What is Canalicular Laceration?
Canalicular lacerations, or tears in a particular part of your eye, can happen to anyone, no matter their age, and can be caused by a wide array of incidents. When trying to understand how serious a tear of this type is, it’s important to understand a bit about the eye’s anatomy.
The canaliculi are small drainage ducts located near the inner corners of your eyelids. Each of your four eyelids, upper and lower on each side, have a small hole called a punctum. The punctum connects to the canaliculus and their job is to help drain tears away from the eye and down into our tear ducts. Most people have an upper and lower canaliculus on each eye, and these usually join together before draining into the tear duct system.
When the canaliculi get torn, it can disrupt the eye’s natural drainage system, which can lead to various problems. It can also potentially damage the surrounding muscles and tendons in the eye socket, and in certain cases, even the bones of the face. Any injury to the bones of the face, or more serious damage to the eye itself, is not covered in this outline.
For now, we will focus on explaining how and why canalicular lacerations happen, how common they are, what our doctors look for when examining these injuries, and the strategies they use to manage and treat a canalicular laceration.
What Causes Canalicular Laceration?
Trauma, or injury, can be direct or indirect, and blunt or sharp. Direct, sharp injuries may be caused by foreign objects like glass, metal, or organic materials. On the other hand, indirect, blunt injuries may happen during personal attacks, such as getting hit with a fist or a bat, poked with a finger, or during car accidents, such as banging against the steering wheel. A dog bite is an example of a mixed injury, both sharp and blunt. The most common cause of such injuries overall, regardless of age, is from fistfights, but dog bites are the most common in children. Among the elderly, falling is the most common cause of such injuries.
One of the first studies exploring the cause of tear duct injuries found that 84% of these injuries happened due to indirect trauma, without injury to the eyelid. This suggests that these injury types might involve stretching the tear duct to the point of tearing.
A more recent study showed that 55% of tear duct injuries were due to direct, penetrating injuries. This same study also suggested that indirect injuries often involve more severe injuries to the facial bones, the eyeball, and other parts of the body.
Risk Factors and Frequency for Canalicular Laceration
Canalicular lacerations are cuts or tears that happen more often in males, especially in children and young adults. The group of people that this injury happens to the least are adults in their middle ages. The most common cause for such injuries is blunt trauma from fist fighting. Older people might get such injuries from falling and hitting their faces. On the other hand, little children who are less than four years old might get such injuries from dog bites, most often from a breed called Pit Bull Terriers. Alcohol and other intoxicants often play a role in these injuries too.
- Canalicular lacerations happen more often in males, children, and young adults.
- People in their middle ages are less likely to get this injury.
- Blunt trauma from fist fights is the most common cause.
- Older people might get these injuries from falling and hitting their faces.
- Children under four years old might get such injuries from dog bites, predominantly from Pit Bull Terriers.
- Intoxicants like alcohol often play a part in these injuries.
Signs and Symptoms of Canalicular Laceration
When a doctor is trying to diagnose a canalicular laceration, which is a tear in the small channels in the eyelid that help drain tears away, they need to take a detailed history and perform a thorough physical exam. The first and most important thing is to make sure there are no injuries that could threaten life or sight.
Upper facial injuries often go hand-in-hand with these types of lacerations, so if someone has trauma in that area, the doctor will likely suspect a canalicular laceration. The cause of the injury and the patient’s vaccination history, particularly for tetanus, are also important factors in managing the condition. Certain individuals, such as those with compromised immune systems, those who smoke, and others with specific risk factors, are more at risk for severe complications like serious infections.
Canalicular lacerations can be difficult to spot during an initial exam, so other diagnostic tools may be needed. Sometimes, a doctor might need to use devices like magnifying loupes, a slit lamp, or a microscope. There are several strategies to help identify these injuries, like injecting a viscoelastic material into the area or using a substance called phenylephrine to constrict blood vessels and contract muscles, which reduces bleeding and makes the wound easier to see. In young children, sedation might be necessary for a complete exam. To test if the tear drainage system is working properly, a doctor might inject dye or air into a tear duct and see if it comes out from the opposite side.
The doctor should also examine eye movement and visual sharpness, and look at the pupils in detail – if they’re shaped like a teardrop, it could mean the eyeball itself has ruptured. Another useful test is to apply a fluorescein dye to the eye to look for scratches on the cornea and to check for Seidel’s sign, which shows leaking fluid from inside the eye. Lastly, the doctor should feel around the face to check for any bone fractures, especially if the injury was caused by a dog bite, which is often associated with facial bone fractures. This is important because if there are bone fractures, they may need to be surgically fixed before the canalicular injury can be treated.
Testing for Canalicular Laceration
When it comes to identifying facial bone fractures or checking for anything stuck in the body (foreign bodies), a specific type of scan called a Non-contrast CT scan is the doctor’s first choice. This scan does not use any dye and provides clear images of your facial bones which can help your doctor look for any damage or breaks.
In certain cases, if your doctor suspects a problem with the bones around your eye (the orbit), a specialized scan called an orbital CT might be done. This focuses specifically on the eye area and can help determine if there are any issues with the bones there.
In some situations, a different type of scan called an MRI might be considered. However, this is usually not necessary once it has been confirmed that there aren’t any foreign bodies present. The MRI is typically not used in these cases because the Non-contrast CT scan provides all the needed information.
Treatment Options for Canalicular Laceration
If you have deep wounds around your eye or globe, it’s crucial to get medical attention quickly. These wounds, especially deep ones or those caused by sharp objects like glass, could damage your eye’s internal structures. When you visit a healthcare professional, they’ll check if you’re up to date with your tetanus shots and update the shots if needed. If something like glass has entered your eye, they’ll remove it and clean your wound thoroughly to prevent infections.
Your healthcare professional may suggest getting a CT scan, which is a type of body scan to check for things that may have entered your eye during the incident and to ensure no bones on your face have been broken. In some situations, like if the injury came from an animal bite, they might give you additional medicines to prevent infections, such as rabies or an antibiotic, depending on your specific situation and health factors.
Your case will be closely overseen by eye specialists who will guide the treatment process. In some situations, an initial skin repair might be performed by an emergency department physician after discussing with the eye specialist. If there’s damage to the canaliculus, a part of your eye that helps with tear drainage, it’s crucial to identify these pieces so they can be properly reconnected. This helps prevent excessive tearing after your eye heals. Absorbable stitches are often used to fix this part of the eye, and in some cases, immediate surgical repair may not be required, depending on your specific injury.
When both parts of your canaliculus are wounded, surgical repair is always needed. In this process, stents (small tubes or supports) are used to help reshape the damaged area and improve the outcome of the repair. There are different types of stents available for injuries affecting one or both parts of the canaliculus.
Kids might need to be calmed down or sedated for a thorough examination or repair. Regardless, the process of repair is fairly similar: the wound area is thoroughly cleaned and numbed, and then a stent is carefully inserted into the damaged eye structure. The stent is precisely positioned and secured using stitches that naturally dissolve over time. Afterward, the area around your eye will be closed using fast-absorbing stitches, and an antibiotic ointment will be applied to the wound.
You’ll be asked to keep the stent in for a specific period, usually six weeks for one-part injuries and up to three months for two-part injuries. Antibiotics might be prescribed for 3 to 5 days after the surgery to prevent infections. You will be given an eye shield for wearing at night and you should avoid rubbing your eye for at least two weeks after the repair.
What else can Canalicular Laceration be?
Cuts or gashes to the eyelid that don’t involve a part of the eye called the canalicular system are common. Usually, someone who has a lot of experience would handle the repair of these simple eyelid cuts. However, when the injury is more complicated, like a cut that goes all the way through the eyelid, a cut that involves fat from the eye socket coming out, or a cut that goes through the edge of the eyelid, then it would need a specialist in eye conditions, called an ophthalmologist, to take a look.
It’s crucial to note that if the eyeball itself has ruptured, this is a medical emergency and must be treated before any injuries to the eyelid can be addressed. Similarly, if there are broken bones in the face that need to be fixed, these need to be dealt with before any injury to the canalicular system, another specific part of the eye, can be repaired.
What to expect with Canalicular Laceration
Most patients who undergo surgery to fix tears in the canalicular, a part of the eye’s tear drainage system, end up with good cosmetic and functional results. This means they don’t experience constant tearing and their tear drainage system works well. The success rates for surgeries related to injuries of the tear drainage system can be as high as 82%.
Possible Complications When Diagnosed with Canalicular Laceration
When the canalicular system in your eye is cut or torn, it might also hurt the muscles around your eye, which can affect how your eyelids work. The most common issues after fixing a torn canalicular system are pain, bleeding, infection, scarring, drooping eyelids, or the need for more surgery later on. In rare cases, people might need to undergo another surgery due to excessive tearing, inward or outward turning of the eyelid, or poor eyelid positioning. If the canalicular system or the tear ducts get cut, it could lead to scars and narrowing of the canal system.
Common Post-Surgery Complications:
- Pain
- Bleeding
- Infection
- Scarring
- Drooping eyelids (ptosis)
- The need for additional surgery
- Excessive tearing (epiphora)
- Inward turning of the eyelid (entropion)
- Outward turning of the eyelid (ectropion)
- Poor eyelid positioning
- Scarring or narrowing of the canal system (stenosis)
Preventing Canalicular Laceration
The patient needs to be informed about how to look after their wound and avoid getting hurt again. It is critical that they understand that there may be complications and that there might even need to be more treatment down the line. If the doctor thinks it’s best to give them preventive antibiotics, the patient should be informed about potential side effects. Using ice and placing pressure on the wound can help reduce swelling, and the patient should be told why this is helpful.
If they needed emergency treatment or had the wound stitched up at a place that provides immediate care, they will be given contact information so they can schedule a follow-up appointment with an eye doctor. This is important for the patient’s recovery, and arranging for this follow-up should be a priority.
