Describe the assessment and repair of eyelid injuries.

Assessment of a Lid Injury

• The first rule OF lid trauma IS that the lid IS not the priority: the globe must be assessed and any open globe injury repaired first. A dramatic lid laceration distracts from a quiet ruptured globe beneath it
• Assessment — visual acuity in both eyes recorded before anything else.
• Examine the globe for a SEIDEL-positive wound, a peaked pupil, hyphaema, a shallow or deep anterior chamber, lens position and the fundus

Principles of Repair

• The lid has a superb blood supply from both carotid systems, so it heals remarkably well, tolerates delayed repair, and requires minimal debridement — every millimetre of lid tissue should be preserved.
• Repair within 24 to 48 hours where possible, but a delayed primary repair still does well; and copious irrigation of a contaminated wound
• A marginal laceration must be repaired with precise alignment, since even a small step is visible and causes notching, trichiasis and epiphora. The technique: a first suture through the grey line to align the margin exactly, then sutures at the lash line and the meibomian orifice line, then tarsal sutures placed partial thickness with the knots anterior, so that no suture material rubs the cornea; the marginal suture ends are tied long and secured away from the globe
• A canalicular laceration is repaired over a silicone stent, either monocanalicular or bicanalicular, left in place for 3 to 6 months; the cut ends are identified under magnification, sometimes aided by irrigating air or fluorescein through the intact canaliculus
• The medial canthal tendon must be reattached where avulsed, and to the posterior lacrimal crest rather than anteriorly.
• Repair the levator where divided, identifying the cut aponeurosis and reattaching it to the tarsus
• Animal and human bites — common in children with dogs; irrigate copiously, give co-amoxiclav, consider rabies and tetanus prophylaxis, and repair primarily despite the contamination.
• Do not shave the eyebrow; it is a landmark for alignment and regrows slowly and unpredictably
• Chemical and thermal burns — irrigate first and at length; the lids are managed conservatively at first, since the extent of tissue loss declares itself over days, and cicatricial ectropion is corrected later with grafting
• Complications of poor repair — margin notching; trichiasis; epiphora from a missed canalicular injury; ptosis from unrecognised levator division; telecanthus from an unrepaired canthal tendon; cicatricial ectropion; and lagophthalmos with exposure keratopathy