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

2. 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.

3. 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.

4. 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.

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

6. Diagnosis Suspicion Common etiologies Epidemiology

7. Necessity of Repair Controversy Jones study Moore and Linberg study

8. Timing of Repair Immediate vs late

9. Discussion I The aim of lid repair Workup

10. Discussion II Blunt injuries

11. Discussion III Lacerations involving the canthal angles

12. 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

13. Proximal Canaliculus The characteristic appearance of the proximal canaliculus

14. Normal Anatomy of the Lacrimal System Essential knowledge

15. Intubation Gavaris Modification of the Quickert- Dryden procedure

16. Anastamosis of the Canaliculus Problems with suturing

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

18. Intubated Nasolacrimal System Double-knotted Silastic Tubing

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

20. Displaced Tubing Most common complication

21. Securing the Tubing One method of several

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

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

24. Rarer Complications Dacryocystitis Epiphora Ectropion Loss of tubing Difficulty removing tubing