Lid & Canalicular LacerationsMounir Bashour, M.D.A Case Report In A Six Year Old Boy

IntroductionA 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/HPI6 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, allergiesSingle 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 LacerationPhoto with similar laceration as found in our patient.

DiagnosisSuspicionCommon etiologiesEpidemiology

Necessity of RepairControversyJones studyMoore and Linberg study

Timing of RepairImmediate vs late

Discussion IThe aim of lid repairWorkup

Discussion IIBlunt injuries

Discussion IIILacerations involving the canthal angles

Intraoperative ComplicationsInabilty to Locate the Medial End of the CanaliculusDifficulty Retrieving Probe from NoseProblems Suturing the Canalicular WallsDifficulty Repairing Medial Canthal Ligament Injury

Proximal CanaliculusThe characteristic appearance of the proximal canaliculus

Normal Anatomy of the Lacrimal SystemEssential knowledge

IntubationGavaris Modification of the Quickert-Dryden procedure

Anastamosis of the CanaliculusProblems with suturing

Medial Canthal Ligament InjuryCorrect Placement of MC Fixation Suture(A) Posterior reflection of MCT behind the lacrimal sac(B,C) Correct fixation point

Intubated Nasolacrimal SystemDouble-knotted Silastic Tubing

Complications With Silicone TubesTube displacementPunctal/canalicular erosion/slittingConjunctival/corneal irritationGranuloma formationEpistaxis

Displaced TubingMost common complication

Securing the TubingOne method of several

ErosionSix knots with 4-0 nylon woven into knotsSecured to lateral vestibule of nose

GranulomaGranuloma formation from silicone tubingDisplaced silicone tubing after patient had caught tubing with finger and pulled loop onto cheek

Rarer ComplicationsDacryocystitisEpiphoraEctropionLoss of tubingDifficulty removing tubing

CANALICULAR LACERATIONS

Diagnosis

Suspicion is a key element in diagnosis of canalicular injury. Until proven otherwise, all lacerations in the medial eyelid and medial canthal area should be presumed to involve the lacrimal drainage system. The distal canaliculus is located very superficially along the lid margin; even trivial injuries within 6 mm medial of the punctum can lacerate the canaliculus. The severity of the injury can vary greatly (Figs. 13-1 to 13-5). Passage of a lacrimal probe through the punctum will confirm canalicular involvement when the probe emerges from the lacerated end of the canaliculus (Fig. 13-6).Dog bites, fist fights, fingernail scratches, and falls are among the more common causes of injury to the canaliculi, and children and young adults are the most common victims.

There is controversy over the need to repair isolated upper (especially) or lower canalicular lacerations. Many ophthalmology residents have heard this or a similar statement: "The conservation of the inferior canaliculus is for tear drainage and the superior canaliculus for the ophthalmologist". Based on the belief that tears can drain well through an intact inferior canaliculus, some ophthalmologists advocate no repair for isolated superior canalicular lacerations. Iatrogenic injury to the uninjured canaliculus, the common internal puncture, or both, is a potential complication of repair. Such injuries are most common when the pigtail probe is used.In a study of student nurses. Jones showed that transit time of tears through the superior and inferior canaliculi is nearly equal. This study casts some doubt on the commonly held notion that the superior canaliculus is of little consequence in tear drainage. Dacryoscintigraphy has shown no statistical difference in tear flow between the upper and lower canaliculi.Linberg and Moore used temporary punctal plugs to create monocanalicular obstructions and found that a single upper or lower canaliculus was inadequate to drain reflex tear secretion completely without symptoms in 50% of patients tested . Patients sustaining canalicular lacerations averaged 18 years of age in one study , raising the possibility of future disease or injury to the uninjured canaliculus. Surgeons have recently reported a 95% success rate in repairing these injuries with appropriate technique.

Trauma often occurs at night or on weekends. Canalicular lacerations need not be repaired immediately. Delay of repair may allow time to obtain an operating team familiar with surgery of this nature. Repair within 24 to 48 hours of injury is preferable; however, surgical correction usually is successful if performed within 5 days of injury. Late repair (weeks to months) is far less likely to be successful because of scarring and consequent difficulty in locating the canaliculus.

The magnification provided by an operating microscope is very helpful in locating the canaliculus and providing better visualization for suturing it. Sedation, anesthesia, suitable stents, fine sutures, suction, and operating microscopes are most readily available in a hospital or ambulatory surgery facility. Off-hours repair in a minor surgery room, without assistance, is often frustrating and unsuccessful.

The aim of lid repair is to restore the anatomical alignment and continuity of the traumatized lids and the damaged lacrimal excretory system.General condition of the patient at the time of the initial examination. Attention must be paid to adequate airway, hemorrhage, shock, neurologic status, type and extent of injury to other parts of the body, and magnitude of the ocular and lid trauma. A preliminary history combined with an early evaluation of the involved eye or eyes aids in the assessment of the overall trauma. The nature of an ocular injury may be such that the eye must be carefully covered and protected until a complete evaluation and repair can be performed in an operating room with the essential equipment on hand. It is far better to perform controlled surgery under ideal circumstances several hours after the admission of a patient to the hospital than to make a hasty, early repair with a disturbed and uncooperative patient in an emergency room where only a limited choice of equipment exists. Undue manipulation by highly motivated but semitrained personnel must be avoided. Well-controlled primary repairs of even severely lacerated lids under ideal surgical conditions often preclude secondary operations.

Ocular contusion causes soft tissue injuries, which in most instances leave slight or no disabilities. Drainage of a localized lid hematoma is rarely required. One must be alert to the sign of the "black eye". This "harmless" sign is often dismissed as insignificant, but it may be associated with a basal skull fracture, fracture of the orbital wall, naso-orbital fracture, deep injuries to the lacrimal system, or with trauma to the extraocular levator muscles or to the globe itself. The incidence of ocular trauma in naso-orbital fractures is thought to be as high as 25 %. It may include recession of the root or dialysis of the iris, contusion injuries to the angle outflow structures with secondary glaucoma, hyphema retinal hemorrhages, retinal holes and retinal detachment. Intrasheath hemorrhages of the optic nerve and deep orbital bleeding may bring about compression of the ophthalmic artery and subsequent visual impairment. Whenever bony trauma is conceivable, an x-ray evaluation is needed and should include tomograms. Often computerized tomography is required, with or without ultrasound evaluation, to rule out nonmetallic foreign bodies.Fractures of the orbital floor or medial wall must be carefully assessed. Forced duction tests need to be performed on both eyes to demonstrate potential entrapment of an inferior rectus or inferior oblique muscle or both. Lacerations in the medial canthal angle demand evaluation of the lacrimal drainage apparatus and the canthal tendon. Lacrimal involvement is usually confirmed by inspection and gentle probing. Integrity of the inferior and superior limbs of medial or lateral canthall tendon scan be assessed by grasping each lid with a toothed forceps and tugging away from the injury while palpating the insertion of the tendon. Medial canthal tendon avulsion should be suspected when there is a rounding of the medial canthal tendon and the presence of acquired telecanthus. Attention to the posterior portion of the tendon's attachment to the posterior lacrimal crest is critical. Treatment of medial canthal tendon avulsions depends on the nature of the avulsion. If the upper or lower limb is avulsed, but the posterior attachment of the tendon is intact, the avulsed limb may be sutured to its stump or to the periosteum overlying the anterior lacrimal crest. If the entire tendon including the posterior portion is avulsed, but there is no naso-orbital fracture, the avulsed tendon should be wired through small drill holes in the ipsilateral posterior lacrimal crest. If the entire tendon is avulsed with a nasoorbital fracture, transnasal wiring is necessary after reducing the fracture. A three-dimensional perspective is crucial in the evaluation and repair of canthal lacerations to insure optimum functional and cosmetic repair, i.e.., the horizontal, vertical, and anterior-posterior position of the canthal angle must always be kept in mind. The different configurations of the medial and lateral canthal angles must also be considered. While the lateral canthal angle is sharp, the medial canthal angle is slightly rounded. Failure to recognize this difference gives rise to postoperative cosmetic and functional problems.

Causes. This frequent and frustrating problem may relate to the severity of the injury, edema, bleeding, inadequate exposure, and lack of magnification. Surgeons who rarely treat canalicular lacerations will probably find it difficult to visualize the medial end of the canaliculus. Tangential cuts make the canaliculus even harder to see than when a perpendicular lacera-tion is present.Prevention. Delay of the repair and application of iced compresses may allow edema to subside. Surgery will be easier in an operating room with an operating microscope and skilled nursing personnel. If a physician is not used to treating canalicular lacerations, referral to a surgeon experienced in this type of repair should be considered.Management. Good, careful retraction and appropriate magnification with an operating microscope should allow visualization of the canaliculus in most cases. Excessive manipulation of the tissues is often counterproductive. Once false passages are established, it becomes more difficult to locate the true passage.Knowing where to look is important. For lacerations close to the punctum, the medial end of the canaliculus will be found close to the lid margin. The closer a lacer-ation is to the tear sac, the deeper the surgeon must look to find the canaliculus. The inferomedial aspect of the caruncle is a useful landmark for locating the roedial end of the canaliculus, which will have rolled white edges and a shiny epithelial lining when seen.

Irrigation of the intact canaliculus can occasionally be helpful when retraction and observation have failed. Sodium hyaluronate and a wide variety of other substances (air, water, steroid, methylene blue, fluorescein) have been used in this method of canalicu-lar identification- Methylene blue is not recommended by the authors, because we object to the "sea of blue" that results when tissues are diffusely stained with this dye.The pigtail probe continues to have its advocates . Despite good results reported with the rounded-tip pigtail probe, the authors prefer to avoid this device because of the potential for common canalicular injury . bleuhaus has suggested a dacryocystotomY to identify the internal common puncture and then retrograde probing of the canaliculi when all else fails.

Difficulty Retrieving a Probe from the Nose

Causes. Many physicians are not familiar with nasal anatomy. It is important to realize that the nasolacrimai duct opening is located on the extreme lateral aspect of the nasal cavity, in the inferior meatus beneath the inferior turbinate. This area is difficult to anesthetize with topical anesthetics, and patient discomfort can be a factor contributing to problems in recovering the probe. Bleeding and swelling of the nasal mucosa typically make direct visualization of the probe difficult. Rigid probes generally are more difficult to recover than more flexible ones.prevention. Unless the surgeon is experienced in this technique, general anesthesia should be utilized. Placing a curve in the probe before passage and turning the probe so that it protrudes intranasally will help with retrieval.Management. The surgeon needs to look or feel for the probe on the extreme lateral wall of the nose beneath the inferior turbinate. A sinus endoscope may help visualize the probe. However, many clever re-trieval devices have been developed. Selecting an intu-bation system with a malleable sheath usually facilitates retrieval. A surgeon knowledgeable in nasal anatomy may be of assistance in probe retrieval.

Gavaris Modification

1.165 The Gavaris Modification of the Quickert-Dryden procedure provides lower canaliculus intubation following lacerations. A silicone rubber stent of 0.025" OD is swaged on to a malleable stainless steel lacrimal probe of # 1 caliber. The end of the silicone stent has a thin flat Silastic plate to stop it from slipping into the canalicular system.1.166 The concept of a "nasal triangle" aids visualization of the anatomical relationship of the nasolacrimal excretory system to the nasal vestibule. The base of this imaginary triangle measures 30-35 mm in adults and 20-25 mm in children. With this in mind, it is easier to understand where and how far a lacrimal probe must be passed. Likewise, a grooved director must be passed 30-35 mm posteriorly and laterally along the floor of the nose to reach Hasner's valve.1.167 To facilitate introduction of the Silastic stent the grooved director is slightly curved and its trough is rounded and polished to make handling of the lacri-mal probe easier. The silicone rubber tubing is cut within the nasal vestibule and left untied.

Causes. When a large gap between the ends of the canaliculus is present, the fine sutures used to join the canaliculus may not withstand the tension. If there is much tension in the sutures due to a large gap, the sutures tend to erode through the delicate canalicular ends as the sutures are being pulled up and tied. Avulsion injuries with trauma to the medial canthal ligament often leave such a gap. Tissue swelling may also be a factor.prevention. Although preferable, suturing of the canalicular ends together is not mandatory. Delay of repair and iced compresses may reduce edema. Management. Temporary tightening of the silicone tubing will relieve the tension during suture placement. Placing several sutures prior to tying any of them may help. A larger (e.g., 8-0) suture will allow more tension to be borne without breaking than will a smaller (e.g., 10-0) suture. Another adjunct is a temporary traction suture to draw the tarsus over to the medial canthal ligament to relieve the pull on the canaliculus.

Causes. The first step in repair of the roedial canthal ligament is recognizing the need to repair it. Avulsion injuries typically sever the medial canthal ligament and canaliculi, particularly in the lower lid. Wulc and Afterberry have shown that the canalicular position of the lid is a particularly vulnerable location, and that either direct or indirect trauma may produce similar injuries. Tissue swelling also complicates repair, as does the surgeon's concern for preserving the canalicular repair that usually is accomplished prior tc the ligament repair. Prevention. The posterior reflection of the medial canthal ligament must be restored. Failure to accomplish this may leave a gap between the lid and the globe medially or cause an ectropion.Management. After canalicular repair is completed, the medial edge of the tarsal plate is sutured to the posterior reflection of the medial canthal ligament. A 4-0 polyglactin or polyglycolic acid suture on a small, strong, half-circle needle is suitable. Suture placement can be difficult because of the deep location and important adjacent structures. The surgeon must avoid placing the suture around the common canaliculus or superior canaliculus but still get a posterior bite on the frontal process of the maxilla. Trauma to the lacrimal sac also should be avoided. The lid position is satisfactory when the lid margin and punctum are in good ap-position to the globe. This suture also bears most of the tension for the canalicular repair.Quickert-Dryden Method of Canalicular Repair1.161 This method of repair entails the introduction of a thin piece of Silastic tubing into a torn lacrimal excretory system. The tubing is carefully swaged onto the tapered end of special wires to a length of about I cm. The wire is introduced into the lacrimal apparatus from the punctum, crossing the laceration and then following the normal contour of the nasolacrimal duct into the nose.1.162 A grooved director is placed underneath the inferior turbinate concha after the nasal mucous membranes have been shrunk with a 4 % cocaine nasal spray. The inferior turbinate concha may have to be fractured to allow for visualization and handling of the Quickert-Dryden silver probe as it emerges from the nasolacrimal duct. The grooved director prevents damage to the nasal floor. The other end of the probe is introduced through the opposing canaliculus, bringing about an intubation of the lacrimal excretory system bridging the laceration.1.163 The Silastic tubing is double-knotted and secured with a 7-0 silk suture to avoid slipping. The tubing is kept short enough to allow its comfortable location within the nasal passages without protruding from the nares. It is allowed to remain in position for three months or more.1.164 At the time of removal a small clamp is affixed to the Silastic knot within the nose prior to cutting the loop in the medial canthal area. This will prevent dislocation or aspiration of the Silastic tube during the process of its removal.

Corneal Ulcer or Abrasion Due to Silicone TubingCauses. This complication is seen in children more often than in adults . One reason for this may be that the distance from the cornea to the medial commissure is shorter in children. A second possible factor is that children may rub the lids more. Abrasions are due to contact between the silicone tubing and the cornea. Secondary infection may develop, causing a corneal ulcer.Prevention. The tension on the tubing should be adjusted carefully. Especially in children, a slightly protruding tube may have constant contact with the cornea. However, such corneal contact can be observed in most cases because corneal damage seldom results.Management. Removal of the tubing will typically result in resolution. A bandage soft contact lens may allow the abrasion to heal and the tube to remain in place. Appropriate antibiotics are necessary to treat infections. Antibiotic ointment may help reduce friction between the tube and the cornea.Epistaxis: Nasal hemorrhages can occur in the immediate postoperative period. They are usually mild and result from minor trauma to the nasal mucosa during retrieval of the lacrimal probes. This complication can be minimized by adequate preoperative vasoconstriction and modification of the lacrimal probe as described earlier. If epistaxis occurs, head elevation, cold compresses and vasoconstrictor sprays are usually sufficient treatment. Nasal packing along the nasal floor and under the inferior turbinate may also be necessary.The most common complication after silicone intubation is lateral displacement of the tube at the medial canthusCauses. A patient may be wiping the eye when a finger accidentally catches the silicone tubing and displaces it laterally. Occasionally, the patient claims that this happened after a cough or a sneeze.Prevention. The patient should be educated about the location of the tube and the importance of avoiding manipulation of the tube. Intranasal fixation of the tubing usually prevents lateral displacement. The authors prefer to tie six single knots in the tubing, weaving a 4-0 nylon suture into the knots. The suture is then placed with a large bite in the lateral vestibule of the nose and is tied loosely. This suture also serves to keep the silicone tubing in an anterior position in the nose to facilitate removal later. An alternative technique is to use a retinal sponge or sillcone strip as a bolster. However, the patients often complain that this bolster seems bulky inside the nose.Management. Repositioning a laterally displaced tube is not an emergency. The patient can be made more comfortable by taping the tubing to the nasal bridge or lower lid until definitive correction can be accomplished (Fig. 14). Sometimes the tubing can be repositioned by grasping it with toothless forceps and advancing it back into the tear ducts. This technique works best when there is minimal displacement.Probing of the nose beneath the inferior turbinate with a Crawford hook will sometimes allow the tubing to be simply repositioned. This is not always easy and may require multiple passes with the hook before the tubing is engaged. If the tubing cannot be located, it may be due to the knot being lodged in the nasolacrimal duct or tear sac. Transcanalicular removal of the tubing is a possible solution but is not very desirable after repair of a canalicular laceration. Furthermore, with multiple knots in the tubing, there is a greater risk of tube breakage and foreign body retention in the cana-liculus after transcanalicular removalThe authors prefer two techniques to reposition the tube. The first method involves cutting the loop of displaced tubing, attaching the cut end of silicone to a probe, and then passing the probe down the nasolacri-mal duct and out the nose. Reintubation can then be performed if necessary. The second method has been described by Gonnering. By passing both probes of a second intubation set through the same punctum, the loop of displaced tubing can be captured and repositioned without removal.

Causes. Canalicular slits are more common with polyethylene than with silicone tubing but may occur with either (Fig. 16). Excessive tension when the tubing is tied may cause it to erode through the canalicu-lus. However, other factors may contribute to the slitting: blinking, excessive stretching of the punctum on dilation, or the patient picking at the tube intranasally.Prevention. The patient should be instructed regarding the location and purpose of the tubing. The surgeon should not be too zealous in dilating the punctum during intubation and should be careful not to place too much tension on the tubing when securing it intra-nasally.Management. Fortunately, the slit canaliculus tends to function well. However, once the surgeon sees the slit developing, removal of the tubing should be considered because progressive erosion of both can-aliculi can result in loss of the tubing into the lacrimal sac. Removal of an intranasal fixation suture may be enough to decrease the tension on the tubing and allow it to remain in place for some additional time.

Granuloma Formation Around Tubing

Causes. The silicone tubing is a foreign body and will sometimes cause an inflammatory response (31,34) (Fig. 15).Prevention. Patients with a history of allergy to sill-cone implants should not have silicone tubing placed. Patients should be questioned preoperatively regarding any history of problems with silicone implants.Management. Usually, removal of the tubing will result in resolution of the granuloma. Alternatively, excision of the granuloma with or without thermal or chemical cautery to the base may allow the tubing to remain in place for a longer period of time. Topical corticosteroid drops also may eliminate the granuloma.

Dacryocystitis with Tubing in PlaceCauses. Infection around the tubing can sometimes result in dacryocystitis. This is very rare following repair of canalicular lacerations. A more common setting is following silicone intubation for obstruction of the nasolacrimal duct in children.Prevention. Contaminated lacerations should be copiously irrigated prior to repair. Topical and systemic antibiotics should be given for contaminated wounds.Management. Removal of the tubing will usually hasten resolution of the infection. Topical and systemic antibiotics should be administered and may allow the tubing to remain in place.Less Common ComplicationsA variety of rare complications can occur. These include spontaneous loss of stent, fistula formation, chronic nasal irritation and congestion, low-grade infection of the nasolacrimal system, and fibrous band formation between puncta.