One of the most intimidating experiences in laceration repair is suturing around the eye. The field you are working on is generally small, the structures are intimidatingly intricate, and you need a steady hand so as not to puncture the globe. And not to mention…by nature of the injury, the patient is watching EXACTLY what you are doing. GULP.
Not to worry. I have three examples below to help you perform these repairs fearlessly.
#1 Beware of the seemingly benign injury–there is a lot of important stuff happening beneath the surface.
This patient fell while wearing his glasses, shattered the lens, and it cut him along the margin of his medial right eye. What’s the pitfall to just simply repairing an injury like this? Wait for it…
Think about the underlying anatomy–medial canthus injuries put you at risk for injury to the lacrimal cannaliculus/tear duct. This is the drainage system for tears, which are produced in the lacrimal gland, wash their way across the surface of the globe, and drain via the lacrimal ducts into the naso-lacrimal duct and out the nose. This is why you sniffle so much when you cry. Yes, you. Don’t deny it.
How does one diagnose a lacrimal duct injury? The first step is just to suspect it, based on remembering the relevant anatomy. As a general principle, always consider what lies beneath the skin surface–this can help you to avoid missing important vascular and tendon injuries too. Any laceration near the bridge of the nose or medial canthus of the eye is a possible duct injury. You’d be most prudent to get an Ophtho consult for lacrimal duct cannulation prior to closure of a laceration like this, as a missed injury to the lacrimal duct can cause some long term problems for the patient.
In a pinch, a poor man’s test which can also clinch the diagnosis is to instill flourescein carefully over the cornea, then place a Wood’s lamp over the laceration. If flourescence is seen in the wound, the diagnosis is essentially made.
If the diagnosis of lacrimal duct injury is made, the treatment involves placement of a stent to allow proper healing and tear drainage. You don’t want to miss these injuries. A potential consequence of missing this injury or incorrect treatment is canal stenosis, leading to excessive tearing, recurrent conjunctivitis, and recurrent stye formation.
#2 Glue is useful around the eye, but not in it.
In the ED, we see quite a few relatively minor lacerations involving the eye adnexa which would generally be amenable to closure with tissue adhesive. However, it’s intimidating to do this around the eye. Getting just a few drops of fresh tissue adhesive glue in to the eye can glue eyelids shut! Not that this is a true emergency–application of petroleum jelly or acetone can loosen the bond and remove it. Still, this is an embarassing situation you’d rather not get yourself into. So instead, try this trick.
Find a tegaderm or like material (basically, a clear polymer plastic sheet, as used to secure an IV line in place). Before removing the stiff paper backing, cut a hole in the material to approximate the size and shape of the wound you aim to repair. Place the sheet over the area of interest, then feel free to glue away with reckless abandon. Remove the tegaderm once the gluing party is done.
#3 Eye Lid Lacerations: Know when to get help, and a few tricks to avoid iatrogenic globe puncture.
Perhaps the most tricky situation involving the eye is the lid laceration. This very amicable patient came in to the ER the morning after a fall. He had no idea what hit him, but he had multiple lacs to his right eye.
On close inspection, he had one laceration across the upper eyelid, and three smaller ones involving the upper and lower eyelid margins.
This is a great example of an eyelid laceration that we can fix in the ER (the one through the superior eyelid, marked by the blue arrow), and another three that we absolutely shouldn’t (the ones crossing the eyelid margin, marked by white arrows).
Simple eyelid lacerations that don’t penetrate the tarsal plate can be closed with 6-0 nylon or vicryl sutures, with a few exceptions:
- If there is fat herniating from a peri-orbital laceration (suggesting the orbital septum has been penetrated, and retrobulbar fat is coming through the wound)
- If ptosis is present in an upper eyelid laceration (suggesting damage to the levator palpabrae muscle)
- Lacerations that traverse the eyelid margin need to be realigned precisely to prevent ectropion or entropion (eyelid turning inward or outward).
The above scenarios indicate lacerations that need to be repaired by an expert, so I called in an ophthalmologist. I watched her diligent repair of these lacerations, which took over an hour to perform. (Yet another reason not to take on this task in a busy ED…) I did learn some great tricks from watching her at work.
If you are going to pursue repair of a simple eyelid laceration, it is still pretty intimidating. Sticking an anesthetic needle or a suture in the needle carries the risk of globe puncture if your hands aren’t steady. One trick of the trade in this situation is to drop some proparacaine to numb the cornea, then place a Morgan lens under the lids to act as an eye shield. This allows you you to suture more comfortably.
A second trick is to place one slightly thicker suture at the start of the repair, with long tails left after the needle is cut off. This can be used to retract the lid from the globe, which also allows for easier, worry-free suturing. One word of caution with this technique is that forceful retraction can somewhat distort the normal anatomy and make aligning the tissues a little tougher.
In summary, lacerations involving the eyelids and eye adnexa are a serious matter. While cosmetic closure is of obvious importance, considerations for these lacerations extend well beyond cosmesis, involving function and attention to underlying structures. I hope these three examples will give you something to bring back to your next repair.