What are the steps and precautions for performing eyelid suturing on a patient with a laceration or incision, considering their medical history and potential risks for complications?

Eyelid Laceration Repair: Procedural Guide and Critical Precautions

For traumatic eyelid lacerations requiring suturing, meticulous technique with proper anesthesia, wound preparation, and layered closure is essential to prevent vision-threatening complications and achieve optimal functional and cosmetic outcomes.

Pre-Procedure Assessment and Patient Preparation

Critical Contraindications to Screen

• Avoid epinephrine-containing local anesthetics in eyelid tissue due to risk of tissue necrosis from prolonged vasoconstriction, particularly in patients with arteritis, Raynaud's phenomenon, or severe microvascular disease 1
• Assess for globe perforation, which occurs in 0.08%-5.1% of eyelid surgeries and requires immediate ophthalmologic consultation 2
• Document baseline visual acuity and pupillary function before proceeding 3

Anesthesia Protocol

• Use 2% lidocaine without epinephrine for local infiltration 1
• Topical anesthetic drops may be applied to the cornea if globe exposure is anticipated 2
• Consider systemic analgesia for anxious patients or extensive repairs 3

Wound Preparation and Corneal Protection

Essential Eye Protection During Repair

• Apply preservative-free methylcellulose or viscous gel lubricant to the cornea before beginning the procedure 2, 4
• If complete eyelid occlusion is not possible due to the laceration, use transparent bio-occlusive dressings as an alternative 2
• Avoid oil-based ointments as they produce more adverse effects than aqueous lubricants 2

Wound Cleansing

• Cleanse surrounding skin and eyelashes with antiseptic solution 2
• Irrigate the wound copiously with sterile saline
• Remove any foreign material or devitalized tissue conservatively 3

Suturing Technique by Anatomic Layer

Margin-Involving Lacerations (Most Critical)

The eyelid margin must be precisely aligned to prevent notching, trichiasis, and chronic irritation:

1. Place the first suture through the gray line (mucocutaneous junction) using 6-0 or 7-0 silk or nylon

   • This suture serves as the key alignment reference 3
   • Leave suture ends long to keep away from the cornea

2. Repair the tarsal plate with interrupted 5-0 or 6-0 absorbable sutures (polyglactin or polyglycolic acid)

   • Pass partial-thickness bites to avoid full-thickness penetration that could abrade the cornea 3
   • Bury knots on the anterior surface away from the globe 5

3. Close the skin with 6-0 or 7-0 nylon interrupted sutures

   • Ensure meticulous eversion of wound edges 3

Non-Margin Lacerations

• Repair in layers: conjunctiva (if involved), tarsus, orbicularis, and skin 3
• Use 6-0 absorbable sutures for conjunctiva and deeper layers
• Use 6-0 or 7-0 nylon for skin closure 6
• Avoid excessive tension that could cause tissue ischemia 7

Critical Intraoperative Precautions

Prevent Globe Injury

• Never pass sutures full-thickness through the eyelid if the globe is in proximity 2, 3
• Use protective corneal shields if available during complex repairs
• Maintain constant awareness of needle depth and trajectory 3

Avoid Tissue Necrosis

• Do not use epinephrine-containing anesthetics - this is the most common preventable cause of eyelid necrosis 1
• Avoid excessive cautery that can cause tissue loss 7
• Preserve as much viable tissue as possible, even if margins appear questionable 3

Postoperative Management

Immediate Care

• Apply topical antibiotic ointment (erythromycin or bacitracin) to the suture line 3
• Prescribe systemic antibiotics if there is contamination, delayed presentation >12 hours, or signs of infection to prevent orbital cellulitis (incidence 1 in 1,100 to 1 in 1,900 after eyelid procedures) 2
• Consider topical corticosteroids to reduce inflammation after 48 hours 2

Suture Removal Timing

• Remove margin sutures at 7-10 days to prevent granuloma formation 3
• Remove skin sutures at 5-7 days 3
• Tarsal sutures are absorbable and do not require removal 5

Follow-up Monitoring

• Examine at 24-48 hours for signs of infection, hematoma, or wound dehiscence 3
• Watch for vision-threatening complications including orbital hemorrhage (rare but requires immediate surgical decompression), endophthalmitis (1 in 30,000 to 1 in 185,000), and preseptal/orbital cellulitis 2
• Assess final eyelid position and function at 4-6 weeks 7

Common Pitfalls and How to Avoid Them

Malposition Complications

• Eyelid retraction or ectropion occurs from excessive tissue resection or scarring - prevent by conservative debridement and tension-free closure 7, 3
• Ptosis can result from levator aponeurosis injury - identify and repair if encountered during exploration 7, 5
• Lagophthalmos (incomplete closure) leads to exposure keratopathy - if present postoperatively, use aqueous gels or humidity chambers rather than artificial tears alone 2, 4

Infection Prevention

• Bacterial superinfection occurred in 75% of eyelid necrosis cases in one series - maintain high suspicion and treat aggressively with systemic antibiotics 1
• Debride any necrotic tissue promptly if it develops 1

Corneal Protection Failure

• Regularly verify complete corneal coverage with lubricant throughout the procedure - inadequate protection causes corneal injuries in up to 60% of at-risk cases 2
• Training on proper eye protection reduces corneal injury incidence by three-fold 2