Lid & Canalicular Lacerations Mounir Bashour, M.D. A Case Report In A Six Year Old Boy

Introduction A short presentation to stimulate a discussion on a practical approach to complex lid/canalicular lacerations. By Mounir Bashour, PGY-3, Ophthalmology, George Washington University, graduate of McGill Medical School.

Case Presentation/HPI 6 yo bm presents with complex lid laceration OS. Secondary to falling from upper bunk bed while playing around 2 AM 7/20/95. Hx of Prematurity (28 weeks) was in NICU for 3 months, no Hx of ROP. Currently good health, no meds, allergies Single parent (father) family.

Examination >4 cm full thickness medial oblique upper lid laceration OS extending into medial canthus. PERRLA, no RAPD. Va 20/30 OU by Snellen. Rotations full, ortho. No corneal abrasion, Seidel negative. Dilated exam reveals picture consistent with resolved early ROP.

Photo of Upper Lid Laceration Photo with similar laceration as found in our patient.

Diagnosis Suspicion Common etiologies Epidemiology

Necessity of Repair Controversy Jones study Moore and Linberg study

Timing of Repair Immediate vs late

Discussion I The aim of lid repair Workup

Discussion II Blunt injuries

Discussion III Lacerations involving the canthal angles

Intraoperative Complications Inabilty to Locate the Medial End of the Canaliculus Difficulty Retrieving Probe from Nose Problems Suturing the Canalicular Walls Difficulty Repairing Medial Canthal Ligament Injury

Proximal Canaliculus The characteristic appearance of the proximal canaliculus

Normal Anatomy of the Lacrimal System Essential knowledge

Intubation Gavaris Modification of the Quickert- Dryden procedure

Anastamosis of the Canaliculus Problems with suturing

Medial Canthal Ligament Injury Correct Placement of MC Fixation Suture (A) Posterior reflection of MCT behind the lacrimal sac (B,C) Correct fixation point

Intubated Nasolacrimal System Double-knotted Silastic Tubing

Complications With Silicone Tubes Tube displacement Punctal/canalicular erosion/slitting Conjunctival/corneal irritation Granuloma formation Epistaxis

Displaced Tubing Most common complication

Securing the Tubing One method of several

Erosion Six knots with 4-0 nylon woven into knots Secured to lateral vestibule of nose

Granuloma Granuloma formation from silicone tubing Displaced silicone tubing after patient had caught tubing with finger and pulled loop onto cheek

Rarer Complications Dacryocystitis Epiphora Ectropion Loss of tubing Difficulty removing tubing