Canalicular Laceration Treatment & Management

Updated: May 05, 2018
  • Author: Christian El-Hadad, MD, CM, FRCSC; Chief Editor: Hampton Roy, Sr, MD  more...
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Treatment

Medical Care

Alcaine or tetracaine can be used to anesthetize the eye. Once any form of open globe injury has been ruled out, the wound should be immediately irrigated with water or saline. One or two drops of povidone-iodine ophthalmic solution 0.5 % can be used to sterilize the ocular mucosa.

Tetanus prophylaxis must be confirmed in any contaminated injury. Rabies prophylaxis with both active and passive immunization may be necessary in certain canine bites; in most domestic dog bites, it is not necessary. The usual workup should be performed for a human bite (see Human Bites).

Postoperatively, most surgeons prescribe a broad-spectrum antibiotic, such as cephalexin or amoxicillin clavulanic acid. Some surgeons do not routinely use systemic antibiotics. [13] Considerations for using antibiotics should include the risk factors for infection. Patients at increased risk for infection include patients taking immunosuppressant medications or steroids and patients with diabetes, rheumatoid arthritis, alcoholism, cirrhosis, asplenia, or any other systemic condition that affects the immune system. Additional factors that increase the risk for infection include the extent and depth of the wounds.

The US Department of Health and Human Services 2013 guidelines recommend antibiotic treatment for facial cat and dog bites. [14] Wound care includes topical ophthalmic antibiotic ointment 4 times per day and ophthalmic antibiotic solution 4 times per day.

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Surgical Care

Acute microscopic repair with either an operating microscope or surgical loupes is required to reanastomose the severed ends of the canaliculi. In most injuries, this repair can be accomplished within 48 hours of the trauma. Successful repairs have been reported within 5 days of the injury. Animal bites should be addressed as soon as possible because of the significant contamination present in the wound. [15]

Repairs on children are best performed under general anesthesia. For most adults, repairs can be performed with monitored anesthesia with intravenous sedation or if an isolated laceration even local anesthesia. In those patients with extensive ocular adnexal trauma or more extensive injuries, general anesthesia may be the preferred anesthetic approach. Local hemostasis and anesthesia are augmented with nasal vasoconstrictors, such as 4% cocaine or phenylephrine soaked cottonoids, and a local injection of 2% lidocaine with 1:100,000 epinephrine (in adults) or 0.5% lidocaine with 1:200,000 epinephrine (in children) to the area of the lacrimal sac and in both the superior and the inferior medial eyelid.

Familiarity with the anatomy of the medial canthal area is essential for accurate repair of the canalicular system. Because of the difficulty in finding the severed ends if one is not experienced with these injuries, a wide variety of methods, such as instilling various fluids (eg, saline, boiled milk, antibiotic solutions, methylene blue, sodium hyaluronate, fluorescein), have been suggested. Laser guidance has been suggested as another alternative. [16] Recently, a modified pigtail probe, which combines both the rounded cannula and an irrigation port, has been designed to facilitate both identification and repair of the lacerated canalicular system. [17]

A study of 63 patients with traumatic canalicular lacerations reported higher success rates in patients treated with direct canalicular wall sutures compared with pericanicular sutures. [18] The modified rounded-eyed pigtail probe method of canalicular repair has been reported to have a 97.4% success rate in re-establishing the severed system. [10] Regardless of the method used to determine the location of the severed ends, they must be anastomosed to recover functional patency.

The puncta must be dilated, and a Bowman probe must be passed delicately through the canaliculus. The severed end of the canaliculus is a shiny white cuff of tissue at the edge of the lumen. Most surgeons favor silicone intubations of the system, with repair of the pericanalicular injury. [19, 20] Intubation of the injured lacrimal system has been shown in an animal model to facilitate successful repair. [21] Intubation can be accomplished with either bicanalicular intubation (either by passing the stent ends through the nasolacrimal duct or by using a modified eyed pigtail probe) or monocanalicular intubation. [22, 23]

Both the monocanalicular and bicanalicular approaches yield excellent outcomes. [24, 10] Care should be taken with repair of the lacrimal system, as unusual complications of passing the metal intubation probe have been reported. [25]

The pericanalicular tissue can be opposed with 7-0 Polyglactin 910 suture. [26] In addition, the medial canthal tendon must be repaired in its anatomic location, posterior to the lacrimal sac at the posterior lacrimal crest. If the disrupted tendon is not repaired, both the appearance and the function of the lid will be abnormal.

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Consultations

Consultation and treatment by an oculoplastic surgeon, who is experienced with the repair of lacrimal injuries, is recommended. Ophthalmic plastic and reconstructive surgeons are trained first in eye diseases and surgery; additional expertise then is obtained in the anatomy of the ocular adnexa. Injuries to the lacrimal drainage system can be quite complex and involve not only the tear drainage system but also the lid anatomy, including the medial canthal tendon. Associated injuries can include full-thickness lid lacerations or orbital fractures.

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Diet

As soon as patients with isolated canalicular trauma recover from anesthesia, they may resume their preoperative diet. Trauma surgeons entrusted with systemic care manage patients with multiple injuries.

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Activity

Normal activity can be resumed following surgery. If orbital fractures have occurred, the patient is asked not to blow the nose because it can cause orbital emphysema. High-pressure activities that require Valsalva maneuvers should be avoided because they can lead to ecchymosis in the lid area or even orbital hemorrhage.

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Prevention

Canalicular injuries resulting from sports injuries could potentially be avoided with proper headgear.

Those lacerations resulting from assault often are alcohol abuse related.

Close surveillance of toddler interactions with the family pet or a known dog may be helpful in preventing a significant number of canalicular lacerations in toddlers.

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Long-Term Monitoring

Children with trauma to the eyelids must be monitored closely to ensure that deprivational amblyopia does not occur from eyelid ptosis.

Patients with traumatic ptosis typically are observed for 6 months before proceeding with repair; exceptions include complete ptosis in a child at risk for amblyopia. The silicone stent is removed 3 months to 1 year after the repair depending on the extent of the trauma.

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Further Inpatient Care

Inpatient care typically is directed by the trauma service admitting the patient.

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Inpatient & Outpatient Medications

Isolated canalicular trauma can be treated on an outpatient basis.

In those patients in whom inpatient care is needed, medications may include intravenous Ancef (1 g q8h in adult for first 24 h).

If the patient is able to take oral antibiotics, then a broad-spectrum antibiotic, such as (Keflex 500 mg qid), can be used for 10 days. A broad-spectrum ophthalmic antibiotic ointment, such as TobraDex, is used 4 times per day to the wounds for the first 2 weeks. An ophthalmic antibiotic solution, such as TobraDex, is used 4 times per day to the lacrimal system for the first 2 weeks.

Patients who are immunosuppressed or who have undergone prior splenectomy are at risk for developing infection with dysgonic fermenter-2 24-48 hours after a dog bite.

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Transfer

Patients with extensive injuries often are transferred to a rehabilitation facility. Postoperative care must include assessing the wound for infection, patency of the lacrimal system, and stent position.

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