Facial trauma often involves injuries to the eyelid and periorbital region. Management of these injuries can be challenging due to the involvement of multiple complex anatomic structures that are in close proximity. Restoration of normal anatomic relationships of the eyelids and periocular structures is essential for optimum functional and aesthetic outcome after trauma. This review provides an overview of the current literature involving soft tissue trauma of the eyelid and periorbital tissue, and highlights key steps in patient evaluation and management with various types of injuries.
Key points
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In periocular soft tissue injuries, the globe must be assessed for the possibility of rupture and conditions that are contraindications to periocular manipulation.
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Lacerations of the canaliculus must be repaired and stented to prevent tearing after injury.
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Lacerations of the eyelid margin must be repaired in a multilayered fashion to prevent eyelid malpositions and cosmetic defects after injury.
Introduction
Soft tissue trauma to the face is a common injury and comprises roughly 10% of all emergency room visits. Because of the potential for posttraumatic functional and cosmetic sequelae, reconstructive expertise is required in the repair of any facial soft tissue injury, especially to the eyelids and periorbital soft tissues. Injuries to the periocular region are often complex and involve multiple anatomic structures. Soft tissue repair with optimal aesthetic and functional outcome can be achieved through meticulous planning and knowledge of facial reconstructive techniques. This article highlights key steps in patient evaluation and management of various types of injuries, and provides a review of current literature involving facial soft tissue trauma.
Patient assessment
After stabilization of the patient, a detailed history of the mechanism of trauma and patient presentation is obtained. A full survey of the face and scalp is then performed, paying attention to signs of surface or penetrating wounds, foreign bodies, and avulsed or missing tissue. Often these wounds are difficult to visualize due to obscuration by debris and dried or coagulated blood, especially in areas that contain hair, such as the scalp and eyebrows. If present, cleaning the affected areas is indicated by irrigation with sterile saline and gentle debridement with gauze. If there is a marked amount of swelling, visualization can be aided by first applying ice to the affected area. If necessary, patient tolerance of the examination can also be helped by injection of lidocaine or moderate sedation in the emergency room. Photographs of the patient with multiple angles should be obtained for medical-legal documentation.
Ocular Assessment
A ruptured ocular globe is one of the few ophthalmic emergencies that warrant immediate surgery. Signs of a ruptured globe include decreased vision, focal bullous or 360° subconjunctival hemorrhage, an irregularly shaped pupil, ocular hypotony, and the presence of blood in the anterior chamber. If any of these signs are noted on the initial examination, prompt ocular protection by an eye shield and evaluation by an ophthalmologist is indicated. Further periocular manipulation, such as examination of the eyelids or surrounding periorbital tissues, should be avoided or conducted with extreme caution to avoid pressure on the ocular globe that may lead to extrusion of intraocular contents.
In cases of significant injury to periorbital soft tissue and bony structures, the potential for concurrent eye damage should be assessed. A ruptured globe is an absolute contraindication to periocular and periorbital manipulation ( Fig. 1 ). Additional ocular conditions that place the globe at high risk during periocular and periorbital manipulation, and possible future permanent decrease or complete loss of vision, include the following: hyphema, dislocated intraocular lens, intraocular foreign body, and retinal detachment. If any of these additional conditions exist, consultation should be obtained from the ophthalmology service to determine optimum time for surgical repair of other facial injuries.
Eyelid Assessment
In the initial assessment of the eyelids, any abrasions, ecchymosis, and lacerations should be noted. The presence of a traumatic ptosis can be assessed by looking for motility deficits while having the patient follow an object in upgaze and downgaze. Oftentimes swelling will limit the motility of the eyelid, and the eyelid motility will need to be reexamined at a future date.
Eyelid lacerations are categorized as partial or full-thickness lacerations. For reconstructive purposes, the eyelid is divided into anterior (skin and orbicularis muscle) and posterior (tarsus and conjunctiva) lamellae ( Fig. 2 ). A full-thickness laceration involves the posterior lamella, and requires a more complex and layered closure. Involvement of the posterior lamella can be detected by examining the upper and lower eyelid margins for discontinuity or a notch. Some lid margin defects are difficult to appreciate on gross examination of the lid. Oftentimes an insignificant-appearing marginal discontinuity will have significant posterior extension; therefore, gentle eversion of the upper and lower eyelids is needed to assess for involvement of the tarsus. If not properly repaired at the time of injury, a large notch will be noted in the eyelid margin with separation of the eyelashes medially and laterally after it heals. This may subsequently affect blinking and the ocular surface interface. Failure to detect a marginal eyelid laceration may also result in a very noticeable aesthetic deformity that is bothersome and noticeable by patients.
The evaluation of eyelid lacerations also involves an assessment for avulsed or missing tissue. A full-thickness lid laceration frequently gives the appearance of missing tissue due to the wide gaping of the separated segments of the eyelid ( Fig. 3 ). The eyelid is usually firmly opposed to the globe by the lateral canthal ligament laterally and medial canthal ligament medially; when split, the separated portions of the eyelid are widely pulled medially and laterally, mistakenly giving the appearance of missing tissue. If the eyelid tissues oppose easily with gentle reapproximation, tissue avulsion is unlikely. If marked edema of the tissues hampers this determination, gentle application of ice for 20 minutes to decrease swelling is helpful.
Involvement of the lateral or medial canthal ligaments can occur with orbital fractures or downward distraction of the eyelid. Disinsertion of the lateral canthal ligament may manifest as rounding of the lateral canthal angle. Due to its insertion at the Whitnall tubercle, rounding of the lateral canthal angle may also be seen in fracture of the lateral orbital wall. In contrast, the medial canthal ligament has 2 attachments: anteriorly to the frontal process of the maxilla, and posteriorly to the thin lacrimal bone. Telecanthus and canthal rounding also can be seen with medial canthal ligament injuries. However, further investigation through imaging is needed to assess for bony involvement ( Table 1 ), as reconstructive techniques vary depending on whether the ligament is solely involved, or if there is bony involvement as well.
| Type | Description | Treatment |
|---|---|---|
| I | Single-segment central fragment | Fixation of fragment to proper positioning |
| II | Comminuted central fragment with fractures remaining external to the medial canthal tendon insertion | Fixation of the fragment with adherence of the canthal ligament |
| III | Comminuted central fragment with fractures extending into bone bearing the canthal insertion | Fixation of the canthal ligament to fixed bone or periosteum |
Lacrimal Assessment
Medial eyelid injuries may involve the medial canthus and violate of the integrity of the lacrimal system. Common mechanisms of injury differ in various patient populations; in the breast-fed infant, pediatric, adult, and elderly populations, the most common mechanisms are blouse hooks, dog bite, trauma, and falls, respectively. Medial canthal lacerations are more commonly seen in children and young adults and more frequently involve the lower canaliculus. Interestingly, upper canalicular injuries are associated with globe rupture in 20% to 25% of cases. Therefore, if a canalicular injury is present, the index of suspicion for an injury to the globe should be heightened.
A thorough examination of the upper lacrimal drainage system is indicated with any injury involving the medial canthal region or medial upper and lower eyelid. Any disruption of the tear drainage system that is not repaired initially may result in chronic epiphora. Superficially, the upper and lower puncta are visible as pinpoint openings along the medial eyelid (see Fig. 2 ), and run vertically for approximately 2 mm in length. The superior and inferior lacrimal drainage system then make a 90° turn medially for approximately 8 mm, and then join to form the common canaliculus, which then connects to the nasolacrimal duct that drains through the inferior meatus into the nose. Therefore, any laceration that occurs medial to the punctum requires probing ( Fig. 4 ) and irrigation to assess for the integrity of the tear drainage system. A more subtle finding may show lateralization of the punctum, which usually also suggests disruption.
Orbital Assessment
Orbital involvement can occur with deep extension of superficial wounds. The orbital septum is a fibrous sheet that serves as the anterior orbital boundary. Deep to the septum lies the true orbital fat, which overlays the 2 elevators of the upper eyelid, the levator aponeurosis and Müller muscle. Visible fat in the preseptal orbicularis area warrants further exploration, as it signifies violation into the orbital space and possible deeper injury to the orbital soft tissues and/or to the eyelid elevators. If there is suspicion for a retained foreign body, imaging can be obtained. Plain radiography and computed tomography (CT) scans are the recommended first line of imaging for most foreign body materials; MRI should be avoided due to risk of metallic foreign body.
The integrity of the bony walls of the orbit and orbital soft tissue contents also may be affected. A detailed discussion of the evaluation and management of orbital fractures can be found in the article by (Scott E. Bevans and Kris. S. Moe’s article, “ Advances in the Reconstruction of Orbital Fractures ”). With regard to the periocular examination in orbital fractures, the examiner can assess for the presence of bony step-offs and subcutaneous crepitus through palpation along the orbital rim. Hypesthesia in the maxillary (V2) division of the trigeminal nerve can occur secondary to bony impingement in orbital floor fractures, direct trauma, compression by soft tissue swelling, or irritation by localized inflammation. An assessment of the patient’s vision is also required to detect optic neuropathy, which can occur in fractures of the optic canal. Last, extraocular muscle entrapment or impingement by bony fragments can be detected by observing ocular motility in upgaze, downgaze, and right and left gaze. Entrapment of extraocular muscles occurs most commonly in the pediatric population, but also can occur in the adult population. Upgaze limitation associated with inferior rectus impingement in orbital floor fractures is the most common, followed by lateral gaze restriction associated with medial rectus entrapment in medial wall fractures. Enophthalmos or muscle contusion can masquerade as muscle entrapment, and can be differentiated from true entrapment through forced ductions testing. The presence of an ocular cardiac reflex, bradycardia secondary to increased vagal tone due to tension on an extraocular muscle, is an indication for emergent release of tissue and fracture repair.
Orbital hemorrhages in the orbital space may occur independently or in association with orbital fractures. Although small hemorrhages can be observed, accumulation of a large amount of blood in the retrobulbar space may lead to orbital compartment syndrome and permanently decreased or complete loss of vision through mechanical stretching of the optic nerve or blockage of ocular perfusion ( Fig. 5 ). Proptosis secondary to posterior volume expansion by a retrobulbar hemorrhage can best be appreciated with a worm’s eye view. To assess for possible optic nerve compromise, the examiner may check the visual acuity and color vision if the patient is alert and oriented. The presence of a relative afferent pupillary defect is also an objective indicator of optic nerve compression and can be assessed in nonresponsive patients. It is important to differentiate a retrobulbar hemorrhage from a preseptal hematoma, as both can present as nonspecific swelling of the eye externally. However, a preseptal hematoma is not typically vision threatening, as it is anterior to the orbital septum and thus does not cause a compartment syndrome resulting in optic nerve compression ( Fig. 6 ).
