aka Ophthalmology Befuddler 034
A 3 year-old boy is brought to the emergency department by his father after coming second best in a ‘head versus chair’ collision.
Q1. What is shown?
Q2. What are aspects of history and examination should be included in the assessment of this injury?
Assume a lid injury is a penetrating eye injury until proven otherwise.
- mechanism, e.g. bite, foreign body, etc
- symptoms, e.g. pain, tearing, altered vision
- visual acuity
- assess superficial structures looking for conjunctival penetration or laceration. Ideally use a slit lamp, or simply a magnifying glass.
- rule out serious eye injury before wound closure — this may require detailed fundoscopic examination depending on the history and mechanism.
- explore the wound fully to assess depth and rule out foreign bodies — lid lacerations may appear deceptively superficial.
- Damage to the nasolacrimal drainage system should be suspected if a laceration is present nasal to the upper or lower eyelid punctum. Punctal dilation and irrigation of the canalicular system may be required.
If you’re not sure what an eyelid punctum looks like or where it is, check out this brief video at RootAtlas.com.
Q3. Describe the management of this injury.
Superficial lacerations can be managed in the ED:
- univeral precautions, antisepsis, irrigation, local anesthesia (e.g. 2% lignocaine with adrenaline), debridement and removal of foreign bodies, closure with 6/0 non-absorbable sutures.
- avoid deep sutures and never suture the orbital septum, which will cause eyelid tethering.
- tetanus prophylaxis
- Antibiotics are not usually indicated — consider in contaminated wounds or following bites.
Is there more to the injury than just a lid laceration?
- Consider the need for C-spine clearance and CT head in the case of head trauma.
- Orbital XR or CT may be necessary to rule out foreign body or orbital fracture.
Q4. Which eyelid wounds require opthalmological referral?
Refer to an ophthalmologist if any of the following are present:
- laceration involving the lid margin
- possible damage to the nasolacrimal duct system (i.e. punctum, canaliculus, common duct, or lacrimal sac) — a laceration that is nasal to either the upper or lower eyelid punctum.
- full thickness lid laceration
- extensive tissue loss or distortion of anatomy
- medial canthal tendon avulsion (suspect when there is displacement, excessive rounding, or abnormal laxity of the medial canthus)
- involvement of the levator aponeurosis of the upper eyelid (producing ptosis) or the superior rectus muscle
- visible orbital fat in an eyelid laceration, indicating penetration of the orbital septum. Such patients require CT imaging and careful assessment of levator and extraocular muscle function.
- associated ocular trauma requiring surgery (e.g. ruptured globe, intraorbital foreign body)
- Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
- Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com]
- NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide, 2007. [link to free pdf]