Eyelid and conjunctival wounds

Eyelid and conjunctival injuries look different depending on the nature of the damaging factor and the place of its application. In some cases, these may be small hemorrhages under the skin, and in others - extensive tears and ruptures of the eyelids. Eyelid injuries are often combined with damage to the surrounding parts of the face, the bones of the eye socket and the eyeball, which are not always immediately noticeable.

The size and appearance of the eyelid and conjunctival wound may not correspond to the severity of the accompanying damage to the deeper parts. Therefore, each person seeking help for any eyelid injury must be carefully examined to detect such hidden disorders. In these cases, examination of visual acuity, transparent media and the fundus is mandatory.

Damage to the eyelids and conjunctiva is often accompanied by edema and hyperemia of the skin and subcutaneous hemorrhage. Sometimes abrasions or wounds appear. In this case, it is necessary to check for subcutaneous emphysema, indicating a concomitant violation of the integrity of the bones of the nose and its paranasal sinuses.

Eyelid wounds may be superficial (non-through), involving only the skin or the skin together with the muscle layer, or deep (through), extending through all layers of the eyelid, including the conjunctiva, with or without damage to the free edge. A through wound of the eyelid usually gapes, its edges diverge due to contraction of the orbicularis oculi muscle. The most severe injury is a complete detachment of the eyelid at the outer or inner corner of the eye. A detachment at the inner corner is accompanied by a rupture of the lacrimal canal. In this case, the outflow of tears is disrupted, lacrimation occurs. Eyelid damage may be accompanied by tissue defects. After eyelid trauma, their cicatricial deformation may develop. Eyelid wounds and contusions are accompanied by extensive subcutaneous and subconjunctival hemorrhages. They are associated with eyelid vasculature. The easily stretchable skin of the eyelids and loose tissue facilitate the spread of blood. If they bleed under the skin of the eyelids, no special treatment is required; it is possible to limit oneself to just prescribing cold (locally) during the first day.

Treatment of eyelid wounds. Patients with eyelid wounds should be given antitetanus serum. Treatment of eyelid wounds should be performed at the microsurgical level.

Features of surgical treatment:

1. perfect lash line matching;
2. correct alignment of the front and back edges;
3. application of deep sutures to the cartilage layer by layer, then to the fascia lines, then to the skin;
4. traction sutures are also required on the lower eyelid;
5. In case of an eyelid defect, external contotomy, plastic surgery, and skin sutures can be performed.

If there is a tear of the eyelid - due to good vascularity, the eyelids should not be cut off, even if they are hanging "by a thread". During treatment, every millimeter of tissue should be preserved to avoid shortening and deformation of the eyelids. In case of a non-through wound of the eyelid, sutures of thin silk or hair are applied to the skin. In case of a through wound of the eyelid, especially if the wound goes in an oblique direction to the free edge of the eyelid or perpendicular to it, sutures are applied "in two tiers": on the conjunctival-cartilaginous part and on the skin-muscle part. First, the cartilage and conjunctiva are sutured, for which it is necessary to evert the eyelid. If the free edge of the eyelid is damaged, then the first suture is applied close to the free edge, or through the intermarginal space. The applied suture is pulled together, but not tied for the convenience of applying other sutures. Only after applying and tying the remaining sutures is the first suture tied. The threads are cut short, the eyelid is straightened. The skin is sutured. 30% albucid ointment is placed behind the eyelids. A bandage is applied to the eye. The operation is performed under local infiltration anesthesia. Dressings are done daily. The sutures are removed on the sixth day.

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Eyelid injury with damage to the lacrimal canal

When the upper eyelid is injured, the upper-inner edge may be injured, the lacrimal gland. If it falls into the wound, the lacrimal sac and lower lacrimal canal are also destroyed. When the lacrimal canaliculus is damaged, the main difficulty (during surgical treatment) is finding the "mouth" of the proximal end of the canaliculus. This is done using a special spiral probe with an opening at the rounded end. One end of the probe is passed through the lacrimal punctum of the remaining canaliculus into the lacrimal sac, and then retrogradely into the proximal part of the torn canaliculus. Then, by rotating the probe, the mandrin is pulled into the lacrimal canaliculus through the opening. Next, the probe is inserted into another lacrimal punctum and the second end of the mandrin is pulled into the distal part of the torn canaliculus. 2-3 immersion sutures are applied to the edges of the canal and the eyelid wound is sutured. The ends of the mandrin are overlapped and glued with a plaster to the skin of the cheek and forehead. To reduce the elasticity of the mandrin in the middle, it is cut with a razor in advance by 2/3 of the thickness. After drawing this zone into the lacrimal sac, the mandrin easily folds in half and lies without deforming the canals. After 2-3 weeks, the mandrin is removed.

Conjunctival injuries

An isolated injury to the conjunctiva of the eyeball is rare, more often it accompanies an injury to the eyeball. The conjunctival wound does not gape even if it is of considerable length. Therefore, it does not need suturing. Gaping of the mucous membrane wound indicates concomitant damage to the elastic Tenon capsule. In this case, first of all, the wound is inspected to determine whether the sclera is damaged. Small foreign bodies are often retained on the surface of the conjunctiva; they are visible during external examination.

Quite often, a foreign body is retained on the conjunctiva under the upper eyelid. A foreign body located here causes a lot of unpleasant sensations (pain that intensifies when blinking, severe photophobia). Such a foreign body injures the cornea. Foreign bodies must be removed immediately. A conjunctival wound longer than 5 mm must be sutured with thin silk, after anesthetizing the conjunctiva with 1% dicaine solution. Albucid or another disinfectant ointment is placed in the conjunctival cavity. The sutures are removed on the 4th-5th day. A conjunctival wound shorter than 5 mm does not require sutures. In these cases, patients are prescribed a 20% albucid solution in the form of drops or ointment.

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Injuries to the external eye muscle

Sometimes the conjunctiva and Tenon's capsule are injured, and the external muscle of the eyeball. Suturing the muscle is necessary only if it is completely torn from the sclera. It is necessary to find the proximal part of the muscle and suture it to the tendon stump with two sutures of catgut. But this is not easy to do due to the muscle's tendency to retraction. Then, using a blunt method (by spreading the ends of the scissors), the connective tissue sheath of the muscle is opened, preferably from the side of Tenon's space, so as not to enter the orbital tissue and not to damage the apparatus of the eye's suspension to the walls of the orbit. If the injury is not fresh and the retraction is significant, then one should focus on the layers of tissue that are most mobile when trying to actively turn the eye in the desired direction. In extreme cases, a strip about 1 cm wide is cut out of them, which contains the soldered muscle. It is sutured to the muscle stump on the eyeball.