Lid & Canalicular Lacerations

Mounir Bashour, M.D.

A Case Report In A Six Year Old Boy

Introduction

• A short presentation to stimulate a discussion on a practical approach to complex lid/canalicular lacerations.

• By Mounir Bashour, PGY-3, Ophthalmology, George Washington University, graduate of McGill Medical School.

Case Presentation/HPI

• 6 yo bm presents with complex lid laceration OS.

• Secondary to falling from upper bunk bed while playing around 2 AM 7/20/95.

• Hx of Prematurity (28 weeks) was in NICU for 3 months, no Hx of ROP.

• Currently good health, no meds, allergies

• Single parent (father) family.

Examination

• >4 cm full thickness medial oblique upper lid laceration OS extending into medial canthus.

• PERRLA, no RAPD.

• Va 20/30 OU by Snellen.

• Rotations full, ortho.• No corneal abrasion, Seidel negative.

• Dilated exam reveals picture consistent with resolved early ROP.

Photo of Upper Lid Laceration

• Photo with similar laceration as found in our patient.

Diagnosis

• Suspicion

• Common etiologies

• Epidemiology

Necessity of Repair

• Controversy

• Jones study

• Moore and Linberg study

Timing of Repair

• Immediate vs late

Discussion I

• The aim of lid repair

• Workup

Discussion II

• Blunt injuries

Discussion III

• Lacerations involving the canthal angles

Intraoperative Complications

• Inabilty to Locate the Medial End of the Canaliculus

• Difficulty Retrieving Probe from Nose

• Problems Suturing the Canalicular Walls

• Difficulty Repairing Medial Canthal Ligament Injury

Proximal Canaliculus

• The characteristic appearance of the proximal canaliculus

Normal Anatomy of the Lacrimal System

• Essential knowledge

Intubation

• Gavaris Modification of the Quickert-Dryden procedure

Anastamosis of the Canaliculus

• Problems with suturing

Medial Canthal Ligament Injury

• Correct Placement of MC Fixation Suture

• (A) Posterior reflection of MCT behind the lacrimal sac

• (B,C) Correct fixation point

Intubated Nasolacrimal System

• Double-knotted Silastic Tubing

Complications With Silicone Tubes

• Tube displacement

• Punctal/canalicular erosion/slitting

• Conjunctival/corneal irritation

• Granuloma formation

• Epistaxis

Displaced Tubing

• Most common complication

Securing the Tubing

• One method of several

Erosion

• Six knots with 4-0 nylon woven into knots

• Secured to lateral vestibule of nose

Granuloma

• Granuloma formation from silicone tubing

• Displaced silicone tubing after patient had caught tubing with finger and pulled loop onto cheek

Rarer Complications

• Dacryocystitis

• Epiphora

• Ectropion

• Loss of tubing

• Difficulty removing tubing