Cicatricial Eyelid Contracture

Educational Objectives

The goal of this program is to improve the management of eyelid burns. After hearing and assimilating this program, the clinician will be better able to:

1. Plan surgical procedures for the repair of severely burned eyelids.

Summary

Severe eyelid burns: edema and outpouring of fluid begin minutes to hours after burn and last 2 to 7 days; despite severe facial burns, tarsal plate and conjunctiva may remain viable; sloughing of necrotic tissue and resolution of edema occur ≈3 wk after burn; cicatricial contracture — develops 1 wk to 18 mo later; problematic shrinkage occurs with formation of myofibroblasts; ocular injury usually minimal; when eyelids opened with retractor, opaque cornea often seen; in ≈90% of cases, stroma appears clear after debriding with cotton swab; epithelial burns heal in 5 to 7 days; apply antibiotics (eg, polymyxin-bacitracin ointment)

Early treatment: remove charred lashes to avoid corneal abrasion; temporary suture tarsorrhaphy useful if eyelid eversion not effective; check for hidden, deep, relatively intact tissue; clean eyelid and debride carefully with saline; avoid debriding viable skin; do not graft prematurely

Treatment after contracture: corneal protection necessary for advancing contracture; perform wide release or incision through contracting tissue; after debriding necrotic tissue, place graft; placing bolster — sutures wide of graft and press backwards against it, thereby flattening edges; suture placed through graft tends to cause “tenting up” and produce (possibly permanent) ridge

Release of contracture: incise across cicatricial forces; use natural creases to hide graft edges; protect pretarsal orbicularis muscle to preserve ability to blink; use traction sutures to overcorrect eyelid, stretching recipient bed (this expands blood supply to graft and minimizes contracture); overcorrect bed using horizontal mattress sutures placed without bolsters; failure to overcorrect results in gapping

Grafts: opposite upper eyelid best source but rarely feasible in patients with extensive burns; skin from infra-axillary area or supraclavicular fossa good for grafts (former avoids scar on neck); thick portion of thin skin, (eg, dorsum of foot) forms best split-thickness graft; to avoid eyelid stiffening, suture into stretched bed without excess graft (also enhances survivability of graft); method — use tight bolster (not sutures) to hold graft in place; soak bolster in antibiotic or apply antibiotic ointment to bottom of dressing and graft; remove in 5 to (optimally) 7 days; for ≈2 wk after dressing removal, clean graft with 3% hydrogen peroxide and moisten with antibiotic ointment; remove traction suture when graft has good color (after ≈7 days, or longer if necessary)

General principles of skin grafting: having graft “take” quickly limits contracture by minimizing loss of graft cells and myofibroblast conversion; reduce distance between bed and graft; allow for graft bed contracture; hiding graft edge — keep axes of incisions in natural skin creases; use eyelid crease for upper eyelid and infraciliary incision for lower; can be hidden in brow edge; immobilize bed with traction sutures (Frost or reverse-Frost); late in operation, perform hemostasis cautery; trim all subcutaneous tissue off graft to minimize distance needed for growth of vessels into graft; drainage holes rarely necessary, unless graft large; pressure dressings usually adequate to eliminate fluid and maintain pressure; sutures should extend from brow to lower orbital rim area; avoid overlapping; excessive stretching impairs adhesion of graft to bed; ongoing healing — as manipulation can cause harm (eg, bleeding under graft), avoid removal of dressing unless patient reports pain or if purulence appears before ≈7 days; neovascular bridge restores vascularity to graft; new vessels form and restore graft viability, allowing lymph drainage to begin; flap vs graft — consider graft if conditions suboptimal for use of flap

Readings

Cabalag MS et al: Risk factors for ocular burn injuries requiring surgery. J Burn Care Res. 2017 Mar/Apr;38(2):71-7; Fitzgerald O’Connor E et al: Periorbital burns — a 6 year review of management and outcome. Burns. 2015 May;41(3):616-23; Spencer T et al: Ophthalmologic sequelae of thermal burns over ten years at the Alfred Hospital. Ophthalmic Plast Reconstr Surg. 2002 May;18(3):196-201.

Disclosures

For this program, the following has been disclosed: Dr. Marrone reported nothing to disclose. The planning committee reported nothing to disclose. 

Acknowledgements

Dr. Marrone spoke at the University of Southern California (USC) Roski Eye Institute 44th Anniversary Symposium, held June 15, 2019, in Los Angeles, CA, and presented by the USC Roski Eye Institute and USC Office of Continuing Medical Education. For information on upcoming CME activities from the USC Roski Eye Institute, please visit keck.usc.edu. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP580601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.