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INJURIES OF THE EYELIDS  

2013-01-08 08:08:34|  分类: ophthalmology 眼 |  标签: |举报 |字号 订阅

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http://www.primary-surgery.org/ps/vol2/html/sect0161.html

INJURIES OF THE EYELIDS

This extends the general method for an injured eye in Section. 60.1. Examine the patient’s eye to see exactly what structures are involved. Make sure his globe has not been injured.

If he has a severe injury to his lids, refer him if you can.

Toilet his injured lids. Don’t remove any skin, unless it is obviously dead or detached. Infection is unusual, so you can always close his wound by immediate primary suture. Use fine instruments, and 6/0 silk or monofilament on his skin. If the edges of the wound are irregular, try to fit them together with great care.

CAUTION! Take great care to keep his lid against his globe, and don’t allow it to become inverted or everted.

If the edge of the patient’s eyelid is intact, you can treat his injury in the same way as any other skin laceration.

If the injury has involved the whole thickness of his lid, approximate the tarsal plate, the muscle layer and then the skin. Disregard his conjunctiva. It is stuck to his tarsal plate, and if you align this, it will align itself.

If the wound gapes, it will do so because the fibres of his orbicularis muscle have been cut. Use 5/0 buried catgut to gyring the edges of the muscle together, before you suture the skin.

If he has lost some of the skin on his eyelid, graft it. Use split skin, and hold the graft in place by the tieover method (57-8).

If less than a quarter of the margin of a lid is involved, as in Fig. 60-1 and B, and C, Fig. 60-2, freshen the lacerated edges by making incisions perpendicular to the skin margins through the full height of the tarsus to excise an ’I’ of tissue. Close the patient’s tarsus with interrupted catgut sutures. Align the lid margin with 7/0 silk sutures, one in the posterior margin through the orifices of his meibomian glands, and another in the anterior margin through the lash line. Allow the sutures to remain 5 mm long and tie them over his skin to prevent them abrading his cornea.

CAUTION! Bring the edge of his lids together accurately by aligning the lash line. If you repair them with their edges notched, part of his cornea may not be covered, so that it will dry out and ulcerate.

\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-60/fig/60-2.eps}
Figure 60.2: WHEN TISSUE HAS BEEN LOST FROM AN EYELID. A, don’t notch the edge of the patient’s lid. B, and C, if less than a third has been lost, close the wound directly. D, and E, if between a quarter and a third has been lost, make a lateral relaxation incision, and divide his lateral canthal ligament, as in the next figure. F, and G, if more than a third has been lost, you will have to make a long relaxing incision, and undermine the tissues of his cheek. H, incising the lower eyelid in the lash line, and in front of the tarsus. 1, if there is not enough eyelid left to cover a patient’s cornea, cover it with flaps of his conjunctiva. Partly after Mustarde, with kind permission.

If between a quarter and a third of either lid margin has been lost, make a small incision just lateral to the patient’s eye, as in D, and E, Fig. 60-2. Divide the upper or lower bifurcation (depending on which lid is being repaired) of the Y–shaped outer canthal ligament in Fig. 60-3 which anchors his eyelids to his orbit. If you don’t divide this Y-shaped ligament when you need to, there will be too much pull medially on the lachrymal apparatus. Don’t divide the main stem of this ligament, or a severe deformity will result.

Before you can move an eyelid across, you will have to split it and undermine the shaded areas in Figs. 60-2 and 60-3. Hold the patient’s injured eyelid with forceps, and incise it in the lash line for 3 mm with a scalpel. Then split it by inserting scissors and spreading them. This will give you the right plane of dissection without injuring his tarsus or his orbicularis muscle. Moving his lower eyelid across will leave a fold of skin in his upper eyelid which you will have to excise and suture.

CAUTION! Don’t try to move the medial part of his lid, or you will interfere with the drainage of tears through his lachrymal apparatus.

If more than a third of a patient’s eyelid is lost, refer him. If you cannot refer him make a longer relaxation incision, as in F, and G, Fig. 60-2.

If a deep horizontal laceration of the patient’s upper lid divides his levator palpabrae muscle, or its attachment to his tarsal plate, try to suture it. This filmy muscle is hard to find in the bloody mess of an acute injury. If you fail to suture it, ptosis will follow.

If you cannot cover his cornea by any of these methods, do a tarsorrhaphy. The simplest way of doing this is to ’raw’ the edges of his lids, and suture them with fine silk, as in Fig. 58-23.

\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-60/fig/60-3.eps}
Figure 60.3: DIVIDING THE OUTER CANTHAL LIGAMENT. A, Make the incision several millimetres below the lash margin. B, find the lateral canthal tendon and divide it. C, undermine the skin flap and repair the defect. After Peyman, Sanders, and Goldberg.

If there is not enough of his eyelids left to do a tarsorrhaphy, grasp his conjunctiva at the upper fornix, with forceps, pass a suture through it, bring it down, and pass it through a similar fold from his lower fornix, in the same vertical line. Use several interrupted sutures to bring a double thickness of conjunctiva across his globe, as in I, Fig. 60-2.

If he presents late when his lid is greatly swollen, toilet his wound, excise the minimum amount of tissue, give him antibiotics, and repair his lid when the swelling has subsided.

INJURIES OF THE CANALICULI

If his upper canaliculus is injured, ignore it. It only drains 10% of his tears.

If his lower lid has been lacerated medial to the punctum, search for the divided cut ends of his inferior canaliculus. It needs microsurgical repair by an expert, so refer him.

If you cannot refer him, take a fine polyethylene or silastic catheter or a monofilament suture, pass this through the punctum, out through the wound and across his divided canaliculus and into his lachrymal sac just below the attachment of his medial canthal ligament to his nasal bones. Suture the wound and leave the monofilament suture in place for a week.

CAUTION! If you don’t repair his lower canaliculus, his tears will flow continually.

INJURIES OF THE CONJUNCTIVA

Most conjunctival lacerations will heal without suturing.

If a laceration is extensive, expose the patient’s eye with lid sutures (23-2). Dissect his conjunctiva away from his globe and search it for a perforating wound. If you find one, go to the next Section. Gently probe the wound and extend it if necessary. Suture his conjunctiva with continuous sutures of 5/0 silk or plain catgut. Silk sutures are more comfortable, but you will have to remove them later. Catgut will be absorbed.

\includegraphics[width=\linewidth ]{/home/kumasi/Desktop/primsurg-tex/vol-2/ch-60/fig/60-4.eps}
Figure 60.4: SUTURING THE CONJUNCTIVA. Don’t suture small lacerations. A, preserve the caruncle and the plica if you can. B, a correctly placed suture. C, if the conjunctiva is folded over like this, an inclusion cyst may develop. D, this suture will allow Tenon’s capsule to herniate into the wound. After Peyman, with kind permission.

CAUTION! (1) Sometimes a major injury is hidden under a small conjunctival wound, so probe it carefully. (2) Don’t probe around inside a patient’s eye. Only probe to see if his sclera has been perforated.

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