This video demonstrates surgical repair of eyelid and canalicular laceration in a child after probably hitting his head on the edge of a table while in day care.
Surgeon: Dr. Harsha Reddy, New York Eye and Ear Infirmary of Mount Sinai
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Dr. Harsha Reddy: In this case, a 1 1/2-year-old boy presented to the New York Eye and Ear Infirmary emergency room after fall at daycare earlier this day. The fall was not directly witnessed, but there was suspicion that he hit his head on the edge of a table. There was no loss of consciousness, and his behavior was normal, as expected, afterwards. He had an unremarkable medical history and his intraocular exam was normal.
His external exam is as shown. There is an approximately 6-millimeter full thickness eyelid laceration in the medial canthal area and displacement of the skin from the medial campus. The skin is slightly retracted away from the edematous orbicularis muscle underneath.
Upon closer exam, we saw that the laceration was medial to the punctum, shown here at the end of the blue line, and in fact it was quite close to the punctum, suggesting the proximal end may be found relatively anteriorly.
A vertical full thickness lid laceration is need. The laceration is medial to the punctum, and there is a high suspicion for canalicular damage. The action of the orbicularis has pulled the cut skin edge laterally, giving the appearance of missing tissue. In addition the disrupt of the orbicularis attachments to the medial tendon has resulted in an tear your displacement of the eyelid.
Afrin-soaked cottonoid sponges are packed beneath the inferior turbinate using a nasal speculum and a bayonet forceps. Using cotton tip applicators and a Weck-Cel sponge, the wound is spread apart as gently as possible to identify the cut end of the canaliculus. Here the lumen is seen surrounded by a ring of mucosal tissue. We recommend avoiding local anesthetic injection, as swelling of the tissue can further distort the anatomy and complicate identification of the severed end.
In this case, there are carpet fibers adherent to the wound. And these are removed. Along with the layer of fibrin that lines the cut edge. Irrigation is performed with the BSS solution. A punctal dilater is used to gently expand the punctal opening. The larger opening will facilitate placement of the olive tip of the Crawford tube at the next step.
Here we see the punctum is expanded. A Bowman probe or dilater now readily identifies the distal cut end of the canaliculus. The inferior punctum is also dilated. A double lobe or single lobe Bowman probe is now passed through the unaffected canaliculus in a standard fashion. Laterally until a hard stop.
And then inferiorly through the nasal lacrimal duct. Marks are made on the skin along the path of the probe. The Crawford tube with olive tip probe is passed through the unaffected canaliculus first. Following the skin marking minimizes the risk of creating a false passage. Note that the tube is thinner and more pliable than the Bowman probes.
A freer elevator is directed towards the inferior meatus which is located below the inferior turbinate along the lateral side wall of the nose. A metal-on-metal contact with the Crawford tube confirms the correct placement. The Crawford retrieval hook is then used to secure the bulb of the olive tip and externalize the tube.
The Crawford tube is then passed carefully through the cut canaliculus through its distal segment. And is then retrieved from the inferior meatus. As shown here, turning the hook away from the nasal side wall until the Crawford tube is detected. And then rotating the hook 180 degrees to engage the bulb minimizes damage to the mucosa and facilitates tube removal.
Given the close relationship of the lacrimal excretory apparatus to the medial canthal tendon, we see how tension along the stent re-approximates the deep anatomy of the medial canthus.
Meticulous suturing of the pericanalicular tissue is essential. Ideally, three points of fixation are achieved. Here, seven micro-sutures are used. The first suture is placed just anterior to the severed end. The second is placed superior to, and at the level of, the cut end. And the third is placed inferior to the cut end near the eyelid margin.
Next, the eyelid margin is closed with eversion of the wound edges. The orbicularis is next closed using interrupted varied 7-0 micro-sutures.
The skin edges are closed with interrupted submucosal fast plane and gut suture. Permanent suture can be used, but in this pediatric patient, we chose absorbable sutures that would not need removal in the office setting. To prevent lagophthalmos, care is taken to suture in a manner that avoids vertical tension on the eyelid.
Here, a series of interrupted horizontal sutures are tied. Using a fine, curved hemostat, the stent is clamped under gentle traction. Three single surgeon knots are tied and the stent is trimmed, leaving 3-millimeter tails. Releasing the clamp allows retraction of the stent into the nasal cavity.
Here, the exposed segment of the tube between the canaliculi is under the appropriate amount of tension and normal eyelid anatomy has been restored.
The pre, intra, and post-operative photographs are shown. The patient had no tearing symptoms and normal dye disappearance test. At three months after surgery, there was no significant scar. There was good restoration of the 3-D contour of the eyelid and good symmetry between the eyelids.
Traumatic eyelid and canna lick laryngectomi lacerations can be challenging to manage. However, in the vast majority of cases, a detailed understanding of the relevant anatomy and a systemic surgical approach will enable successful repair with excellent functional and cosmetic outcomes. Thank you for your attention.
January 31, 2018