can occur with notching of the eyelid margin or with traumatically induced laxity. The inability of the eyelids to properly move the tears may lead to:

•epiphora;

•dellen formation; or even

•corneal ulceration.

The canalicular system carries tears from the puncta to the lacrimal sac. Evidence suggests that the lower canalicular system is primarily responsible; however, in some people, the superior part of the system removes most of the tears.1

PEARL... Patients with canalicular laceration always require repair. It is impossible to determine preoperatively whether the superior or lower canalicular system is dom-

inant in the injured individual.

The canalicular system is very close to the conjunctival surface. An extremely medial cutaneous eyelid laceration may not involve the canalicular system if the wound is superficial.

PEARL... A conjunctival laceration in the medial aspect of the eyelids probably

involves the canalicular system.2,3

The levator muscle is the primary elevator of the upper eyelids. The levator aponeurosis is the tendon of the levator muscle. The levator muscle has numerous attachments in the eyelid, all of which may be involved with trauma. Insertions of the levator include:

•conjunctiva;

•superior tarsus;

•anterior tarsus;

•orbital septum; and

•skin.

The levator attaches to the conjunctiva at the superior fornix, the superior border of the tarsus through Müller’s muscle, and the anterior face of the tarsus through the levator aponeurosis. Attachments to the orbital septum and skin are also consistently found. Eyelid trauma can lacerate or contuse the levator muscle or stretch and break the levator aponeurosis.

Eyelid trauma can compromise the levator function. Lacerations or contusive trauma may lead to traumatic ptosis. The ptosis may persist for a variable period of time and often resolves spontaneously only long after the other manifestations of trauma have healed.

Traumatic ptosis caused by contusion often improves spontaneously.4 Characteristics of such a ptosis are:

•history of eyelid trauma;

•poor levator function; and

•slow but almost always full recovery.

The initial treatment for traumatic ptosis, which has been caused by contusion, is observation. It is not unusual to see complete recovery 6 months following

the accident. If full recovery does not occur, exploration of the eyelid and repair of the ptosis are indicated.

Evaluation

The evaluation and diagnosis of eyelid trauma begin with a history and physical examination and observation. For the ophthalmologist, it is of paramount importance that a thorough eye examination be performed. Eyelid lacerations are often accompanied by severe globe injuries and retained orbital foreign bodies (see Chapters 24 and 36).5–7

PEARL... Dramatic eyelid injuries may conceal dangerous ocular, orbital,

and/or neurologic injuries (see Chapter 10).

•Even very small eyelid lacerations may involve the canalicular system. A high index of suspicion is important when evaluating the medial eyelids. Medial conjunctival lacerations often involve the canalicular system. Probing the canalicular system is easily accomplished in the ER.

PEARL... For complex lacerations, irrigation of the lacrimal system with sterile saline can be performed. Saline exiting from

the wound is a sure sign of canalicular laceration.

The levator muscle is evaluated by observing the excursions of the upper eyelids. Traumatic ptosis or mechanical ptosis may be documented. If possible, a lacerated levator aponeurosis should be repaired primarily. Mechanical ptosis, when seen without eyelid lacerations, may be due to:

•eyelid swelling;

•contusion to the levator aponeurosis;

•neurologic damage; and

•levator damage.

Without a laceration present, it is often wise simply to observe the ptosis for a period of time. Exploration of the levator muscle is not indicated unless an eyelid laceration and potential levator muscle or aponeurosis damage are observed.

Effective emergency evaluation of children is sometimes impossible in the ER (see Chapters 9 and 30). Probing and irrigation of a potentially lacerated canalicular system is contraindicated in the young or uncooperative patient. An examination under

anesthesia is commonly needed to arrive at a definitive diagnosis.

P I T F A L L

Patient care should never be compromised for lack of an adequate examination.

Radiology has limited importance in the evaluation of eyelid trauma. An orbital CT scan should be ordered when the suspicion of a retained orbital foreign body is present (see Chapter 36).

Eyelid lacerations often occur due to animal bites.8,9 The history of an animal bite should be reported to the authorities so that the animal can be observed for rabies.7 Medical personnel may be required by local law to file the report of an animal bite injury (see in more detail later in this chapter).

Appropriate use of antibiotics, tetanus toxoid, and all prophylactic measures apply in case of eyelid trauma (see Chapters 8, 9, and 28 and the Appendix).10

Timing

Eyelid margin lacerations do not require immediate repair. Injuries of inebriated patients, presenting at night or on the weekend, can be repaired when experienced personnel become available during “regular business hours.” After a thorough examination, antibiotic ointment and a patch will stabilize the patient until a definitive repair can be performed in 24 to 48 hours. It is usually not wise to delay the repair for over 48 hours.4

PEARL... Eyelid lacerations do not have to be repaired immediately.

Management

Eyelid margin lacerations are commonly seen in ERs.

•Simple eyelid margin lacerations can usually be repaired in the ER under local anesthesia (see Chapter 8). To perform an adequate repair, proper equipment, lights, and support personnel must be present.

•Children and uncooperative patients and those with more complex injuries must be repaired in the operating room under general anesthesia.

The anatomy of the upper and lower eyelids guides the techniques for repair. Traditionally, the eyelid has been described as having two layers:

376 • SECTION V NONGLOBE INJURIES

•an anterior lamella, consisting of the skin and the orbicularis muscle; and

•a posterior lamella consisting of the conjunctiva and the tarsus.

The approximation of these lamellae forms the basis for eyelid repair. By meticulous and precise closure, the overall goal is to restore the eyelid’s:

•contour;

•function; and

•anatomy.

The eyelid has several anatomic structures that help to achieve the proper alignment:

•the eyelash line;

•the gray line; and

•the meibomian gland orifices.

The eyelash line is a consistent landmark, which will help with the proper suture placement and alignment of the eyelid. There are normally three linear rows of lashes on the upper eyelid and two linear rows of lashes on the lower eyelid.

P I T F A L L

Proper alignment of the eyelashes and proper orientation of the eyelashes are important. Suture imbrication of the eyelashes can lead to trichiasis once healing has occurred.

The meibomian gland orifices are another invariable eyelid margin landmark. The meibomian gland orifices arise in the tarsus and extend throughout the length of the tarsus. Placing eyelid margin sutures through the meibomian orifice line will provide a firm reapproximation.

The gray line is the surface projection of the muscle of Riolan. This invariable anatomic landmark is usually the location of the most posterior eyelid margin suture. The eyelid margin sutures, when properly placed, can be secured away from the conjunctiva with one additional skin suture.

The typical surgical process is the following:

•The first suture to place when repairing an eyelid margin laceration is at the eyelid margin. A 6-0 silk suture through the meibomian gland orifices will align the eyelid margin. The first well-placed suture will help with the placement of all subsequent sutures. By pulling on the lid margin suture, the tarsus will become aligned and aid in deep

suture placement. Silk sutures at the eyelid margin are preferred because they are soft, easy to work with, and have less memory than sutures composed of nylon or synthetic fibers.

PEARL...

must not be in contact with the cornea.

•Once the eyelid margin is properly aligned, deeper sutures are introduced to secure the lacerated tarsus.a

P I T F A L L

When placing tarsal sutures, care must be taken that the suture does not penetrate through the full thickness of the tarsus, otherwise a suture-induced keratitis will develop.

•Similarly, the surgeon must protect the globe from inadvertent needle point injury. A corneal protector is usually available.b

•The upper eyelid tarsus can usually be reapproximated with two to three deep sutures. The lower eyelid tarsus requires one to two deep sutures. The deep suture knots should be tied in such a way that the knot is directed toward the skin surface. Fortunately, if the deep sutures extrude, they typically do so through the skin’s surface instead of leading to suture keratitis.

•In many cases when an eyelid has been lacerated, the orbicularis muscle develops spasms, pulling the wound wide open.

PEARL... The contraction by the unopposed pull of the orbicularis muscle is one reason why lid margin lacerations look

more severe than they usually are.

•It is very unusual for a lid margin to be missing in cases of simple lacerations. Careful reapproximation and firm support by the sutures allow adequate healing.

aA 5-0 Dexon suture with a D-1 needle is a good choice for eyelid margin lacerations. The needle is a spatulated, half-circle needle, and these characteristics allow precise lamellar placement through the lacerated tarsus.

bThe corneal protector must not distort the eyelid’s position.

•After the tarsal sutures have been placed, the orbicularis muscle is evaluated. If it appears to be gaped, the same 5-0 Dexon suture can be used to reapproximate the orbicularis muscle.

•The skin is usually in excellent approximation after the closure of the tarsus and orbicularis muscle.

Sutures of 6-0 silk can be used for eyelid margin and skin closure. For perpendicular lid margin lacerations, the skin sutures are typically placed deeper and wider than they are when closing lacerations that parallel the eyelid margin. Deeper and wider bites help stabilize the lid laceration and counteract the pull of the orbicularis muscle.

The silk eyelid margin sutures at the gray line and the meibomian gland line are reinforced by a 6-0 silk suture at the eyelash line. These sutures are carefully placed to prevent any imbrication of eyelashes. During the healing phase it is important that the lashes maintain a proper orientation because scarring and contraction may develop within the eyelid margin as it heals. After all the eyelid margin sutures have been placed, one additional skin suture can be placed on the anterior lamella, which pulls the eyelid margin sutures away from the cornea and secures them into an anterior position.

PEARL... It is very unusual to have missing tissue from an eyelid laceration.3

Complications

The most common complication of eyelid margin lacerations is lid notching. This usually results from poor initial approximation or development of a wound gap, caused by postoperative eyelid swelling or orbicularis pull. Lid notching can disrupt the tear pump and tearing can occur. If the eyelid notching is a cosmetic detriment or symptomatic, a revision can be performed.

If eyelid margin revision is necessary due to either notching or trichiasis, a bloc of eyelid tissue may be taken, which includes the abnormal eyelid margin. The proper repair of an eyelid margin defect requires the full-thickness bloc excision of the corresponding tarsus. A full pentagonal bloc excision will allow proper eyelid reapproximation.

PEARL... Pentagonal excisions of eyelid margins must include the full height

of the tarsus.

Eyelid alopecia can develop when scarring and trauma destroy the eyelash follicles. In most patients,

focal eyelid margin alopecia is of little consequence. It may be camouflaged with makeup or permanently repaired with a bloc excision of the damaged eyelid margin.

Keloid formation after extensive eyelid lacerations is fortunately rare. The incidence of keloid formation increases in pigmented patients with severe trauma. As with so many problems in medicine, keloids tend to improve over time. The medical management of keloids involves judicious use of steroid injections, dermabrasions, and late wound revision.11,12

CANALICULAR LACERATIONS

Successful repair of canalicular lacerations (Fig. 35–1) requires the surgeon to be familiar with the canalicular system’s anatomy and its relationship to the eyelid and the nasal structures. A lack of knowledge of these structures should prompt a referral to an oculoplastic surgeon who has experience in the area.

All lacerated canalicular systems should be repaired.

P I T F A L L

A persistent myth in medicine is that the upper canalicular systems do not need to be repaired. As mentioned previously, however, evidence shows that both the upper and lower canalicular systems are needed to carry away tears.1

PEARL... All canalicular lacerations need to be repaired.

FIGURE 35–1 Left lower eyelid canalicular laceration.

378 • SECTION V NONGLOBE INJURIES

The diagnosis of a lacerated canalicular system can be difficult. Very often, even relatively trivial eyelid lacerations involve the canalicular system. The nasolacrimal system can be gently probed and/or irrigated to establish the diagnosis. When examining children, an examination under anesthesia is often the only way to rule out the possibility of a canalicular laceration (see Chapter 9).

The canalicular system begins at the punctum at the upper and lower eyelid. A few facts that are helpful to remember are the following.

•The canalicular system has a short vertical component and then runs parallel to the medial eyelid margin on the conjunctival surface.

•The more medial the laceration of the canalicular system, the more posterior the cut edge of the canalicular system will be found.

•The canalicular system enters the lacrimal sac between the anterior and posterior halves of the medial canthal tendon.

•The nasolacrimal duct enters the lateral nose beneath the inferior turbinate. A stent passed through the nasolacrimal duct will enter the nose beneath the inferior turbinate. To retrieve this stent, its entry into the nose must be identified.

A variety of stents are available to facilitate canalicular system repair.13–15 The authors prefer the Crawford system, which consists of silicone tubings attached to two malleable probes. The probes have a small bulb at the end, which facilitates their removal from the nose with a Crawford hook. Monocanalicular systems also exist for surgeons who are less familiar with the nasal anatomy. A bicanalicular intubation is preferred because it is less likely to become dislodged.

Surgical Technique

The repair of eyelid canalicular lacerations begins with adequate patient preparation.

•In cooperative patients and in skilled surgical hands, modified local anesthesia can be used.

•In all other instances general anesthesia should be used because some discomfort is involved, and epistaxis may lead to airway compromise in the nonintubated patient.c

•The identification of the proximal canaliculus is the most difficult aspect of canalicular laceration repair. With patients under general anesthesia, no local anesthesia should be used in the area of the canalicular laceration until the proximal cut edge

of the canalicular system has been found. A cotton applicator stick, patience, and gentle retracting exposure will often reward the surgeon with a cut canalicular edge. Gentle traction at the edge of the wound may help in the identification.

•If the canalicular system is difficult to identify, gentle irrigation of fluid into the uncut canalicular system may help in the identification of the laceration.16 If the proximal canalicular system cannot be found, the eyelid should be closed without further manipulation.

P I T F A L L

The use of a pigtail probe is contraindicated because it has a high incidence of damage to the uninvolved canalicular system.17

•When the proximal and distal ends of the canalicular system laceration have been identified, stents can be passed through the canalicular system to bridge the laceration with tubing (Fig. 35–2). The injured canalicular system should be intubated prior to the uninjured canalicular system.d

•Once the silicone tubing is in place, the medial canthal tendon can be repaired. With the tendon reapproximated, there is no reason for a suture to be placed in the cut edge of the canalicular system. The stent will keep the canalicular system in good alignment and approximation.

d If it is impossible to intubate the injured canalicular system, at least the uninjured canalicular system can avoid iatrogenic damage.

•A properly placed bicanalicular stent does not need to be sutured into the nose. The nasal end of the tubing can be tied with five or six knots and allowed to retract back into the nose. The knots should be located at the tip of the inferior turbinate. The tubing should not exert any traction on the punctum or slitting of the punctum may occur.

•Once the stents are in good position and the medial canthal tendon has been closed, the eyelid laceration is repaired in a standard and layered manner.

Complications

The major complication of canalicular system repair is the failure to diagnose the problem and failure to restore canalicular integrity, which results in tearing. Inability to repair the canalicular system may lead to chronic tearing, which may require a reexploration of the eyelid or a conjunctivo-dacryocysto-rhinostomy with a Jones tube. Spontaneous early dislocation of the stent is a relatively frequent complication of bicanalicular silicone intubation.

P I T F A L L

Ideally, the stent should remain in place for 2 months. Earlier, inadvertent removal may lead to improper healing and long-term tearing.

PEARL... Patients must be encouraged not to rub their eyes or to pull at the

tube in the medial canthus.

If the silicone tubing becomes dislodged and a loop is visible in the palpebral fissure, a decision must be made whether to replace or remove the tube. It is often possible simply to rethread the silicone tubing back through the canalicular system with a pair of forceps. Forcible nose blowing may at times help replace the tube within the nasolacrimal outflow tract. A 0-00 Bowman probe can be used to force the tube back through the system. If replacement of the tube is unsuccessful, early removal is the best option.

Two months is the usual time for stent removal. Patients may notice ocular irritation, mild tearing, and mucus formation at this time. The stent can be removed by cutting the loop of tubing in the palpebral fissure after the instillation of topical anesthetic. One edge of the cut tubing can be grasped with the forceps and the tubing can be pulled out through the previously undamaged canaliculus. Another option is to

cut the tubing at the medial canthus and to have the patient forcibly blow the nose. The stent typically will fall out through the nasal vestibule, either immediately or over the next several days.

EYELID AVULSION

Severe eyelid avulsion injuries are frequently seen in MVCs and industrial injuries.

P I T F A L L

In most cases of severe avulsion injury, the eyelid remains on a vascular pedicle and can be replaced at the time of surgical repair. In no case should a potentially viable tissue be discarded.

During the initial evaluation of the patient with an avulsive injury, the tissues must be handled with care. Tension or pressure may compromise the tenuous vascular supply of the avulsed tissue and lead to tissue loss. When evaluation of the eyelid has been completed, the avulsed tissue may be protected under a patch.

The repair of eyelid avulsion injuries requires meticulous layered closure.

•In many cases, foreign body debris is present and needs to be thoroughly removed. Any organic foreign bodies need to be irrigated free, if possible; cultures may be obtained.

•The layered closure of an avulsion injury begins with deep closure of the medial or lateral canthal tendons.

•All canalicular lacerations must be addressed; see earlier in this Chapter.

•The levator muscle, if involved with the laceration, needs to be examined and, if possible, primarily repaired. In the area of the avulsion injury, not at the eyelid margin, 6-0 nylon sutures can be used to close the anterior lamella. This suture is a good choice because postoperative swelling and wound tension can be expected.

P I T F A L L

As a rule, absorbing sutures should not be used for this type of trauma repair. The tensile strength of an absorbing suture is simply not adequate for the postoperative swelling.

380 • SECTION V NONGLOBE INJURIES

•As a rule, the conjunctiva and septum are not closed when repairing an eyelid avulsion. The conjunctiva will be in good approximation if the levator and tarsus are correctly reapproximated. Any conjunctival sutures will lead to corneal abrasion and pain (see Chapter 14).

•The orbital septum should never be closed because this may result in a restrictive ptosis or lagophthalmos. The septal attachments between the orbital rim and the levator should remain completely open as contraction of the septum during the healing phase is uncontrolled and may lead to restriction of the levator muscle. Leaving the septum open also allows easy egress of orbital hemorrhage and may prevent orbital injury due to postoperative swelling and bleeding.

PEARL... Do not repair the orbital septum.

When avulsion injuries are accompanied by tissue loss, reconstructive surgery is more complicated. The initial goal is to stabilize the eyelid and protect the eyeball. Initial procedures, such as a tarsorrhaphy, may protect the eyeball until definitive reconstructive surgery can be performed. A variety of techniques for reconstructing missing eyelids is available. An oculoplastic surgeon who has experience in eyelid trauma or eyelid cancer surgery should be consulted in these complicated cases.

TRAUMATIC PTOSIS

Traumatic ptosis is not an uncommon consequence of eyelid trauma (Fig. 35–3). Ptosis may be seen both with lid lacerations and with contusion injuries.

The initial repair of a traumatic ptosis requires a careful and layered lid repair. If ptosis is present after meticulous lid closure, the treatment of choice is observation (Fig. 35–4).

PEARL... Traumatic ptosis often improves spontaneously for up to 6 months

after injury.18–20

Evaluation of the patient begins with careful history of the accident; special attention needs to be paid to the mechanism of injury. Scarring of the eyelid may produce a cicatricial ptosis with poor lid excursions. Evaluation of the eyelid may demonstrate a full-thick- ness scar. In these patients, an eyelid exploration with release of any scarring and special attention directed to the orbital septum, will often improve the situation. It is not uncommon for the levator function to remain poor after reconstructive surgery, due to neuromuscular damage.

In trauma patients in whom the levator function is normal, dehiscence of the levator aponeurosis is frequently found. Swelling caused by the accident can easily lead to a levator aponeurosis disinsertion. Repairing the levator aponeurosis should lead to a

satisfactory lid height and contour. The levator function is the most accurate predictor of surgical success.

PEARL... Patients with poor levator function often require more extensive pto-

sis surgery, including possible sling placement.

CICATRICIAL ECTROPION

A cicatricial ectropion of the eyelid may result from:

•tissue loss; or

•contraction of the septum.

Patients with cicatricial eyelid problems complain of:

•ocular pain and irritation due to incomplete lid closure or chronic exposure; and demonstrate

•scleral show and poor lid closure.

The evaluation of a patient with cicatricial changes involves determining which lamella of the eyelid is involved in the cicatrizing process.

•If ample skin is present, a posterior lamellar spacer (e.g., AlloDerm) or a hard palate graft will be needed to correct the defect.

•If inadequate skin is present, a full-thickness skin graft will be needed to correct the eyelid position.

•The retroauricular area is the second choice of skin donation. This skin is easily obtainable, and the donor site is readily hidden behind the ear. The retroauricular skin closely matches the eyelid skin in color and thickness.

•The third option for obtaining skin for eyelid reconstruction is from the supraclavicular area. This skin, however, is slightly thicker and the donor site is not as easily hidden.

BITE INJURIES

Bite injuries to the eyelid are not infrequent, especially in children. Eyelid evaluation of a dog bite victim often requires examination under anesthesia in this patient group. Special attention to the canalicular system must be paid because puncture wounds from the animal’s teeth may produce deep damage to the canalicular system and lacrimal sacs.

P I T F A L L

When dealing with a dog bite injury, documentation of the dog’s health and temperament is necessary. Reporting the injury to authorities may be required by law.

Upper eyelid lagophthalmos is not an unusual finding following severe eyelid trauma. Treatment is directed at the involved lamella of the eyelid.

•In cases in which the orbital septum has been tethered to the eyelid, an eyelid exploration with a complete lysis of adhesions is necessary. Fat pads in the eyelid can be transposed or fat can be transplanted to the eyelid to provide a buffer between the septum and the underlying levator muscle.

•If the upper eyelid lagophthalmos is due to an anterior lamellar deficiency, a full-thickness skin graft may be necessary.

Skin grafts in the eyelid are often extremely well tolerated. The choice of a donor site for a full-thick- ness skin graft is unlimited.

•The most closely matched skin is from the opposite eyelid. In many patients, a blepharoplasty on the uninvolved eyelid will provide ample skin for reconstructive purposes.

Meticulous repair of the injuries can often lead to complete functional and cosmetic recovery.21,22 Although perfect results are possible in many cases, suboptimal results are often seen; they should be avoided by meticulous, layered closure of the eyelid and canalicular system in the operating room. Consider referral to a medical center where competent oculoplastic surgeons are available.

SUMMARY

Eyelid and canalicular injuries are frequent complications of severe trauma by blunt or sharp objects. Repairing these tissues is rarely emergent, and often can wait for careful intervention performed by someone intimately familiar with the anatomy and reconstruction of these structures. Improper initial repair can lead to significant and lasting visual as well as cosmetic side-effects.

382 • SECTION V NONGLOBE INJURIES

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17.Kennedy RH, May J, Dailey J, et al. Canalicular laceration: an 11-year epidemiologic and clinical study. Ophthalmic Plast Reconstr Surg. 1990;6:46–53.

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