Delay in repair is acceptable while more life threatening injuries are dealt with, but it is important to ensure that the globe is protected from pressure until penetrating injury is excluded, and the cornea is protected from dehydration until the lids can be repaired. One should always check for penetrating injury when the patient is under general anaesthetic before embarking on repair of eyelid lacerations.If the globe is intact, or when it has been repaired, lid lacerations should be repaired. This should be performed before repair of other facial lacerations, because primary closure in circumstances where tissue loss has occurred elsewhere in the face may result in stretching and difficult closure in the periocular region. The upper lid takes priority and should be repaired before the lower lid. Avoid excising tissue from the eyelids, as even
apparently devitalised tissues may regain perfusion when anatomical relationships have been restored. In repairing the lids, it is important that the tarsal plates are accurately aligned to prevent eyelid deformity, and the eyelid margins must be smooth to prevent corneal damage.
These do not gape and can be left if small. Larger, slightly gaping wounds can be closed with a subcuticular technique.Lacerations perpendicular to the orbicularis fibres These have a tendency to gape and healing by primary intention leaves an unsightly scar, producing distortion of the eyelid margin and poor functional results. The obicularis should be closed with interrupted 6/0 catgut sutures. The skin is closed with 6/0 silk or nylon using an everting technique.Lacerations to the levator muscle.The levator can consistently be found under the pre-aponeurotic fat pad and the severed ends brought into apposition using 6/0 catgut or Vicryl. Lacerations of the levator aponeurosis will heal spontaneously if less than half of its width is involved.When the levator muscle is severely damaged it may be easier to perform an accurate primary repair of other lid structures and repair the levator as a secondary procedure under local anaesthesia, using the movement of the muscle in upgaze to help identify the proximal end.
In orbital trauma in children it is important to take steps to prevent amblyopia by measures aimed at reducing swelling rapidly (ice packs, prompt treatment of infection) and occluding the fellow eye if necessary. While it would be acceptable to delay the repair of a traumatic ptosis in an adult, this would carry the risk of amblyopia in a child and a temporary brow suspension should be carried out urgently if necessary. It is preferable to use a non integratible material for the suspension such as a prolene suture or silicone rod so that it can be removed subsequently if the ptosis recovers.
