LA CONSTRUCCIÓN CON LADRILLO

(See Figure 3.8.4.)

A. Place a 6-0 silk suture from gray line to gray line, entering and exiting the gray line 2 to 3 mm from the laceration edge. Put the suture on traction with a hemostat to ensure

good reapproximation of the splayed tarsus and gray line. Do not tie this suture yet.

P.27 P.28

B. Realign the tarsal edges with multiple interrupted sutures placed anteriorly (5-0 or 6-0 polyglactin on a spatulated needle). In the upper eyelid, 3 to 4 sutures can usually be placed. In the lower eyelid, 2 to 3 sutures are typically the maximum. A single tarsal suture is inadequate for appropriate tarsal

realignment. It is important to take only lamellar (half-thickness) bites through the tarsus and to avoid the underlying conjunctiva to minimize the risk of postoperative corneal injury.

C. Failure to reapproximate the tarsus will result in eyelid splaying and notching.

D. Tie down and trim the tarsal sutures. Tie down the marginal silk suture leaving long tails.

E. Place and tie another 6-0 silk marginal suture either anterior or posterior to the gray line suture, again leaving long tails. Frequently, however, the posterior suture is unnecessary and its absence decreases the risk of postoperative corneal abrasion.

F. Use interrupted 6-0 plain gut sutures to close the skin along the length of the laceration. Incorporate the tails of both silk marginal sutures into the skin suture closest to the eyelid margin.

Note

If patient reliability is questionable, use absorbable (e.g., 6-0 Vicryl) sutures for every step.

Note

Figure 3.8.4. Marginal eyelid laceration repair: A: Reapproximate the gray line with a 6-0 silk suture. B: The most important step is to realign the tarsal edges with multiple interrupted 5-0 or 6-0 absorbable (e.g., Vicryl) sutures. Take partial-thickness bites. C: Failure to realign the tarsus will compromise the integrity of the eyelid, resulting in splaying and notching. D: Tie the tarsal and gray line sutures. E: Place another marginal 6-0 silk suture. F: Suture the skin with

interrupted 6.0 plain gut, securing the tails of the marginal sutures.

This marginal suture provides no structural integrity to the eyelid; its main function is to align the eyelid margin anatomy to ensure a good cosmetic repair.

Follow-Up

If nonabsorbable sutures are used (e.g., silk), eyelid-margin sutures should be left in place for 5 to 10 days, and other superficial sutures for 4 to 7 days. The integrity of an eyelid margin repair is in the longer lasting tarsal sutures. Therefore, the eyelid margin sutures can be removed as soon as 5 days

postoperatively.

3.9 Orbital Blow-Out Fracture Orbital Blow-Out Fracture Symptoms

Pain on attempted eye movement (orbital floor fracture: pain on vertical eye movement; medial wall fracture: pain on ab-/adduction), local tenderness, eyelid edema, binocular diplopia, crepitus after nose-blowing, recent history of trauma. Tearing may be a symptom of nasolacrimal duct fracture seen with medial buttress or Leforte II fractures, but this is typically a late complaint. Acute tearing is usually due to ocular surface irritation (e.g., conjunctival chemosis, corneal abrasion, iritis).

Signs

Critical. Restricted eye movement (especially in upward or lateral gaze or both), subcutaneous or conjunctival emphysema, hypesthesia in the distribution of the infraorbital nerve (i.e., ipsilateral cheek and upper lip), point tenderness, enophthalmos (may initially be masked by orbital edema).

Other. Nosebleed, eyelid edema, and ecchymosis. Superior rim and orbital roof fractures may show hypesthesia in the distribution of the supratrochlear or supraorbital nerve (ipsilateral forehead) and ptosis. Trismus, malar flattening, and a palpable step-off deformity of the inferior orbital rim are characteristic of tripod (zygomatic complex) fractures. Optic neuropathy may be present.

Differential Diagnosis

z Orbital edema and hemorrhage without a blow-out fracture: May have limitation of ocular movement, periorbital swelling, and ecchymosis due to soft-tissue edema and hemorrhage, but these resolve over 7 to 10 days.

z Cranial nerve palsy: Limitation of ocular movement, but no restriction on forced-duction testing. Will have abnormal results on force generation testing.

Work-Up

1. Complete ophthalmologic examination, including measurement of extraocular movements and globe displacement. Compare the sensation of the affected cheek with that on the contralateral side; palpate the eyelids for crepitus (subcutaneous emphysema); palpate the orbital rim for step-offs; evaluate the globe carefully for a rupture, hyphema or microhyphema, traumatic iritis, and retinal or choroidal damage. Measure IOP. Check pupils and color vision to rule out a traumatic optic neuropathy (see 3.11, Traumatic Optic Neuropathy). If eyelid and periocular edema limit the view, special techniques may be necessary (e.g., use of Desmarres retractors, lateral cantholysis, examination under general

anesthesia).

2. Forced-duction testing is performed if restriction of eye movement persists beyond one week. See Appendix 6, Forced-Duction Test and Active Force Generation Test

3. CT orbit scans (axial and coronal views, 3-mm sections, without contrast) are obtained in all cases of P.29

suspected orbital fractures. Bone windows are especially helpful in evaluation of fractures (see Figure 3.9.1). If there is any history of loss of consciousness, brain imaging is required.

Note

It is of paramount importance to rule out intraocular and optic nerve injury as quickly as possible in ALL patients presenting with suspected orbital fracture.

Treatment

1. Broad-spectrum oral antibiotics [e.g., cephalexin (Keflex) 250 to 500 mg p.o., q.i.d.; or erythromycin 250 to 500 mg p.o., q.i.d.] for 7 days. The use of prophylactic antibiotics in orbital fracture is controversial. Antibiotics are recommended if the patient has a history of sinusitis, diabetes, or is otherwise immunocompromised. In all other patients, the decision about antibiotic use is left up to the treating physician.

2. Instruct patient not to blow his or her nose.

3. Nasal decongestants [e.g., pseudoephedrine (Afrin) nasal spray b.i.d.] for 3 days. Use is limited to 3 days to minimize the chance of rebound nasal congestion.

4. Apply ice packs to the orbit for the first 24 to 48 hours.

5. Consider oral steroids (e.g., Medrol dose pack) if extensive swelling limits examination of ocular motility and globe position. If corticosteroids are used, systemic antibiotics should also be considered.

6. Neurosurgical consultation is recommended for all fractures involving the orbital roof, frontal sinus, or cribriform plate and for all fractures associated with intracranial hemorrhage. Otolaryngology or oral maxillofacial surgery consultation is recommended for frontal sinus, midfacial, and mandibular fractures.

7. Surgical repair should be considered based on the following criteria: