Etiopathogenesis, management and outcome of Lid Trauma at Sarojini

Objective: The main objective is to study the causes of eye lid injuries of patients, management of injury and final outcome in terms of functional and cosmetic aspects among the patients attending the occuloplasty department, in Sarojini Devi Eye hospital Hyderabad. Methods: This prospective interventional study was undertaken in patients who attended in occuloplasty department, in Sarojini Devi Eye hospital Hyderabad, and diagnoised on the basis of history, clinical symptoms and signs, and try by radiological study. A total of 60 cases of eyelid injuries were studied. Results: Eye lid injuries were common in males (57%) and in females (22%), among children male (18%) 1 case were common in case of female children 2 (4%). Most of the eye lid injuries were present in the age group between 20-39 years i.e 25 cases (41%). Among the 60 patients RE 36 (60%) is more common than LE 24 cases (40%), in half of the patients 30 cases (50%) were injured, followed by upper lid 19 (30%), both eye lids were injured in 11 (18%) cases. Conclusions: Eye lid trauma was 3 times more common in males than females, in the present study road traffic accidents (48%) were most common cause for eye lid injuries, 48% of eye lid injuries are full thickness without canalicular involvement, most of these injuries are usually associated with other globe injuries,66.33% of cases were managed with direct closure. Significant injuries with dog bite and with blouse hook while feeding were seen in children these were usually associated with medical canthal and lateral canthal injuries.


Introduction
Eyes are the very important and delicate structure of human body. Therefore nature gives the full protection by eyelids and bony orbit. Eyelids are the first bull work against the various external injuries to which the eyes are constantly exposed. Road traffic accidents, blasts, falls etc. are the major causes resulting in injuries to eye lids. If repair is performed immediately according to the principal of lid reconstruction, dysfunction and deformity can be avoided. Improper repair of traumatized eyelids results in facial disfigurement and greater insult to eyelids itself [1].
It is the nature of trauma to occur in a variety of ways and often in complex combinations. To approach the problems presented by trauma to the eyelid effectively, the ophthalmologist needs to have not only a thorough training in eyelid and orbital anatomy, but also a firm knowledge of general approaches to trauma repair that can be intelligently adapted to the needs of each situation [2]. Before attempting the repair of eyelid trauma, thorough systemic and ocular evaluations must be performed and other significant trauma problems resolved. A complete dilated fundus examination is mandatory, since major and minor eyelid trauma may be associated with various ocular problems, including microscopic hyphaema, angle recession, and retinal detachment.' The primary reason for attending to the globe before the lids is to avoid inadvertent pressure applied to the potentially ruptured globe and special care is required when opening the oedematous eyelids [3]. Echymosis and edema are most common presenting signs of blunt trauma. Injuries of eye lids are very common after penetrating facial trauma. Such injuries can vary from simple skin abrasions to more complex cases that have extensive tissue loss and fracture of the underlying Metallic objects were responsible in 28.5% followed by vegetative matter (11%). Mechanical trauma was present in 94.5% while 5.5% suffered from chemical trauma. In 94.5% cases with mechanical trauma, 60.5% sustained closed globe injuries and 26% had open globe injuries [5].
The main objective is to study the causes of eye lid injuries of patients, management of injury and final outcome interms of functional and cosmetic aspects among the patients attending the occuloplasty department, in Sarojini Devi Eye hospital Hyderabad.

Material and Methods
This prospective interventional study was undertaken in patients who attended in occuloplasty department, in Sarojini Devi Eye hospital Hyderabad, and diagnosed on the basis of history, clinical symptoms and signs, and try by radiological study.
A total of 60 cases of eyelid injuries were studied. This study was carried out for two years of period beginning from October 2010 to October 2012. The parameters studied were causes of eye lid injuries, age and gender of the patients, extent of injury and the reconstructive surgical procedures.
Data collection procedure: The relevant data was recorded in already performed case sheets. In that the entire data of injury including mode of injury, time interval between injury and first-aid management taken at hospital was noted.
Most of the details were recorded from the patients as narrated by him or her if they are co-operative. In case of children the information was taken from attendant who was one parent or others.

Method of clinical examination-General information
was done to look for injuries other than ocular injuries. All system were examined. Ocular examination was done, starting from the ocular adnexa with a touch and slit lamp. All patients were underwent comprehensive opthalamic examination and preoperative evaluation which include

Detailed clinical history
BCVA by snellens chart-In slit lamp examination all injuries were examined and documented, including of orbital walls or any other globe injuries if present. Papilary reactions, RAPD, IOP and globe integrity, In all injuries depth, extent of injury was documented and all foreign material was removed to some extent. Wound depth was estimated by gently separating the wound edges with cotton tipped applicator. The eye lid were examined carefully to determined the integrity of the margin, skin and tarsus.
Lacrimal drainage system was examined by syringing, eye lid movements were examined to know the function of levator and orbicularis occuli and other muscles. A saline moistened dressing was placed over the injury until surgical intervention and protective shield to prevent the further injury.Posterior segment examination with direct and indirect ophthalmoscope, 90 D lens in case of clear media.
Investigations-For all patients only a few laboratory tests are needed to complete the evaluation of the patients with lid injury. A complete blood count, serum chemistries are often required for anesthesis purpose.
Coagulation studies are helpful if patients are using anticoagulant medication or vit. K. Ultrasonographic

Tropical Journal of Ophthalmology and Otolaryngology
Available online at: www.medresearch.in 252|P a g e examination of the contents of the globe, extraocular muscles, orbit and optic nerve is often helpful.For all cases where the cause of injury is external object X-ray orbit was taken to rule out presence of any orbital fracture. CT scan was recommended for exact localization of site of fracture and also to know the extent of fracture. For all cases in addition to careful evaluation and surgical planning we counseled patient about intra-operative and post operative complications and advised to stop anticoagulants if they were on treatment.
Anti tetanus prophylaxis 1.5 ml 1M to all patients was given who have not received for past 10 years, others is for rabies if the cause is dog bite 20-40 IU/kg bwt, and again 3,7,14 and 28 days later. Antibiotic prophylaxis was given to all patients.
General surgical considerations-All surgical procedures were done under local anesthesia directly in to the lids or peribulbur anaesthesia, if the patient is a child under GA.
Simple lacerations were repaired with simple direct closure with 6-0 vicryl, without tension complicated lacerations were repaired with interrupted sutures and was maintained correct re-approximation of the wound edges in correct anatomical position and was maintained approximate tension.
Eye lid marginal lacerations repaired by 3-suture technique with 6-0 absorbable suture material. Eye lid injury with minimum tissue loss was repaired and sutured in a layer by layer with 6-0 absorbable suture material meticulously after freshen up the lid margins. Eyelid injury with moderate tissue loss in upper and lower lids were repaired by advancement of lateral tissue or by canthotomy or by cantholysis.
Eye lid injury with large defects-in upper and lower lids were repaired by lid sharing procedures culterbeared procedure. In lower lid defects were repaired by sharing procedure like musturde operation in two stages.
All patients were treated post operatively with topical and systemic antibiotics and anti inflammatory agents to control the inflammation.
Follow up of every case was done on first post operative day, first week, and 6 weeks. During each visit uncorrected and best corrected visual acuity, slit lamp examination, lid movements, lid marginal alignment and complications were noted.
Based on extent and depth of eyelid involvement the patients were classified in to  Prtial thickness eyelid injuries  Full thickness eyelid injuries with canalicular lacerations  Full thickness eye lid injuries without canalicular lacerations.

Results
We have observed road traffic accidents as most common cause.

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Available online at: www.medresearch.in 253|P a g e

Figure-6:Associations of eye lid injuries
In the present study eye lid injuries are presented as isolated eye lid injury and associated other eye injuries

Discussion
In the presentstudy, out of 60 cases, 25 (41%) cases were in 3 rd decade. In Nigerian study 30% of people were in 3 rd decade of life. The difference in incidence was due to referral bias [6].
In the present study, incidence in male was in 34 cases (57%) and female was in 13 cases (22%) this infers male predominance in the present study. These results were similar to study conducted by Milind Naik [7]. The incidence of lid injuries was more in male children (18%) than female children (4%). In the present study association of lid injuries with globe injury was seen in 17 cases (28.33%). The results were similar to study conducted by Milind Naik (25%)In the present study, RE injuries were common 36 cases (60%) than LE injuries 24 cases (40%), half of the patients (50%) presented with lower lid injuries. Upper lid injuries were seen in 19 cases (31.66%). Both UL and LL were injured in 11 cases (18.335).
In epidemiological study on eye lid injuries the incidence of upper lid injuries was 47.22% lower lid was 30.55% and both lid injuries was in 22.22%. In the present study, main etiological factor causing eyelid injuries was Road traffic accidents, which was seen in 29 cases (48%) followed by dog bite in 4 cases (7%) injuries with horn of animals in 7 cases (12%), and injury with blouse hook in 3 cases (5%) injuries with blouse hook were seen while breast feeding. But in Nigeria study RTA causing lid injuries were only 27.3% the high incidence of road traffic accidents causing eye lid injuries in the present study infers that in our area, the road traffic accidents are more common than other areas because of ignorance, illiteracy and in obedience of road traffic rules and regulations [6].
In the present study according to the extent of injury, we found that full thickness eye lid injuries without canalicular lacerations were 29 cases (48%), followed by partial thickness eye lid injuries in 18 cases (30%) and full thickness eye lid injuries with canalicular lacerations were 13 cases (22%). Milinf N. Naik and et al. conducted a study and reported that 36% canalicular involvement in all eye lid injuries [7].
In the present study, 3 cases (75% of dog bite cases) were associated with canalicular injury. Kennedy and associates also reported dog bites and scratches as common cause for canalicular injuries [8].
In the present study, 38 cases (63%) were managed with direct closure. Similarly in Nigerian study, 60.6% of cases were managed with direct closure. Herzum and et al [9] have conducted a study on eye lid injuries and epidemiological aspects, in their study they stated that 55.55% of cases were managed with direct closure 0% 20% 40% 60% 80% 0.10hr 10-24hr More than 24 hrs

No of cases
Tropical Journal of Ophthalmology and Otolaryngology Available online at: www.medresearch.in 256|P a g e In the present study 7 cases (11.66%) were repaired with flaps. Kennedy et al in their study revealed the 31 closure with flaps was done in 21% of cases [8].
In the present study, direct closure of lid injury along with the repair of other injuries was done in 10. Cases (16.66%), Canalicular repair was done in 5 cases (8.33%). According to Fang Bai [10]canalicular repair was done in 5% of cases.
In the present study out of 60 patients on follow up we observed ectopion in 3 cases which were managed by secondary surgical procedure. Keloid was found in 2 cases. Epiphora was noted in 1 case after canalicular repair with stent. Evisceration was done for 5 cases to prevent sympathetic opthalmitis, in those presented with open globe injury with visual acuity PL-VE.
In the present study visual outcome was not much effected except in eye lid injuries associated with globe injuries. Several studies on primary canalicular injuries found a similar trend and showed that the single lower canalicular involvement was the most common, followed by single upper canalicularinvolvement and bicanalicular involvement [11][12][13][14].

Conclusion
All age group are involved but incidence of eye lid trauma is more in age group of 20-39 yrs (41.6%). Eye lid trauma was 3 times more common in males than females, in the present study road traffic accidents (48%) were most common cause for eye lid injuries, 48% of eye lid injuries are full thickness without canalicular involvement, most of these injuries are usually associated with other globe injuries, 66.33% of cases were managed with direct closure. Significant injuries with dog bite and with blouse hook while feeding were seen in children these were usually associated with medical canthal and lateral canthal injuries. Adequate primary repair of the lid injury gives the most satisfactory result and meticulous lid repair is mandatory for lid injuries for cosmentic and function of the eye lid.