How to Repair Eyelid Lacerations - Home | AAEP...How to Repair Eyelid Lacerations Diane V.H. Hendrix, DVM, Diplomate ACVO Author’s address: Department of Small Animal Clinical Sciences,

How to Repair Eyelid Lacerations

Diane V.H. Hendrix, DVM, Diplomate ACVO

Author’s address: Department of Small Animal Clinical Sciences, College of Veterinary Medicine,University of Tennessee, Knoxville, TN 37996-4544; e-mail: [email protected]. © 2013 AAEP.

1. Introduction

Eyelid lacerations are common in horses and shouldbe regarded as surgical emergencies to prevent un-desirable tissue devitalization, infection, scarring,corneal desiccation, and corneal ulceration. Lacer-ations usually can be repaired in the standing, heav-ily sedated horse. General anesthesia may berequired when there is extensive trauma or with anunruly horse. Even when horses are not evaluatedimmediately after the trauma and infection mayhave begun, repair should always be attempted im-mediately and with minimal debridement to preventfurther tissue damage. Although a complete oph-thalmic examination should be performed in allhorses with eyelid lacerations, ocular examinationusually reveals a normal globe; however, it is notunusual to have two lacerations, with one beingmuch smaller than the other. Lacerations usuallyare caused by nails and hooks protruding fromboards in the barn or stall, from fence wire or treebranches, or from sharp metal protuberances intrailers. Unfortunately, even with extensive studyof the horse’s surroundings, the cause of the lacera-tion is rarely determined.

An understanding of eyelid anatomy and physiol-ogy is imperative for proper surgical repair becauseof the importance of perfect alignment of the eye-lid margin and the close proximity of sutures tothe cornea. A normal eyelid margin is crucial for

globe health. The eyelid margin prevents hair fromcontacting the cornea and allows the lids to haveperfect contact with the corneal surface. This nor-mal eyelid contact during blinking removes precor-neal debris and spreads the tear film over the corneato prevent desiccation. Under normal conditions,there are no hairs or cilia on the eyelid margin.Meibomian gland openings form a row of tiny spotsalong the lid margins. These glandular openingsserve as an important landmark for the figure-eightsuture.1 The haired eyelid skin is very thin, withno redundancy. The palpebral conjunctiva linesthe bulbar side of the eyelid and is also very thin,approximately 10 cell layers thick. The tissue be-tween the skin and the palpebral conjunctiva fromsuperficial to deep contains the orbicularis oculimuscle, the stroma (which contains the levator pal-pebral superioris muscle in the upper lid), and thin,fibrous tissue referred to as the tarsus. For thepurpose of this report the layers of the eyelid will bereferred to as the skin, stroma, and conjunctiva.Whereas the muscles that open and close the eyelidsare important physiologically, they are not easilyvisible when the eyelid is lacerated and do not re-quire special attention during the repair.

Knowledge of eyelid innervation is also importantfor laceration repair. A branch of the facial nerve(auriculopalpebral nerve) controls the orbicularis oc-uli muscle, which closes the eyelids. This nerve

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HOW-TO SESSION: OPHTHALMOLOGY

NOTES

must be blocked to assist in ocular examination andeyelid repair. Local anesthesia of the auriculopal-pebral branch of the facial nerve only suppressesmotor function to the eyelids and does not blocksensation. Sensation to the eyelids and cornealsurface is provided by branches of the trigeminalnerve, which must also be anesthetized to facilitatelaceration closure.

Eyelid laceration repair is relatively easy aslong as several key points are followed. The pur-pose of this report is to provide step-by-step instruc-tions on eyelid laceration repair that will leave thehorse with anatomically and physiologically normaleyelids.

2. Materials and Methods

Initial Ocular Examination

The first part of the examination, including externalexamination and reflexes, should be performed be-fore sedation and nerve blocks are administered.An external examination of the head is necessaryfor any horse that has had trauma. Symmetry ofthe orbits and sinuses and globe position should beevaluated. Palpation of the orbital rim may revealfractures. Eyelid swelling is common with eyelidlacerations, but more diffuse severe swelling mayindicate blunt trauma in addition to the sharptrauma that caused the laceration.

The menace response and palpebral reflexes areevaluated next. The menace response involvesmaking a sudden hand motion near the eye beingtested and is confirmed with closure of the eyelid orshying of the head away from the motioning hand.It is usually obvious in adult horses, but foals maynot have a fully developed menace response until9 days of age. Some foals may have a partial re-sponse a day before showing a complete response, orthey may have an asymmetrical response initially.2

Sedation and Local Anesthesia

After the initial ocular exam and physical exam,sedation should be used to facilitate the remainderof the ocular examination. Sedation is imperativein almost all horses with a painful eye. Detomidine(10–20 �g/kg IV) is very effective because it pro-vides analgesia as well as sedation. Xylazine (0.5–0.75 mg/kg IV) is effective in horses that only re-quire sedation. If analgesia becomes necessary,butorphanol (0.01–0.02 mg/kg IV) can be adminis-tered in conjunction with the xylazine. These sed-atives generally act for the duration necessary to doa complete ophthalmic exam. Additional sedationprobably will be necessary if eyelid repair is per-formed after the examination.

The auriculopalpebral nerve block is generally theonly injectable local anesthesia needed to assist withthe ocular examination. Akinesia of the auriculo-palpebral nerve prevents active closure of the pal-pebral fissure, thus facilitating ocular examination.The nerve block is performed by injection of 1 to

2 mL of 2% lidocaine subcutaneously near thebranch of the auriculopalpebral nerve. The nervebranch is located by running the index finger overthe anterior aspect of the zygomatic arch. Thenerve can be strummed where it runs perpendicu-larly across the zygomatic process of the temporalbone. A 25-gauge needle is inserted superficial toand parallel to the nerve. The syringe is attached,and lidocaine is injected. Gently rubbing the areaafter removing the needle will facilitate diffusionof the lidocaine into the tissue. Avoid the arteryand vein that run with the nerve. If the block issuccessful, the lid movement and strength will beimpaired.

Complete Ocular ExaminationIn addition to sedation and the auriculopalpebralnerve block, a good light source, darkened examina-tion area, and magnification source are necessaryfor complete ophthalmic examination. A directophthalmoscope and Finoff transilluminator are ex-cellent rechargeable light sources. Bright pen-lights can also be used. The direct and consensualpupillary light reflexes are evaluated with the use ofthe strong focal light source. When a horse is seenfor an eyelid laceration, special attention is paid tothe eyelid margins, with evaluation for multiple lac-erations and the presence of foreign bodies (Fig. 1).If a foreign body is present, Graefe fixation forcepsor thumb forceps may be used to grasp the objectafter administration of topical anesthetic. The nor-mal conjunctiva is glistening, very thin, translucent,and pale pink. When the eyelid is lacerated, theconjunctiva often becomes chemotic, hyperemic, orhemorrhagic. The conjunctiva should also be eval-uated for foreign bodies or extensive trauma.

Fluorescein staining should be performed on all eyesthat have received an eyelid laceration. Whereaslarge ulcers are easily visualized with white light,small corneal ulcers are more easily visualized with

Fig. 1. Examination for eyelid laceration. Special attention is paidto eyelid margins, with evaluation for multiple lacerations andthe presence of foreign bodies.

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the use of magnification and a cobalt blue filter.Depth of any ulcers or corneal lacerations should bedetermined. If a full-thickness corneal lacerationis present, fibrin, blood, or iris usually comes fromthe wound. Some cases with evidence of severetrauma will also have orbital fractures.

Generally if the cornea does not have signs oftrauma, the anterior chamber, lens and posteriorsegment will be spared as well. However, at least abrief examination of the anterior chamber, iris, andlens should be performed with the use of a focal lightsource. The anterior chamber is evaluated foraqueous flare, blood, fibrin, and hypopyon. Occa-sionally, miosis will be present with no other ante-rior chamber signs; this is still indicative of milduveitis. With the great majority of eyelid lacera-tions, the eye itself is completely normal because theeyelids have successfully protected the globe andabsorbed the brunt of the trauma.

Preparation for Surgery

After sedation and akinesia of the auriculopalpebralnerve, the next step in preparing for laceration re-pair is the surgical preparation and analgesia of theeyelids and cornea by anesthetizing the trigeminalnerve. The affected area should be prepped withdilute betadine solution and saline. Betadine scruband alcohol should not be used because they are toxicto the corneal epithelium and can cause corneal ulcer-ation. After surgical preparation, the palpebralbranch of the trigeminal nerve is blocked.3,4 Theeasiest way to block the palpebral branch of thetrigeminal nerve is to perform a line block with 2%lidocaine and a 25-gauge needle in the skin justperipheral to the affected part of the eyelid. Thisensures that anesthesia of the lacerated portion ofthe eyelid that will be sutured. The bulbar con-junctiva and cornea should also be anesthetizedwith the use of 0.5% proparacaine hydrochlorideophthalmic solution to diminish responses if theglobe is accidently contacted with instruments orsutures during the repair. This is best applied byspraying the solution from a tuberculin syringe inwhich the tip of a 25-gauge needle has been brokenoff. Always keep this syringe at least 6 inches fromthe cornea because the broken needle tip is stillsharp.

In most cases, the eyelid is only lacerated, and notissue has been ripped away. Severe swelling andcongestion in the lacerated tissue can alter its ap-pearance and give the illusion that tissue is missing,but the lid should be closed as a simple appositionuntil one is sure that tissue is missing. Unfortu-nately, the horse has very little extra eyelid skin,which makes it difficult to perform blepharoplasticprocedures. Keeping this in mind, preparation ofthe surgical bed should be minimal. If there isquestion as to the viability of the lacerated tissue, itcan be scarified with a dry, sterile 4 � 4 gauze pad ora scalpel blade until bleeding is observed. Avoidexcising tissue that has any potential for viability.

Because the eyelid is so well vascularized, the tissuemay recannalate. The edges of the laceration areoften jagged. This should be pieced together withsuture rather than being excised to make a cleanedge. An eyelid pedicle created by a lacerationshould never be simply excised because exposurekeratitis and ulceration probably will occur. If thenasal canthus is involved, the nasolacrimal systemshould be evaluated for patency. If the nasolacri-mal system has been damaged, general anesthesiamay be required for the repair.

Special Surgical Considerations

The eyelids are extremely vascular, and hemorrhagefrom incisions may be profuse. However, cauteryshould never be used because excessive scarring canlead to conformational changes of the eyelid. Su-ture choices that would be considered contraindi-cated at other locations are routinely used for theeyelids because of the copious blood supply. Forexample, polyglactin 910a is the preferred suture foreyelid lacerations. Characteristics of polyglactin910 that make it favorable for eyelid margin appo-sition include excellent knot security and handlingand the fact that it becomes soft when wet. Addi-tionally, because they are absorbable, polyglactin910 sutures do not need to be removed; this is adesirable feature when removing very small suturesin the equine eyelid. Some texts mention buryingthe suture knots or suturing the conjunctiva. Al-though it is important to close gaping distances be-tween the lacerated conjunctival edges, one mustavoid closing the conjunctiva in a way that the su-ture might contact the cornea and cause ulceration.The conjunctiva heals very quickly, even when it isnot in perfect apposition.

Simple Two-Layer Closure

The instruments needed for eyelid laceration repairinclude Bishop-Harmon forceps or other fine-toothed forceps, Derf or Castroviejo needle holders,and Stevens tenotomy scissors. The preferred su-ture is 5–0 polyglactin 910 with a spatula or cuttingneedle. First, the stroma, which is the tissue be-tween the conjunctiva and skin that contains thetarsus and orbicularis oculi muscle, is apposed withsimple continuous or simple interrupted suturessuch that the deep aspect of the suture does notprotrude through the conjunctiva and contact thecornea. The knot of this suture must be orientedaway from the conjunctiva and toward the skin.This step can be skipped with very small lacerationsand may even hinder perfect apposition in thesesituations. Next, the eyelid margin is apposed witha figure-eight suture (Fig. 2A).1 Bites should besmall (approximately 2 mm), and bites on one side ofthe laceration should mirror those on the oppositeside. If the eyelid margin is not squarely apposed,the figure-eight suture should be redone. Suturetags are left long and pulled away from the eye byincorporating them into the simple interrupted su-



ture that is used to appose the skin distal to theeyelid margin (Fig. 2B). The tails of the figure-eight suture must be situated on top of one squareknot and below at least one additional square knot.If the lacerated margin affects the canthus, a hori-zontal mattress suture or simple interrupted suturemay be placed in the margin, still incorporating thetags into the first simple interrupted skin suture toavoid corneal contact by the knot. The remainderof the lacerated tissue is apposed with simple inter-rupted sutures. The pieces often must be “quilted”together because the edges may be jagged or narrow(Figs. 3 and 4). Excision of any skin should beavoided if possible.

Complicated LacerationsWhen a portion of a lid or an entire upper or lowerlid has been torn away, there are few options. Ifthe lower eyelid is affected rather than the uppereyelid, the cornea is more likely to remain healthy

because the upper eyelid more actively protects theeye. Even portions of the temporal or nasal uppereyelid can be absent and the cornea remainshealthy. After the laceration edge heals, removingskin hairs that contact the cornea may be beneficialif the horse is painful or has keratitis (Fig. 5). Cryo-therapy of offending hairs can be attempted but maynot be effective. Electrolysis may be necessary.Although it may be tempting to perform a modifiedHotz-Celsus procedure to remove a crescent of tissueto roll the haired skin away from the cornea, thisgenerally is not beneficial and allows for more cor-neal exposure. Blepharoplastic techniques such asH-plasty can be attempted, but contracture of thesurgery site tends to occur.

If the nasal canthus is involved in the laceration,the nasolacrimal duct may be damaged. In thesecases, general anesthesia probably will be necessaryto repair the nasolacrimal duct or to place a stent.4

Damage to the nictitating membrane can be re-paired with the use of a simple interrupted patternof 6–0 polyglactin 910, once again, taking care toavoid suture contact with the cornea.

Fig. 2. A, Placement of the figure-eight suture pattern. Theneedle enters the skin just behind the eyelid margin (1, bluesuture), exits the stroma of the eyelid, and enters the stroma onthe opposite side. The suture then exits on the eyelid margin atthe line of meibomian gland openings and is passed externally(2, purple) to enter the meibomian gland opening on the oppositeside. For the third pass, the suture is passed out of the eye-lid stroma, across to the stroma on the opposite side, and exitsthe skin behind the eyelid margin (3, magenta). B, Completefigure-eight suture is shown. Tags from the figure-eight suture(1) are laid across the knot from the first simple interruptedsuture knot (2) to prevent contact with the cornea.

Fig. 3. A, This eyelid laceration extended from the lateral can-thus to the midpoint of the upper eyelid. Swelling was severe. B,The same horse immediately after repair. Note the suture lo-cated medial to the main repair. This horse had a smaller lac-eration not evident in the picture of the laceration.



If the surgical repair dehisces within a day or twoof repair, it can often be repaired again with fresh-ening of the laceration edges. If the dehiscence

is not treated immediately, the eyelid will be dis-figured and a wedge resection may be necessary(Fig. 6). Alternatively, small areas of dehiscencemay heal with granulation tissue.

Postoperative CarePostoperative care for eyelid lacerations often in-cludes a protective hood with a hard cupb over theeye to minimize self-trauma. Additionally, a topi-cal broad-spectrum ophthalmic antibiotic oint-ment is used to lubricate the cornea and preventsecondary infection of the repaired laceration. Mostcommonly, triple antibiotic ophthalmic ointment(neomycin, polymyxin, and bacitracin) is applied tothe laceration site and the cornea. Flunixin meglu-mine, or phenylbutazone should be administeredevery 12 hours for 2 to 5 days, depending on thedegree of swelling and severity of the laceration.

Fig. 4. A, This horse had a laceration of the upper eyelid withmultiple tears in the skin. No skin was excised from this eyelidbefore repair. Pedicles of skin were incorporated into the su-tures. B, The same horse immediately after repair. Repair wassuccessful in restoring eyelid integrity and function. Swellingwas resolving the following day.

Fig. 5. This horse lost the temporal aspect of its uppereyelid. Trichiasis is present, but the cornea appearsnormal.

Fig. 6. This horse’s eyelid was lacerated and repaired 2 weeksbefore evaluation. Repair had been attempted but appeared tohave dehisced. A wedge resection to remove the tissue from thelast visible meibomian gland in the lower eyelid to the lateralcanthus with a two-layer figure-eight closure was recommended,but the owners declined. No keratitis is present, but an imma-ture cataract and evidence of previous posterior synechia is seen.



If the horse received tetanus toxoid 6 months or longerbefore injury, it should be revaccinated. Treatmentwith systemic trimethoprim sulfamethoxazole is indi-cated when infection is present.

If any other ocular trauma is found, it should betreated appropriately. A superficial ulcer should betreated with triple antibiotic ophthalmic ointmentevery 6 to 8 hours, and ophthalmic atropine every 12to 24 hours and the already prescribed nonsteroidalanti-inflammatory drug (NSAID) should be given.Mild anterior uveitis probably will respond to thesystemic NSAID and ophthalmic atropine givenevery 12 to 24 hours. For treatment of more severeocular diseases such as corneal lacerations, ophthal-mic texts should be consulted.

3. Results

With just a few key techniques as described above,the vast majority of eyelid lacerations can be easilyand successfully repaired. There are no retrospec-tive studies discussing equine eyelid laceration re-pair in the peer-reviewed literature; however, yearsof experience have shown that use of the describedtechnique produces excellent results. The figure-eight suture has been published in multiple texts,and procedures similar to those described here havebeen published.1,5–7 With the use of the describedtechnique, complications are rare. Occasionally,the tip of the lacerated eyelid margin will becomenecrotic. If the area is located at the lateral can-thus, it may heal with granulation tissue withoutfurther complication. Alternatively, the necrotictissue may need to be excised and the figure-eightsuture replaced. Several horses have been seenthat were not repaired in the described manner, orveterinary care had not been sought. Some wereseen in which conjunctival sutures had been “bur-ied,” with the knot toward the cornea rather thantoward the skin side of the eyelid. In these cases,the cornea was ulcerated, and the horses were verypainful. In some cases, it was possible to removeonly the offending sutures, but in others, the entireprimary surgical repair had to be removed to accessthe offending sutures.

4. Discussion

Eyelid laceration repair according to this describedtechnique is effective for several reasons. First, ap-position of the eyelid margin with the figure-eightsuture ensures that there will be no defects in theeyelid margin that would allow for corneal traumaor desiccation. Second, the palpebral side of theeyelid is closely apposed with the placement of moresuperficial stromal sutures rather than conjunctivalsutures, which allows for quick healing by migrationof conjunctival epithelial cells without the danger ofcorneal ulceration from conjunctival sutures. Last,the use of a small needle and fine sutures allowsfor precise suture placement without excessivedamage to the tissue. The only pitfalls to this pro-cedure are the need for good lighting, getting accus-tomed to the smaller suture, and the learning curveassociated with placing a proper figure-eight suture.The lighting can be provided with a surgery light orheadlamp. Handling the small suture with a smallneedle and placing the figure-eight suture can befrustrating initially, but, with practice, good light-ing, and heavy sedation, the apposition that can beobtained is well worth the effort.

References and Footnotes1. Stades FC, Gelatt KN. Diseases and surgery of the canine

eyelid. In: Gelatt KN, editor. Veterinary Ophthalmology. 4th

edition. Ames, Iowa: Blackwell Publishing; 2007:563–617.2. Enzerink E. The menace response and pupillary light reflex

in neonatal foals. Equine Vet J 1998;30:546–548.3. Hendrix DVH. Eye examination techniques in horses.

Clin Techniques Equine Pract 2005;4:2–10.4. Labelle AL, Clark-Price SC. Local anesthesia for ophthal-

mic procedures in the standing horse. Vet Clin North AmEquine Pract 21 Jan 2013 [Epub ahead of print].

5. Schoster JV. Surgical repair of equine eyelid lacerations.Vet Med 1988;83:1042–1049.

6. Plummer CE. Equine eyelid disease. Clin TechniquesEquine Pract 2005;4:95–105.

7. Wilkie DA. Ophthalmic procedures and surgery in thestanding horse. Vet Clin North Am Equine Pract 1991;7:535–547.

aVicryl, Ethicon Inc, Somerville, NJ 08807.bEye Saver, Jorgensen Laboratories, Loveland, CO 80538.



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How to Repair Eyelid Lacerations - Home | AAEP...How to Repair Eyelid Lacerations Diane V.H. Hendrix, DVM, Diplomate ACVO Author’s address: Department of Small Animal Clinical Sciences,