Loss or destruction of eyelid tissue should always be treated as a threat to vision. The upper lid especially is important in this respect. The immediate concern is to ensure that the cornea is properly covered when the eyelids are closed. If more than one-third of the margin of the upper lid is lost, this must be replaced by grafting from the lower lid. When less than one-third is missing, the gaping wound can usually be closed directly. Up to one-third of the lower lid can also be closed by direct suturing. When more than this is lost or when it has been transferred to the upper lid, a slide of tissue from the lateral canthus can be effected, combined if necessary with a rotating cheek flap.
One of the most important features of the repair of lid injuries is the method of suturing. If the lid margin is involved, the repair should be made using the operating microscope and the fine suture material available in an eye department (Figure 16.5). An untidy repair can result in a permanently watering eye because of kinking of the eyelid. This interferes with the proper moistening of the cornea during blinking or when asleep. Special attention must be
paid when the medial part of the eyelid has been torn, as this contains the lacrimal canaliculus. Again, unless repair is carried out using an accurate technique under general anaesthesia in theatre, the risk of a permanently watering eye is increased.
Contusion of the eyelids, otherwise known as a black eye, is of course a common problem, especially on Saturday nights in a general casualty department. Usually, the presence of a black eye is an indication that the afflicted was smart enough to close his eye in time to avoid injury to the globe. It is unusual to find damage to the eyes after Saturday night fist-fights, unless a weapon was involved. Broken beer glasses produce devastating injuries to the eyes as well as to the eyelids.
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