1. Key Points

1. Eyelid injuries may be associated with ocular, orbital, and even intracranial injuries hence always rule out associated systemic trauma, occult globe injuries, or traumatic optic neuropathy. Globe involvement has been reported to be around 61% with eyelid injuries. Management of intra-ocular or systemic injuries takes precedence.
2. The presence of orbital fat in the wound indicates the orbital septum has been breached and the repair requires a higher level of expertise to prevent postoperative complications.
3. Laceration in the medial aspect of the eyelids is likely to involve the canalicular system. It is a myth that upper canalicular tears can be left unrepaired. In case the primary surgeon lacks knowledge or expertise in these structures, a prompt referral to an experienced oculoplastic surgeon would prevent any significant and long-lasting cosmetic was well as functional complications.
4. Since the tissues retract along the fibers of orbicularis oculi, the eyelid defect may appear much more extensive and dramatic than it usually is.
5. The eyelid tissues are extremely vascular and rarely undergoes necrosis unless infected. Hence refrain from excision of any eyelid tissue.

2.Documentation:

An exact, detailed, well-documented history in the medical records is a must in all patients presenting with a history of trauma. Photographic documentation at the time of initial consultation, and at every future visit to record progress, is mandatory.

3. Goals or repair:

1. To re-establish anatomical configuration.
2. To restore physiological function.
3. To provide optimum cosmetic appearance.

4.Timing of Repair

1. Isolated eyelid injuries are not an ophthalmic emergency. Thorough cleaning and inspection of the wound with the removal of all superficial foreign particles is essential before treatment planning. Usually, antibiotic ointment and a patch will stabilize the eyelid and protect the cornea until definitive management can be undertaken.
2. The repair may even be delayed for several days (ideally not more than 48 hours) in case of excessive eyelid edema, infection, intoxicated or uncooperative patients.

5.General measures:

1. Tetanus prophylaxis is recommended.
2. Eyelid lacerations may be due to an animal bite, especially in children. Anti-rabies prophylaxis should be considered if the vaccination status of the animal is unknown.
3. Associated telecanthus signifies avulsion of the posterior limb of the medial canthal tendon, which can happen in isolation, or along with a nasal-orbito-ethmoidal (NOE) fracture, in which case the patient may also present with a history of epistaxis. Imaging (CT scan) is indicated if there is any suspicion of associated orbital fractures.
4. If the wound is infected, pus should be collected and sent for culture and sensitivity. A broad-spectrum antibiotic like amoxicillin+ clavulanate is prescribed till the results become available (usually in 48 hours) and the antibiotic is modified accordingly.

6. Non-surgical management:

Non-marginal superficial eyelid lacerations parallel to the relaxed skin tension lines (RSTL) can be aligned with tissue glue (fibrin or cyanoacrylate/Dermabond^©) or even adhesive sterile tape (steristrips). This method is especially useful in young children.

7. Anesthesia:

Local anesthesia with 2% lignocaine with 1:100,000 adrenaline 15 minutes before surgery can be used to achieve hemostasis. General anesthesia is preferred in children, uncooperative patients and complex eyelid injuries.

8. Surgical technique:

The eyelid is divided into an anterior lamella consisting of skin and orbicularis; and a posterior lamella consisting of tarsus and conjunctiva. The eyelid margin has a few consistent anatomic landmarks which help us to achieve normalcy. These are the eyelash line, the grey line and the meibomian gland orifices. Full-thickness margin repairs are initiated by placing a suture through the tarsus in line with the meibomian orifices, with 6-0 nylon, with the suture ends left long. The lid margin defect is slightly everted at the time of repair, to prevent notching. The closure should be done with minimal tension. Horizontal mattress suture is used for margin apposition when there is tension in the opposing cut ends. Next, two to three interrupted 6-0 polyglactin sutures are placed partial-thickness in the tarsus with the knots facing the skin surface. The conjunctiva usually never requires suturing. Simple interrupted sutures with 6-0 nylon or silk are placed at the lash line and the anterior wound edge. The sutures ends are kept long to avoid corneal contact. The overlying skin are then closed with 6-0 nylon, silk or prolene interrupted sutures. The tails of the eyelid margin sutures which have been left long are buried under the skin sutures to keep them away from the corneal surface. Closure is done in layers obliterating dead space. Proper alignment and orientation of the eyelashes is important to prevent trichiasis. In children, to avoid the risk of further general anesthsia, 6-0/ 7-0 absorbable catgut or polygalactin sutures can be used to close skin as well. The septum should never be sutured as it would lead to lagophthalmos.

9. Postoperative instructions:

Antibiotic ointments, lubricating eye drops, and NSAIDs are prescribed. The wound should be kept clean and moist.

10. Follow-up:

Permanent sutures are generally removed at five days, except eyelid margin sutures, which are removed at seven to ten days. A comprehensive ocular examination is mandatory at each visit, especially in children. Patients should be counseled that complete wound healing and scar formation requires 6-12 months, and further intervention may be required in the future. Postoperative traumatic ptosis usually recovers completely by six months.