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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 57  |  Issue : 2  |  Page : 122-127

A study on evaluation of eyelid trauma in a tertiary care center


1 Department of Ophthalmology, Regional Institute of Ophthalmology and Government Ophthalmic Institute, Chennai, Tamil Nadu, India
2 Department of Ophthalmology, Regional Institute of Ophthalmology, Chennai, Tamil Nadu, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Dr. Malarvizhi Raman
Department of Orbit and Oculoplasty, Regional Institute of Ophthalmology and Government Ophthalmic Institute, Egmore, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_28_19

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  Abstract 


Aim: This study aims to evaluate traumatic eyelid injuries and assess functional outcome following treatment. Materials and Methods: A prospective study of 30 cases of lid injury was conducted at Orbit and Oculoplasty Department, Regional Institute of Ophthalmology and Government Ophthalmic Institute, Egmore, Chennai, Tamil Nadu, for 12 months from February 01, 2017, to February 01, 2018. Data collected were entered into Excel Spreadsheet and analyzed using STATA statistical software package release 11. Results: The incidence of lid injuries was more in males (63%) compared to females (37%). The most common mode of injury of the eyelid was accidental fall (36.7%) and assault (23.3%). Majority of the cases presented within 6 h of injury. Full-thickness involvement was seen in 20 patients (66.7%). Involvement of the eyelid margin was seen in 18 patients (60%) and was managed by three-layer margin suturing canalicular involvement in 8 cases (26.7%) underwent monocanalicular stent placement. About 40% of patients complained of epiphora and were not satisfied with cosmetic results. Conclusion: This study reveals that young adult males, most of whom were workers, were more prone to eyelid injuries. Timely meticulous management of the eyelid injury with minimal debridement of the wound and tension-free suturing gives better cosmetic outcome. Epiphora, notching of lid margin, or ectropion was the most common complication postoperatively.

Keywords: Canaliculus, eyelid injury, lid margin, stent


How to cite this article:
Anuradha A, Raman M, Jarika J. A study on evaluation of eyelid trauma in a tertiary care center. TNOA J Ophthalmic Sci Res 2019;57:122-7

How to cite this URL:
Anuradha A, Raman M, Jarika J. A study on evaluation of eyelid trauma in a tertiary care center. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Sep 16];57:122-7. Available from: http://www.tnoajosr.com/text.asp?2019/57/2/122/266385




  Introduction Top


Eyelids are protective structures acting as curtains in front of our eyes.[1] Perfectly contoured and aligned lids give beauty to the eyes. Henceforth, meticulous repair of any defect or injury to the eyelids due to trauma is essential for the best possible cosmetic outcome.

Injuries to the eyelid are divided into two categories: blunt trauma and penetrating trauma.[2] Trauma to eyelids is common among the young as well as old age group. In children and adolescents, trauma is usually due to sports-related injury and accidental falls, whereas in adults, it is common due to fist fights and road traffic accidents. The treatment of lid laceration depends on the depth and location of the injury.[3] Canalicular injuries and lacerations are repaired with microsurgical intervention.[4] Lacerations with mild tissue loss can be managed by performing a lateral cantholysis.[5] Laceration with extensive loss may require major reconstructive procedures.[6]

The outcome of the surgical repair depends on the time of presentation, location, extent of tissue loss, and involvement of canthus and margin.


  Materials and Methods Top


A prospective study was conducted at Orbit and Oculoplasty Department, Regional Institute of Ophthalmology and Government Ophthalmic Institute, Egmore, Chennai, Tamil Nadu, for 12 months.

Incidence, mode of injury, various clinical presentations, mode of treatment, and its outcome in traumatic eyelid injuries were analyzed. Thirty patients with eyelid injuries were included in the study. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13] show preoperative pictures of eyelid injuries and the post operative pictures. Lid injuries associated with open globe injury, orbital fracture, and poor general condition were excluded from the study.
Figure 1: Preoperative full-thickness lid tear

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Figure 2: Preoperative full-thickness lid tear

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Figure 3: Preoperative partial thickness lid tear

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Figure 4: Preoperative partial thickness lid tear

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Figure 5: Preoperative canalicular injury

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Figure 6: Postoperative monocanalicular stent

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Figure 7: Preoperative canalicular injury

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Figure 8: Postoperative canalicular stent

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Figure 9: Preoperative tissue loss

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Figure 10: Postoperative primary suturing

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Figure 11: Ectropion

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Figure 12: Notching

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Figure 13: Epiphora

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A detailed history of present illness, mode of injury, visual acuity using Snellen acuity chart, slit lamp biomicroscopy of anterior segment, extraocular movements, intraocular pressure using Goldmann applanation tonometer, direct and indirect ophthalmoscopy was recorded. Complete hemogram and radiological imaging-X-ray orbit, computed tomography, B scan were done as and when required.

Under local anesthesia wound cleansing, gentle debridement was done. According to the site of the involvement, primary closure was done with 6-0 silk. Lid margin lacerations were repaired prior to extra marginal lacerations for better anatomical realignment. Three layer suturing was done at level of gray line, lash line and mucocutaneous junction. Medial canthus injuries involving the canaliculus were managed by insertion of canalicular stents (Monoka, mini- Monoka stent).

Statistics

Data collected were entered into Excel Spreadsheet and analyzed using STATA statistical software package release 11 by (statacorp., TX, USA). We used the two-sided independent-samples t-test to compare means across dichotomous variables (i.e., men vs. women); the one-way ANOVA test for comparison of means across multilevel variables. Simple calculations such as percentages, proportions, and mean values were derived. A Type I error of 0.05 was considered in all analyses.


  Results Top


General characteristics

Mean age of presentation was 35 years. About 63% were male, mean time of presentation being 27.3 h, 60% had marginal involvement, 27% had canalicular and levator involvement [Table 1].
Table 1: General characteristics

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Mode of eyelid injury

Accidental self-fall was found to be the most common mode of injury both among males and females (36.7%) followed by assault in 7 patients (23.3%) and road traffic accidents in 6 patients (20%).

Eyelid thickness involved

Full thickness of eyelid was involved in 67% whereas 33% had partial involvement of the lids.

Treatment

All 30 cases were taken for surgical repair, 2 cases (6.7%) were treated with intravenous antibiotics first followed by surgical repair as these cases were associated with infection. Primary simple closure was done in 15 cases (50%) including all partial thickness wound. Even in the cases with tissue loss primary suturing was done, no graft was needed. All 8 cases (26.7%) of margin involvement injuries underwent three-layer margin reconstruction. Monocanalicular stent was placed in 5 cases (16.7%) where lower canalicular involvement was present [Table 2].
Table 2: Treatment given in study group

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Munk score

Munk score was given for all the cases, if the patient does not complain of epiphora-0 score, if occasional epiphora requiring dabbing less than twice a day-Grade I, epiphora requiring dabbing 2–4 times Grade II, if dabbing needed 5–10 times/day then Grade III, if dabbing needed more than 10 times Grade IV. Patients with no epiphora with 0 Munk score were 18 (60%) in number, followed by Munk score of II in 6 cases (20%) [Table 3].
Table 3: Munk score in postoperative cases

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Schirmer's test

Patients were subjected to Schirmer's test on follow-up visit. One patient (3.3%) had Schirmer's value <12 mm. In 19 cases (63.3%), the Schirmer's value is between 12 and 16 mm. Ten patients who had epiphora had Schirmer's value of more than 16 mm [Table 4].
Table 4: Postoperative Schirmer's test

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Postoperative cosmesis

Postoperatively, 18 patients (60%) were satisfied with outcome, whereas the other 12 cases were not satisfied. Of 12 cases, 7 had prominent scar, 3 had notching, and 2 had ectropion [Figure 11], [Figure 12], [Figure 13].

Age versus postoperative cosmesis

Younger age group had better postoperative cosmesis [Table 5].
Table 5: Comparison between age and postoperative cosmesis

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Community versus time of presentation

Rural population presented late (41.26 h) [Table 6].
Table 6: Comparison between community and time of presentation

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Canalicular injury versus Munk score

Canalicular involvement is associated with postoperative epiphora [Table 7].
Table 7: Comparison of canalicular injury and epiphora

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Time of presentation versus postoperative cosmesis

Patients presented late had poor postoperative cosmesis.


  Discussion Top


Tabatabei et al.[7] conducted a study on eyelid lacerations in 98 patients and he concluded that males (75.3%) were more affected than females, which is consistent with our study in which males were involved in (63%) of cases. They also showed that mode of injury was by accident in 57 (58.2%) cases followed by assault in 19 cases (19.4%) similar trend was seen in our study where accidental fall was the leading cause of injury in 36.7% cases and assault in 23.3% cases.

In a study conducted by Demir and Gül[8] mean age of the patient presenting with injuries was 31.5 years with males being more common (75%) which was comparable to our study where the mean age of the patients was 34 years and males were commonly affected.

Kennedy et al.[9] reported inferior canalicular injury as the most common one (66%) followed by superior canaliculus (28%) and bicanalicular injury (6%). Similar results were concluded by Jordan et al.[10] in a study in which 50% of the people had involvement of inferior canaliculus and 23% superior canaliculus involvement and 4% bicanalicular involvement, which are similar to our study where inferior canaliculus was involved in eight cases and superior only in one case.

The analysis included the various causes of lid injury, variability in their presentation, and the outcome of various treatment modalities.

The findings of the analysis are as follows

The most common age group affected was children and young adults. About 63.3% of patients were below the age of 40 years. Mean age was 35 years. The incidence of lid injuries was more in males (63%) compared to females (37%) the difference was found to be quite significant. Laterality of eye involvement is almost same in both the eyes right eye (53%) and left eye (47%). The most common mode of injury of the eyelid was accidental fall (36.7%) and assault (23.3%) which was more common in males and young adults. People coming from rural areas were more common (63%) as compared to urban areas (37%). Time of presentation was different, minimum time taken was 2 h and maximum time was 148 h, but majority presented within 6 h of injury in 13 patients (43.3%). Visual acuity at the time of presentation was good for most of the patients 6/6–6/18 in (66%), 6/24–6/60 in 9 cases (23.7%). The thickness of the eyelid involved in injury also varied, full-thickness involvement was seen in 20 patients (66.7%) whereas only 10 patients (33.3%) had partial thickness involvement. The involvement of the eyelid margin was seen in 18 patients (60%). Canalicular tear in 8 cases (26.7%) of which 7 were involving inferior canaliculus. In a study of epidemiological aspects of eyelids injuries[11] in Munich, canalicular injury was found in 16% of patients levator involvement (traumatic ptosis) was seen in 8 cases (26.7%). Infection was present in 2 cases (6.7%) both of whom presented late to us. Tissue loss was observed in 3 cases (10%) in the study group; however, no graft was needed for the management of these cases. Partial thickness wound not involving margin was managed with primary suturing (50%) margin involved cases managed by three-layer margin suturing (26.7%). Monocanalicular stent placement in canalicular involvement cases (16.7%), intravenous antibiotics was given in two infective cases (6.7%). Epiphora following repair was the most common complaint by 12 patients (40%). Munk score for epiphora was evaluated, 6 patients had Grade II while 4 patients had Grade III epiphora. Only 10 patients among the 12 cases who complained of watering had Schirmer's value more than 16 mm. Twelve patients (40%) were not satisfied with the cosmetic result. Postoperative visual acuity was almost similar to preoperative visual acuity in all cases. The younger age group had better postoperative cosmesis. Those in rural areas had a late time of presentation compared to urban population. Those with canalicular injury had a higher rate of postoperative epiphora. Patients who presented late had bad postoperative cosmesis [Table 8].
Table 8: Comparison between time of presentation and postoperative cosmesis

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  Conclusion Top


  • This study reveals that young adult males, most of whom were workers from rural areas were more prone to eyelid injuries as usually men are more commonly engaged in higher risk jobs, operating vehicles and are also involved in a higher rate of assaults and also had late time of presentation to hospital. Younger age group had better postoperative cosmesis
  • Time of presentation plays an important role in the outcome of the eyelid injury repair, earlier the presentation lesser was the rate of complications such as infection, epiphora, and cosmetic dissatisfaction
  • Lower canaliculus involvement was more than the upper canaliculus because of the more prone position of the inferior canaliculus to the injury as well as loose approximation of the lower lid to the globe medially
  • Epiphora was the most common complication seen postoperatively which was seen in injuries involving the eyelid margin and canalicular injuries. Margin involving injuries lead to notching of margin or ectropion postoperatively. Early stent extrusion leading to stenosis of canaliculi also resulted in epiphora in these patients
  • Timely meticulous management of the eyelid injury with minimal debridement of the wound and tension-free suturing makes the wound more esthetically appealing. It also helps in restoring its anatomy and functionality to its previous state as accurately as possible.


Limitations

  • Small sample size.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kanski's Clinical Ophthalmology Eyelid Trauma. 8th ed. Elsevier publication. p. 1.  Back to cited text no. 1
    
2.
American Academy of Ophthalmology. Basic and Clinical Sciences Course: Orbit, Eyelids and Lacrimal System Section. 7th ed. European board of ophthalmology subcommittee; 2015-2016. p. 187.  Back to cited text no. 2
    
3.
Parsons Disease of the Eye. 22nd ed. Elsevier publication. p. 468.  Back to cited text no. 3
    
4.
American Academy of Ophthalmology. Basic and Clinical Sciences Course: Orbit, Eyelids and Lacrimal System Section. 7th ed. European board of ophthalmology subcommittee; 2015-2016. p. 195.  Back to cited text no. 4
    
5.
Collin JR. Eyelid reconstruction. A Manual of Systematic Eyelid Surgery. Ch. 6. Elsevier publication. p. 116.  Back to cited text no. 5
    
6.
Kanski's Clinical Ophthalmology Eyelid Trauma. 8th ed. Elsevier publication. p. 863.  Back to cited text no. 6
    
7.
Tabatabei A, Kasaei A, Nikdel M, Shoar S. Clinical characteristics and casuality of eyelid laceration in Iran. Oman Med J 2013;28:97-101.  Back to cited text no. 7
    
8.
Demir T, Gül FC. Results of canalicular laceration reperation by pig- tail probe and silicon tube entubation. İnönü Üniv Fakültesi Derg 2011;18:87-90.  Back to cited text no. 8
    
9.
Kennedy RH, May J, Dailey J. Canalicular laceration. An 11-year epidemiologic and clinical study. Ophthal Plast Reconstr Surg 1990;6:46-5.  Back to cited text no. 9
    
10.
Jordan DR, Ziai S, Gilberg SM, Mawn LA. Pathogenesis of canalicular lacerations. Ophthalmic Plast Reconstr Surg 2008;24:394-8.  Back to cited text no. 10
    
11.
Herzum H, Holle P, Hintschich C. Study of Epidemiological Aspects of Eyelid Injuries in Munich Germany; 2001;98:1079-82.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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