The eyelid, when injured, may lacerate or tear
The beginning of the tear duct called the canaliculus is in the eyelid, therefore if the eyelid is torn it may also tear the duct.
What are the benefits of surgery?
Surgery is carried out to suture the eyelid back together. This ensures that a notch or defect does not form in the eyelid. It also makes sure that the eyelashes remain in a line. If the laceration involves the canaliculus (tear duct) this can be repaired.
The lower eyelid was lacerated in an accident. The tear duct was damaged. The eyelid has been repaired with very little scarring. The lacrimal stent used to aid repair of the tear duct can be seen. This is removed after 3 months
What is eyelid and tear-duct trauma surgery?
The two cut ends of the eyelid are stitched back together. The deep sutures used are dissolvable. The skin sutures have to be removed a week later. To repair the tear duct a stent is placed inside it, running from the eyelid through the Canaliculus and down into the tear duct. The stent is only 1 millimeter thick and made of very fine rubber. The only part of the stent that you will be able to see is a few millimeters of it running from the upper lid canaliculus down into the lower lid canaliculus or a small flat silicone end that lies flush on the surface of the eyelid. The stent may be left in for up to 6 months and is removed simply in clinic. The operation should take approximately 45 minutes to complete and is usually carried out as a day case. The operation may be carried out under local anaesthetic, with or without sedation, or general anaesthetic depending on the extent of the injuries. After anaesthetic drops have been put in both eyes, an injection of local anaesthetic is given just beneath the skin of the upper eyelid. This is similar to dental anaesthesia and usually takes less than 30 seconds to give. Local anaesthetic with sedation involves an anaesthetist administering intravenous sedation via a drip so that you are very relaxed and may not remember having the operation. General anaesthetic means that you are completely asleep.
Top - a lower eyelid laceration with damage to the lower part of the tear duct; Bottom - the eyelid and tear duct have been repaired
Are there alternatives to surgery?
It is not possible to correct the problem without surgery. Without surgery the eyelid may not align properly leaving the eyelashes out of line or rubbing on the eye. A notch may form in the eyelid. If the tear duct is not repaired you may develop a watery eye.
What is an orbital fracture?
The orbit is the bony eye socket that contains the eyeball, eye muscles and lacrimal gland. There are also nerves, arteries, veins and orbital fat. An orbital fracture may occur after blunt trauma to the eye, eyelids or area around the eyelids. Any of the 4 walls of the orbit may fracture but commonly it is the floor and medial(nasal) wall that are fractured. The mechanism of fracture is displacement of the eyeball back into the socket, which causes a rapid rise in orbital pressure causing the thin orbital bones to out-fracture or “blow out”. For this reason these fractures are also known as “blow out fractures”. Orbital tissue, particularly eye muscle and fat may become trapped in between the fractured bone edges causing limitation of eye movement and double vision. If a fracture is large, orbital tissue may sink into it, dragging the whole eye with it. This may cause the eye to move back into the socket creating a sunken appearance (enophthalmos).
What are the symptoms and signs of an orbital fracture?
The white of the eye is usually red due to dilated blood vessels. The exception to this is in children where the bone is immature and may “green stick” fracture. This white eye blow out fracture with limitation of eye movement and sometimes pain and nausea on eye movement is an emergency.
Double vision, meaning seeing two images instead of one.
Pain, which may be worse on eye movements, particularly in the direction of double vision.
The eyeball may protrude from the eye socket (proptosis) if there has been bleeding in the eye socket.
The eyeball may sink back into the socket (enophthalmos) if the fracture is large.
Vision may deteriorate due to haemorrhage pressing on the nerve of vision. This is an emergency and requires urgent treatment.
The upper cheek, side of nose and upper teeth on the side of the fracture may be numb. This is because a sensory nerve runs inside the bone in the floor of the orbit and may be damaged by the fracture.
How is an orbital fracture treated?
You must not blow your nose for 6 weeks as this may force air under the skin and lead to infection. You should take oral antibiotics for 1 week. Your eye movements will be assessed by an orthoptist in the eye department. Not all fractures require surgery. Many will not cause long term problems if left to heal. Indications for surgery include: double vision looking straight ahead; a significant amount of enophthalmos (sunken eye); a very large fracture without symptoms but which, in the opinion of an experienced surgeon, is very likely to cause symptoms in the future. The incision used depends on the site of the fracture. Fractures in the lower orbit may be approached from the inside of the lower eyelid, sometimes with a small 7-10mm skin incision at the outer corner of the eyelids. Fractures of the medial (nasal) wall of the orbit may be approached from behind the lower eyelid or by a small incision between the eyelids in the corner of the eye near to the nose. The fracture is repaired by removing the tissue that is trapped in it and then covering the fracture with a plate of man made material called MEDPOR or PDS. The implant may simply sit over the fracture or if the fracture is large, it may be fixed to the rim of the orbit with screws. The procedure will require an overnight stay. This operation is carried out under general anaesthetic, which means you are completely asleep with a breathing tube inserted.
What are the risks and possible complications of eyelid and orbital surgery?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in this operation. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics.
Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on the area is usually enough to control minor bleeding.
A haematoma collecting in the orbit, behind the eye, may compress the nerve of vision and threaten eyesight. It is extremely rare for this to occur. It presents as pain, loss of vision and a bulging forwards of the eyeball. It is an emergency and as such is initially treated in an accident and emergency department where Mr. McCormick or an on call Ophthalmologist will attend to you.
Any orbital surgery carries a very small risk of permanent loss of vision. This could be due to damage to the nerve of vision during the procedure or bleeding after the operation.
Any orbital surgery carries with it a risk of double vision. In most cases, if this occurs, it is temporary but rarely it is permanent. Permanent double vision may be corrected with surgery or prisms in spectacles.
Whenever the skin is incised a scar may form. Every attempt is made by Mr. McCormick to minimise and hide scars but sometimes they can be visible.
You will have the opportunity to discuss the risks and benefits of surgery and anaesthesia with Mr McCormick and the anaesthetist prior to surgery.
What will happen before surgery?
Before the operation you will be seen in the clinic by Mr. McCormick. He will ask you about the eyelid problem. He will also ask about other medical problems you have, medications you take and any allergies (bring a list or the tablets themselves with you). He will examine your eyes. If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia. You will be asked to read and sign a consent form after having the opportunity to ask any questions. If you are to have a general anaesthetic or local anaesthetic with sedation you will also see a preoperative assessment nurse. She/He will carry out blood tests and an ECG (heart tracing) if required. She/He will also advise you if you need to starve before the operation. If simple local anaesthesia is used you will not need any of these investigations and you will not need to starve prior to surgery.
What should I do about my medication?
Mr. McCormick will want to know all the medication that you take and about any allergies you have. In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin), rivaroxaban, dabigatran, apixaban, ticagrelor, dalteparin. This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.
What should I expect after surgery?
Usually a pad will be placed on the eye, which will remain until the following day when you can remove it. For 10 days the wound should be cleaned using boiled water that has cooled down and sterile cotton wool balls.
After the pad is removed, antibiotic ointment should be applied to the skin wound and the eye three times a day for 2 weeks.
It is normal for there to be swelling of the eyelid following surgery. This gets worse over the first 48 hours then starts to improve. It may take up to 6 weeks to resolve.
The skin sutures used will be removed at 7-10 days in clinic.
The time when you can return to normal activities varies from person to person. Many are happy to do so after 2 – 3 days and the vast majority after a week.
If an eye pad is placed it should remain until the next morning when you may remove it.
For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls.
Chloramphenicol ointment to the eye and wound, three times a day for 2 weeks.
If you have had orbital surgery, do not blow your nose for 6 weeks.
Follow up appointment 1 week later.