Overview of Eyelid Laceration
When you cut or tear your eyelid, the way it is treated can depend on several things, like how deep or wide the cut is, and where it is on the eyelid. Doctors typically look at three types of eyelid cuts:
1. A cut that doesn’t involve the edge of the eyelid (the part where your eyelashes are).
2. A cut that does involve the edge of the eyelid.
3. A cut that affects the nasolacrimal system – this is the part of your body that makes tears and helps them drain out of your eyes.
The type and location of the cut can help doctors figure out the best way to treat it.
Anatomy and Physiology of Eyelid Laceration
The eyelid is a complex part of our body with lots of different parts, all with their own jobs to do. It’s vital for doctors who are treating injuries to the eyelid to have a good understanding of these parts.
We’ll start with the skin. The skin of the eyelid is very special because it doesn’t have any fat underneath it making it the thinnest layer of skin on the body. One part of the eyelid skin is firmly attached to the layers underneath it, while another part is loosely connected, allowing fluid to build up in case of injury or swelling. If an injury happens that only affects the eyelid skin, doctors will use very fine thread to stitch the wound because the skin is so thin.
Next, we have a muscle called the orbicularis oculi muscle, right under the skin. This muscle helps us close our eyelids. Some parts of this muscle work automatically (like when we blink without thinking about it) and other parts function when we intentionally close our eyes.
Then, we have a thin layer of fibrous tissue called the orbital septum. This acts as a divider between the front and the back parts of the eyelid. Behind this, we find the orbital fat which is divided into multiple sections. If you’ve ever noticed that the eyelid has a sort of padded feel, that’s because of these fat pads.
Some other important muscles are involved in opening and closing your eyelids. Among these muscles, the levator muscle in the upper eyelid and the capsulopalpebral fascia in the lower one are particularly important.
The eyelid also contains some dense tissues called the tarsal plates that give the eyelids their shape and hold the follicles for your eyelashes. The upper tarsal plate is bigger than the lower one.
The innermost layer of the eyelid is called the conjunctiva. This layer helps to keep your eyes moist and lubricated.
Last but not least, we have tiny openings on the inner corners of both upper and lower eyelids called puncta. These are the start of a little tube system that carries tears away from the eyes and down into your nose.
All these parts work together to help your eyelids do their job – which is to protect and moisten your eyes.
Why do People Need Eyelid Laceration
Any damage that affects the way the eyelids look or work can lead to a specific problem. In most cases, if the skin of your eyelid gets a cut or tear that is 2 millimeters long or longer, it will need to be fixed by a doctor.
When a Person Should Avoid Eyelid Laceration
There aren’t any hard-and-fast rules that say a torn eyelid cannot be stitched back together. But, if a patient’s eyeball is also ruptured, doctors must first examine and fix the eyeball before attending to the eyelid. Furthermore, lacerations that happened due to significant contamination or bites from a human or an animal might need unhealthy tissue to be cut away. Despite this, doctors usually will stitch the eyelid right away. However, in cases where the wound is badly contaminated, doctors might decide to leave the wound open and delay stitching it up.
Using a local anesthetic with epinephrine to numb the area for repair is generally avoided in patients having Raynaud’s phenomenon (a condition that affects blood flow to hands and feet), sickle cell disease (an inherited disorder that affects red blood cells), arteritis (inflammation of arteries), or severe microvascular disease (a condition affecting small blood vessels). Although, it’s important to note that ‘necrosis’ or death of a part of the eyelid following the use of lidocaine (a local anesthetic) with epinephrine is not common.
Equipment used for Eyelid Laceration
To fix a cut on your eyelid, the doctor will need the following tools:
- A Castroviejo needle driver: it’s a special tool that helps the doctor hold and use the stitch needle more accurately on delicate areas like the eyelid.
- Castroviejo 0.5 mm forceps: this is another precision tool that helps the doctor grab the tiny tissues of the eyelid without causing damage.
- Suture: This is the medical term for stitches. The doctor uses 6-0 silk, 6-0 plain gut, or 6-0 polyglactin sutures which are thin and gentle on the eyelid.
- Cautery: This is used to stop any bleeding by heating the tissue. It’s very precise to ensure only the bleeding point is touched.
- Stents: These might be used if the cut is deep or in a difficult area. They help to support the natural shape of the eyelid during healing.
- Standard prep materials for the sterile procedure: It’s essential to keep the area clean during the procedure to prevent infection. These materials could include sterilizing solutions and clean drapes.
All these tools help the doctor to repair the laceration so you can heal properly without leaving a noticeable scar.
Who is needed to perform Eyelid Laceration?
If you get a cut on your eyelid that doesn’t involve the edge of the eyelid or the canalicular system (drainage system of your eyes), a general doctor or a plastic surgeon can do the repair in the emergency room. But, if the cut is at the edge of your eyelid, the drainage system of your eye, or the muscles that connect the eyelids to the eyeball (canthal tendons), a specialized eye doctor or an eye plastic surgeon needs to do the repair. This is because these are more complicated and require special skills.
Preparing for Eyelid Laceration
Think about getting a tetanus shot to prevent infection. Also, it might be necessary for you to undergo some scans or x-rays to help the doctor understand your situation better. Your doctor will decide where the best place to make the repair is; either in an operating room or right by your bedside. Certain symptoms like damage to the tear drainage system, eyelid muscle, or the thin tissue separating your eye from your eyelid along with significant tissue loss might mean that the surgery has to take place in the operating room.
When it’s time for the procedure, you’ll be asked to lie down flat on your back. The doctor will numb your eyes with some drops and shield the affected eye to protect it during the procedure. They will then clean the skin around your eye with a povidone-iodine solution, which is a commonly used disinfectant. If there’s any debris or foreign objects in the wound, they’ll remove it, and then put a sterilized sheet over the area to keep it clean.
If your tear drainage system is involved, the doctor might stuff your nasal cavity with sponges soaked in oxymetazoline (a type of medicine to reduce swelling) and 4% lidocaine (a numbing medicine).
Finally, they’ll inject a local anesthetic, which is a medicine to keep you from feeling pain, just under your skin. They will use a solution of 2% lidocaine mixed with epinephrine, which is used to slow down the absorption of the lidocaine so it lasts longer, in the smallest amount necessary to make sure you’re comfortable during the procedure.
How is Eyelid Laceration performed
For a simple and superficial eyelid cut, the doctor will stitch the skin edges back together. They use either silk or a plain gut sutures. This is a kind of thread that lasts for a short time and then dissolves. The stitches are placed about 1 mm from the skin edge, and they are spread about 2 mm to 3 mm apart. This is done to neglect tightly tying the stitches to your skin as tight stitches can restrict the delicate tissue. If the doctor uses silk sutures, they will need to be removed later. Contrarily, if they use the absorbable type like the gut sutures, you won’t have to go back to get them removed.
If your eyelid cut also involves the margin of the eyelid, then the doctor will use various techniques to align the wound edges. The common technique has four steps:
The doctor will stitch the edges of your eyelid margin together using a 6-0 Silk stitch. This particular stitch goes from one part of your eyelid to another called the gray line. They’ll leave the thread untied.
Next, the doctor will use another type of stitch, the 6-0 Vicryl, to mend the edges of another portion of your eyelid, called the tarsal plate. These stitches are tied and cut short after. This helps in keeping the eyelid firm.
The doctor will put an additional marginal suture, a type of stitch parallel to the first one but closer to your lash line.
Lastly, your doctor will use the same method as in the simple, superficial eyelid cut to stitch the skin.
If your eyelid cut also involves the part known as the canaliculus, the doctor has slightly different steps to follow.
In the beginning, the doctor will dilate, or widen, both upper and lower puncta, a term for the tiny openings in your eyelids. If one punctum is not affected, the doctor will probe it to the sac. This process is to ensure there are no obstructions.
Then, the doctor will identify the two ends of the affected canaliculus. They’ll place a tiny or Crawford stent if needed, depending on which part of your canaliculus is involved. A stent’s job is to keep your canaliculus open.
After inserting a stent, the doctor will then stitch the skin in the same way as in the simple, superficial eyelid cut.
The stitching methods can be different if they use a miniature or Crawford stent.
In case of a miniature stent, the doctor will push a stent through the opening of the cut canaliculus and out the end part. Then, the doctor will stitch the cut edges of the canaliculus and the surrounding tissue together. They’ll leave these stitches untied until all the deep ones are in place.
In a Crawford stent scenario, the process is slightly different. The stent is placed through the opening of your cut canaliculus and out the far end. Then, it is passed through the starting end of the cut canaliculus and moved through the tear and nose tear ducts. The doctor will then get the stent end out of the nose. After this, the other stent end goes through your unharmed canaliculus in the same way. In the end, the doctor will tie, cut, and trim the stent ends in your nose before stitching the skin.
Possible Complications of Eyelid Laceration
If you get a cut on your eyelid that doesn’t affect the small drainage canals in your eye (canalicular system), you might have several complications. You could have an unspotted injury, an infection, a notch in your eyelid, or an uneven shape to your eyelid. It’s also possible to have difficulty fully closing your eyelid (lagophthalmos), dry eye from exposure (exposure keratopathy), holes in the wall between your eye area and nose (septal perforation), or fat from your eye socket pushing forward (prolapse of orbital fat).
You might also have injury to your cornea (the clear front surface of your eye), a shortened area inside your eyelid where your eye touches your lid (shortening of eyelid fornices), wound separation (wound dehiscence), inward turning of your eyelid (entropion), inward turning of your eyelashes (trichiasis), or excessive bleeding (hemorrhage).
If your eyelid cut involves the small drainage canals in your eye, you might experience additional problems. This can include watery eye (epiphora), migration of a small tube used to keep the canal open (stent migration), and nosebleeds (epistaxis).
What Else Should I Know About Eyelid Laceration?
Your eyelids play a crucial role in several functions: they help distribute tears evenly across your eyes, allow tears to drain properly, protect your eye’s surface, and contribute to your appearance. If your eyelid gets cut, this can alter its shape and position, potentially leading to problems with tear production and drainage, damage to the surface of your eyes, or changes in your appearance.
To prevent these issues, a cut or tear in your eyelid needs to be carefully repaired. This process helps to restore the normal structure of your eyelid, ensuring that it can continue to protect your eyes and help them stay moisturized, while also maintaining its normal appearance.