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Year : 2014  |  Volume : 22  |  Issue : 1  |  Page : 22-32

Management of ocular and periocular burns

Department of Burns and Plastic Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication15-Dec-2014

Correspondence Address:
Sujata Sarabahi
Department of Burns and Plastic Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, B-18, First floor, Kailash Colony, New Delhi - 110 048
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-653X.146997

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Facial burns commonly involve the eyelids. The eyeball as such is usually protected due to the blink reflex, bell's phenomenon, and protective movements of arms and head. Ocular sequelae are seen secondarily due to retraction of the burned eyelids which leads to drying of cornea and its subsequent ulceration and perforation. Permanent visual impairment is rare if prompt management is done. Superficial lid burns usually heal spontaneously and can be managed conservatively with ophthalmic antibiotic ointments, artificial tears. However, in deeper burns, early surgical intervention in the form of eschar debridement or release of contracted lids and resurfacing defects with split skin grafts can prevent secondary corneal damage. This review article elaborates the principles of management of acute ocular and periocular burns as well as the long-term management of eyelid burns.

Keywords: Cornea, eyelid burns, grafting, ocular, tarsorrhaphy

How to cite this article:
Sarabahi S, Kanchana K. Management of ocular and periocular burns. Indian J Burns 2014;22:22-32

How to cite this URL:
Sarabahi S, Kanchana K. Management of ocular and periocular burns. Indian J Burns [serial online] 2014 [cited 2022 Nov 28];22:22-32. Available from: https://www.ijburns.com/text.asp?2014/22/1/22/146997

  Introduction Top

More than two-thirds of facial burns involve the eye or periocular area and 7.5-27% of all patients treated for burns have ocular involvement. [1] Eighty-four percent of these are due to chemicals and 16% due to thermal injury. Reflex blinking of eyelids in response to heat and smoke usually protects the cornea and eyelid margins. Frequent ocular injuries seen as a result of facial burns include lid burns, corneal burns, foreign bodies, abrasions, perforations, and contracture leading to ectropion. [2] Because of the life-threatening nature of severe burn injuries to the face and the associated massive swelling of eyelids, ocular injuries may not be noticed early and treatment may be delayed. Most ocular sequel including corneal ulcerations usually are seen secondary to post burn eyelid deformities. Appropriate early intervention can have a significant effect on the final outcome for the burn patient. [1] This paper is a review of the current literature regarding management of eyelid burns and the role of burn surgeon involved in their care.

  Etiopathogenesis Top

Burns to the eyelids may be caused by thermal, electrical, chemical, or ionizing radiation sources. The severity of burns depends on the intensity of the burning agent, both the quantity of heat transmitted by the burning agent and amount of the burning agent, the duration of exposure, body's response, the use of any protective devices, first aid, and irrigation of the burnt eye. [3],[4]

  Thermal burns Top

Thermal burns may be due to flame and hot liquids. There is a perfect co-ordination between the cranial nerves 2, 3, 5, 7 causing rapid reflex closure of the eyelids, abrupt head movements, and Bell's Phenomenon. [5] Therefore, most of the flash burns are superficial. [Figure 1] In flame burns, period of exposure is longer and results in deep burns [Figure 2].
Figure 1: Superficial burns involving the eyelids and periocular region

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Figure 2: Deep burns involving the eyelids and periocular region

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Liquid thermal burns vary in severity depending on the substance. Steam from hot liquids and liquids exploding after removal from a microwave may also splash into the eye and cause burns. The temperature of non-combustible liquids, like water, is usually less on contact, and such liquids dissipate rapidly from the initial contact area, thereby causing only superficial damage. On the other hand, the temperature of combustible liquids, like gasoline, at contact is usually high and these liquids tend to be more viscous and may ignite clothing. Therefore, the damage is more localized but often deeper. [6]

  Chemical burns Top

A chemical burn may be due to acid or alkali [Figure 3]. The severity of the injury is directly correlated with the duration of exposure and the causative agent (quantity, pH, and penetrability). Alkalis are lipophilic and penetrate more rapidly than acids. Saponification of cell membranes causes cell disruption and death. The damaged tissues stimulate an inflammatory response causing liquefactive necrosis. [7] Depending upon the degree of penetration, there is loss of corneal and conjunctival epithelium, stromal keratocytes, and endothelium. They may even pass into the anterior chamber rapidly damaging the iris, ciliary body, lens, and trabecular network. Damage to the endothelium may cause thrombosis to the episcleral vessels. [8] Acids cause protein coagulation in the corneal epithelium and superficial stroma which limits further penetration. As a result they cause superficial and non-progressive burns. An exception to this rule is that hydrofluoric acid being a weak acid causes liquefactive necrosis. [7]
Figure 3: Chemical burns involving the left eye and left side of the face. Direct injury by the acid has caused keratitis and corneal opacity, conjunctival congestion and severe ectropion of the upper eyelid

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  Electrical burns Top

The damage to the eye in electrical burns may be due to a contact or a flash burn. Contact burn occurs in case of current passing through head and orbital region. The initial damage is to the cornea, conjunctiva, and uveal tract. Due to the low resistance of the retina and optic nerve, these structures are rarely involved. In later stages, a stellate cataract may appear even if the initial injury has not caused much damage [Figure 4] and [Figure 5]. Apart from the injuries due to domestic and high tension wires, other etiologies are lightning flashes, electroconvulsive therapy, cardioconversion shock, and in urological procedures. [9]
Figure 4: Post electric contact burn to the scalp (resurfaced defect with flap cover) developed cataract of right eye after 6 months of the injury

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Figure 5: A high tension contact electric burn to right side of the face and right eye with total loss of vision due to pthisis bulbi and exposure of zygoma

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Flash burns are due to intense heat with a momentary exposure causing burns of the surface as in thermal burns. Most injuries seen with flash burns involve the eyelids and are superficial because of the ocular protective mechanism.

  Radiant energy burns Top

These burns are caused due to ultraviolet (UV) rays, lasers, and welding arcs. With UV burns, epithelial injury results in a punctate keratitis. Although the pain is often delayed, UV corneal burns are exquisitely painful. Skiers at high altitudes are particularly susceptible to this injury. Welders who view the arc without protective goggles are at risk for injury. [7] Lasers used in industries and medical practice also can lead to direct retinal injury and, rarely, corneal injury. [10] Burns may also occur due to X-rays, gamma rays, and nuclear explosions. [11]

Eyelid burn injuries, healing, and complications

  1. First-degree burns: Involving the epidermis only. Erythema and pain are common.
  2. Second-degree burns:

    1. Superficial partial-thickness burns: Involves the epidermis and some papillary dermis.
    2. Deeper partial-thickness burns involves the epidermis, papillary, and reticular dermis. If infection or re-injury occurs, the wound may convert to a full-thickness injury.

  3. Third-degree burns: These are full thickness burns involving the subcutaneous tissue and may include muscle.

  The burns may involve Top

I. Direct injury to the globe

Mild burns are associated with hyperemia, conjunctival ecchymosis, chemosis, and erosion of corneal epithelium. In mild acid burns, "ground glass appearance" of the cornea is seen. The actual burn of cornea is rare in thermal burns but the injury is usually secondary to exposure, drying, and infection due to deep eyelid burns and is therefore preventable. In severe thermal burns, there is corneal opacification associated with extensive and deep damage to the tissues. Globe rupture is seen in extreme cases [Figure 6] and [Figure 7]. [8] In chemical injury to iris and lens, there is mydriasis and fast development of cataract. Blood aqueous barrier is destroyed leading to iridocyclitis and fibrinous excudates. Visible blood vessels are thrombosed and dark. An inflammatory response is triggered by the toxic substances leukotrienes, prostraglandins, histamine, angiotensin (LT, PG, HA, AT) released from the burnt cells. [12] In mild burns, this reaction is self-limiting while in severe burns, it causes further damage to surrounding structures. [13]
Figure 6: A direct thermal injury to the left eye causing corneal opacities in the initial stages which later on lead to corneal rupture, panophthalmitis and pthisis bulbi. Though the superficial facial burns have healed significantly, the ocular complications have lead to the enucleation of the eye

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Figure 7: A direct thermal injury to the right eye leading to conjunctival congestion, corneal opacification and pus in the anterior chamber (hypopyon)

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2. The eyelids only

First-degree burns usually does not produce any deformities. In second-degree burns, there is subcuticular or dermal fibrosis with sparing of orbicularis fibers leading to ectropion only. In third-degree burns, there is muscle involvement also, which leads to more severe ectropion and lid shortening. [5] Exposure keratitis with or without secondary infection leads to corneal and conjunctival damage causing corneal opacities and destruction of globe in severe cases [Figure 8].
Figure 8: Exposure keratitis secondary to both upper and lower eyelids ectropion later forming corneal opacities in a patient with periocular burns. Also there is loss of eye lashes and lateral 1/3 of eyebrows indicating that the burn was deep

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3. The adjacent soft tissues only: Cheek, nose, forehead, and temporal region

The skin contraction displaces the eyelids which might involve the canthi. The lower lid tends to be more severe due to less loose skin available [Figure 9].
Figure 9: Burns involving the skin of lower face and neck with contracture leading to secondary ectropion lower eyelid though there was no ocular or periocular involvement

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4. The eyelids and adjacent soft tissue

The deformities produced are a combination of both 2 and 3.

Healing process

Re-epithelialization of wounds occurs from epithelium located at wound edges and skin appendages, such as hair follicles, sebaceous glands, sweat glands, and their ducts. In large areas, granulation tissue bridges the wound before epithelialization occurs. Wound contraction occurs in second-and third-degree wounds and aids in restoring epithelial continuity. This property of wound contraction of surrounding skin of the face distorts the eyelids and hence impairs their function. Owing to the thinness of skin and absence of subcutaneous fat and rich blood supply, the slough on the lid separates early and easily. The raw surface created has to be grafted immediately if contraction of wound and subsequent deformity of lids is to be avoided.

Complications of eyelid burns

Eyelid burns may damage lacrimal, conjuctival, and eyelid glands which can decrease tear production or their scarring may also inhibit lacrimal drainage system and blink reflex which increases the risk of corneal drying, abrasions, ulcers, and perforations, thus leading to visual debilitation. [5]

Contraction of the surrounding skin in second-degree and third-degree burns leads to lagophthalmos and ectropion in later stages [Figure 10]. This might involve the upper and lower eyelids both eventually leading to exposure keratitis, corneal opacities, and ulcers. Presence of infection might worsen the condition leading to corneal perforation, pthisis bulbi, and loss of vision. Long-term complications due to eyelid scarring are distichiasis, ectropion, entropion, trichiasis, epiphora, or ulcerations.
Figure 10: a) Post burn ectropion involving the upper and lower eyelids of both the eyes with inability to close the eyelids (b) The same patient with a good Bell's phenomenon acting as a protective mechanism to prevent corneal opacities (c) Amount of upper eyelid excursion after ectropion release and grafting of the upper eyelids

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In patients where the trauma to the eye is direct from the heat of the agent, a varying degree of severity of complications may arise like corneal edema, ulceration, limbal ischemia, symblepheron, conjunctival scarring, and conjunctivalization of the cornea [Figure 11]. [8]
Figure 11: Follow up case of deep chemical burns to face involving both eyes showing symblepharon in right eye and surgical tarsorrhaphy in left eye

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Chemical burns produce a long-term complications of angle closure glaucoma, corneal scarring, and keratoconjunctivitis sicca. [11] Cataract is a long-term complication of electricity burns or UV radiation injury which takes about 6 months to develop [Figure 12]. [9]
Figure 12: Cataract left eye in a patient 6 months after the contact electric burn in the occiput with no injury near the eyes

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  Ophthalmologic and eyelid evaluation Top

The initial examination of eyelids

  1. The depth and extent of burns in the eyelid and facial area should be initially assessed.
  2. The presence of eyebrow hairs and eyelashes should be documented. Loss of these is usually associated with a deep partial-thickness or full-thickness burn. Furthermore, the presence of eyelashes indicates sparing of the eyelid margin. [14]
  3. Conjunctival edema is noted which is produced by a combination of fluid resuscitation, positive pressure ventilation, and mild exposure, or the burn itself [Figure 13].
    Figure 13: Conjunctival edema in a patient two days after post burn resuscitation and positive pressure ventilation

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  4. Bell's phenomenon: In the presence of a partial-thickness burn, eyelid contracture produces progressive lagophthalmos and corneal exposure. Therefore, the presence or absence of a Bell's phenomenon should be documented. A good Bell's phenomenon can help prevent a corneal epithelial defect even in the presence of significant lagophthalmos [Figure 10]b. [2] This reflex may be temporarily absent in a heavily sedated or paralyzed patient. With an absent Bell's phenomenon and concern regarding lagophthalmos, daily ophthalmic review or close communication between the ophthalmologist and burn unit staff is required to monitor signs of increased conjunctival redness or chemosis, mucus discharge, or corneal exposure as their presence would prompt earlier surgery. [2]
  5. Foreign bodies should be removed with irrigation and cotton swabs, including careful sweeping of conjunctival fornices. [3],[15]

The ophthalmic examination

Ocular examination should be done as early as possible because eyelid usually swell and shut after burns which may make evaluation difficult. Early ophthalmic referral identifies ocular sequelae and offers a broader range of treatment options before the development of secondary complications. The most critical issue in a burn patient is the integrity of the corneal surface. Use of fluorescein strips and a cobalt blue light identifies any corneal damage. In addition, a portable slit lamp allows a more detailed examination than would otherwise be possible. Corneal thinning, usually the result of lagophthalmos, is only detectable by a portable slit-lamp. Intra-ocular pressure monitoring by a Tono-pen, near vision chart, and direct ophthalmoscopy forms the part of examination. One should also check for loss of conjunctiva due to burns, especially if there is involvement of both palpebral and bulbar conjunctiva which can cause symblepheron formation.

Roper scale classifies corneal burns into four grades [16]

Grade 1:

There is only corneal epithelial loss, no conjunctival ischemia. Prognosis is good.

Grade 2:

Cornea has significant haziness. Limbal ischemia is <1/3 limbus. Some permanent scarring may occur.

Grade 3:

Cornea has significant haziness. Limbal ischemia is <1/2 limbus. Prognosis is variable as vision is impaired.

Grade 4:

Cornea is opaque. Limbal ischemia is >1/2 limbus. There is a possibility of global perforation. Prognosis is poor.

  Initial management Top

In the acute evaluation of facial, neck, and periocular burns, the medical caregiver must also observe for co-existing inhalational burn injury and its timely management. For local management of eyes and eyelids, the following steps should be taken:

1. Irrigation and removal of foreign bodies

Immediate irrigation is of paramount importance after chemical or thermal burns. Victims are disabled by a severe reflex blepharospasm. Initial first aid involves passive opening of the eyelids and effective irrigation of the eye. All aspects of the conjunctiva and cornea should be irrigated by making the patient to look in all directions. [17] Ringer lactate is the most ideal fluid for irrigation as it has similar osmolarity as that of aqueous humor. [18] Plain water, normal saline are other choices which have lesser osmolarity. Since water is easily available everywhere, it is most commonly recommended for irrigation. At least 500-1000 ml of irrigation fluid for 15 min has to be used (ANSI). In thermal burns, it cools the ocular surface and removes any inflammatory substances from it. [13] In chemical burns, about 2 liters fluid should be used for irrigation and universal indicator paper can be used to determine the pH of external eye. When neutral, patient should be checked periodically to confirm that no continual damage is occurring by residual particles or chemicals. Particles are sometimes trapped in the fornices or upper eyelid. Therefore, ectropinization and intensive cleaning of the cul de sac is mandatory.

2. Prophylactic ocular lubrication

Use of artificial tears for a minimum of four times a day with ointment at night should be started within 24 hours of the burn to counter the effects of lagophthalmos. [19] Any epithelial defects require administration of topical antibiotics especially to cover gram-negative organisms. Pseudomonas eruginosa is the most common organism to infect the cornea in these situations. Topical anesthetic drops to be applied to reduce pain and facilitate irrigation in chemical burns. [14]

3. Trimming of the eyelashes

Singed eyelashes present in thermal eyelid burn should be trimmed with fine scissors to avoid the possibility of char falling into the eye and prolonging ocular surface discomfort. The blades of the scissors must be covered with an ophthalmic ointment in order to prevent the cut lashes from falling into the conjunctival sac. [20]

4. Wound management

Head end of the bed should be elevated. The eyelids should be cleaned of any debris as soon as possible using saline-soaked gauze. A tulle grass, silicone covered nylon mesh, or an alginate dressing can be used. Dressings are favored over the traditional exposure method which often desiccates the burn and may extend the depth of the burn. In deeper burns, an allograft can be used as a dressing without surgical debridement to provide protection and aid healing. [21]

Mild first-degree burns with no eyelid contraction may be treated with topical ophthalmic antibiotic ointment and artificial tears. If there is significant eyelid swelling and drooping, cool compresses may be required. In second- and third-degree burns with significant eyelid retraction causing lagophthalmos, in addition to the above treatment, a moisture chamber or cellophane occlusion is placed over the lubricated eye which prevents moisture from evaporating from the surface of the eye. If these are not available or surrounding skin is severely burnt, a suture tarsorraphy may be done. Although this is a temporary measure and may not prevent eyelid retraction, nor is it a substitute for eyelid repair with skin graft; yet in rare cases, it may be the only option for protection of the globe. In severe third-degree burns of the eyelids, surgical relaxing incision over the burn eschar to release the cicatrizing ectropion is given and in addition to this, a suture tarsorraphy may also be required [Figure 14] a and b.
Figure 14: (a) Ectropion of all the eyelids in a patient after 2 weeks of thermal burns. (b) Release and split skin Grafting of the upper eyelids and full thickness grafting of the lower eyelids has been done

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1. Surgical procedures

a. Temporary Suture Tarsorrhaphy

In the presence of lagophthalmos with a severe burn of the eyelid skin, a suture tarsorrhaphy is useful and effective in aiding closure. Suture tarsorrhaphy involves passing a 4-0 suture (nylon, silk, vicryl) through a foam or rubber bolster and through the eyelid skin 4 mm inferior to the eyelashes. The suture comes out of the lower lid through the gray line and then passes through gray line of the upper lid and out through the skin 4 mm above the upper lid lashes. The ends are passed through another bolster and tied over it pulling the lids closed. Bolster reduces chances of cheese wiring through the injured tissues [Figure 15] a-c.
Figure 15: (a) Deep burns involving the face with initial signs of limbal ischemia. (b) and (c): Temporary tarsorrhaohy done on both the sides to prevent further damage.Further required debridement of eschar and grafting to prevent ectropion. (b) and (c): Temporary tarsorrhaohy done on both the sides to prevent further damage. Further required debridement of eschar and grafting to prevent ectropion

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Another modification of this procedure is "Draw string tarsorrhaphy " in which suture is passed through the lower eyelid skin 1 cm apart emerging through the gray line of the lower eyelid. These sutures are then passed through the gray line of the upper eyelid to emerge just below the brow approximately 1 cm apart. A bolster is used to support the lower eyelid to help prevent cheese wiring, and the sutures may be passed so that they emerge at the pre-tarsal upper eyelid (rather than below the brow) if no upper eyelid burn exists. It is also important to avoid passing sutures posterior to the gray line to avoid corneal abrasions. The two suture ends can either be tied to the level of the brow or taped to the forehead using a Steristrip. This type of "draw-string" suture tarsorrhaphy lasts approximately 2 weeks in severe eyelid burns before cheese wiring occurs and the sutures need replacement.

Another simpler option is the use of a Frost suture. This is particularly useful if there is healthy skin on the brow or the cheek to which the frost suture can be taped. This is technically easier than the draw-string tarsorrhaphy and still allows easy access for examination and treatment.

b. Surgical Tarsorrhaphy

A surgical tarsorrhaphy would seem ideal at the 2-week stage when eyelid contracture occurs. Tarsorrhaphy does not appear to prevent wound contraction where cicatricial ectropion is present. [22] A combined lateral tarsorrhaphy with a skin graft produces good results. This maintains lateral elevation and provides further blood supply to the lower eyelid if horizontal shortening has been performed at the same time. Following a gray-line incision at the lateral eyelid margin, the intra-marginal posterior lamella skin is removed, and upper and lower eyelid tarsoconjunctival flaps are sutured using 6-0 vicryl mattress sutures through the cut tarsal edge on the margin. The anterior lamellar (skin and muscle layer) is closed with vertical mattress silk sutures everting the eyelashes away from the globe and supported with bolsters. As the risk for ectropion persists for months due to persistent eyelid shrinkage, a tarsorrhaphy would need to remain in place until facial scars mature. [23]

c. Masquerade Procedure

In severely damaged eyelids where sloughing has occurred and no viable adjacent skin or tissue exists, the masquerade procedure can be carried out as a viable method of closing the eye until further reconstruction can be accomplished. In this procedure, all necrotic tissue including orbicularis and eyelid margins are excised, a conjunctival flap from the remaining upper and lower eyelid tarsal or bulbar conjunctiva are mobilized and sutured together. This covers the anterior surface of the globe with the epithelial surface of tarsal or bulbar conjunctiva. A split thickness skin graft is then applied to cover the entire eyelid area, leaving a small gap nasally and temporarily for drainage of tears. This full-thickness flap is divided horizontally approximately 1-3 months later to create new eyelid margins. Slight eyelid eversion may develop, along with problems of stiffness, ptosis, and variable lagophthalmos; however, the eyelids generally function normally and, more importantly, are able to cover the ocular surface.

d. Split-thickness Dermal Grafts

In the presence of large corneal and scleral defects, where conjunctival flaps may be difficult to fashion, alternative use of a split-thickness dermal graft was reported by Mauriello. [24] The graft was harvested from the thigh after raising a superiorly hinged, thin epidermal flap. A thin dermal graft may then be harvested from the exposed dermal bed, taking care to maintain surface orientation of the graft. The epidermis flap is then perforated and closed. Remaining corneal epithelium is removed with a blade, and the graft is placed on the defect and sutured with 10-0 nylon sutures to healthy sclera and with 7-0 polyglactin to conjunctiva.

e. Tenonplasty

In the absence of nearby conjunctival flaps, the globe can be protected by this procedure. It involves the dissection of the Tenon's layer, anterior advancement, and suturing to the globe at limbus. This provides vascularity and promotes corneal epithelialization. [25]

f. Grafting of the eyelids

In the initial stages of large burns treatment, the priorities may mean burns elsewhere. Moreover, there may be little available skin graft. In addition, good blood supply, redundant eyelid skin, and viable skin intermixed with deep burn may help avoid contracture in first 2-3 weeks. Eyelid grafts when applied in acute stage has to be repeated several times as a split skin graft will contract as against a full thickness graft. However, if thick skin graft is applied when all reaction to burns has subsided, one stage grafting will suffice as the effect of contracting scars of adjacent tissues is minimized.

In general, therefore, eyelid burn debridement is performed at a later time compared to burns elsewhere. [22] Ectropion, lagophthalmos, and tissue destruction becomes evident by 2-3 weeks post injury. During ectropion release all tightness must be relieved in both dimensions and all scar tissue excised. Injury to tendon of LPS should be avoided. Sometimes after this procedure, very little palpebral orbicularis muscle may be left. It is observed that, despite this, its function always returns. Release (with or without excision of eschar) with skin grafting has to be performed when above-mentioned signs appear. [2] [Figure 10]c, [Figure 16]a-c and [Figure 17]a and b
Figure 16: (a) 3 weeks post electrical contact burn with exposed skull bone, ectropion of left upper eyelid and exposure keratitis (b) Grafting of the raw area of the skull after debridement of the dead bone, release of the upper upper eyelid ectropion and coverage with a thick split skin graft (c) Postoperative picture after two weeks of grafting

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Figure 17: (a) and (b) 3 months postoperative picture of a patient with ectropion all eyelids, after release and grafting showing good eyelid movements and proper closure of palpebral aperture.

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Technique of release of established ectropion and skin grafting: A skin crease incision is used for upper eyelid and a subciliary incision for the lower eyelid. The dissection must be from canthus to canthus, extending 2 cm beyond the lateral canthus and well into the nose medially. The eyelid margin is stretched using a gray line silk traction suture often overlapping the other eyelid as much as possible. A layered dissection and excision of the cicatrix is performed until a complete release is achieved. A full-thickness or a thick-split skin graft (depending upon the upper or lower eyelid) is fashioned to fit the recipient bed and 6-0 sutures are used to fit the graft with "epithelial outlay" technique. A petroleum gauze is placed and a bolster dressing done. The traction sutures are maintained for 5-7 days. [27],[28] The full thickness graft (FTG) is usually taken from post auricular, supraclavicular, upper arm, or groin in that order. Though FTG contracts minimally when compared to the split thickness skin graft (STSG), hair growth in the grafted site is a problem to be dealt with. In case of extensive burns, STSG is used initially and FTG is reserved for later stage owing to limited available skin.

Staging of eyelid grafting

If both upper and lower eyelid require grafting, to maximize the stretched graft bed for each eyelid, grafting is performed at separate sessions. The lower eyelid must be operated first followed by upper eyelid with a minimum of 5-7 days duration between the two.

In bilateral surgery, this may require closure of both the eyes with a special concern to infection. Increased discharge or pain prompts removal of the pad or bolster to allow examination.

Management of sequelae

The eyelids should be evaluated at a later stage for their retraction, protraction, tear pump function, and cosmetic appearance.


This can be corrected by lower eyelid sling procedure.

A strip of temporalis fascia or fascia lata is passed in the pretarsal, suborbicularis plane using a suture loop or Wright's needle and sutured to medial canthal tendon and either to lateral periosteum or lateral orbital rim via a drilled hole. This just provides vertical support as in facial palsy patients as it does not overcome contraction or tissue deficit.


This occurs after eyelid malposition is corrected. This is initially managed at the time of ectropion surgery with epilation. Repeated epilation and electrolysis is required. Despite all measures fine hair recurs which can be treated by cryotherapy.

Canthal deformities

Severe webbing, hypertrophic folds, vertical contractures, forward displacement of punctum, and epiphora are common in later stages of deep burns involving the canthi.

Multiple Z plasties, five flap Z plasties, excision and replacing the defect with FTSG, and local transposition flaps are the options for their management.

  Reconstructive flaps for eyelid region Top

In burns, owing to the limited normal adjacent skin, the flaps in this region are limited.

Lower eyelid defects [29],[30]

  1. Defects involving up to 1/3 of the eyelid can be closed directly in layers. Any defects more than this will lead to excessive tension by direct closure.
  2. Defects involving 1/3 to 1/2 of the eyelid: Can be corrected by Tenzel's semicircular rotation flap. A semicircular musculocutaneous flap beginning at the lateral canthus is rotated and sutured into the defect. The lateral canthus is then fixed, conjunctiva is rotated and sutured to cover the posterior defect, and the skin closed at the donor region.
  3. Defects of more than 1/2 of the lower eyelid: Can be corrected by Modified Huges procedure. It is a tarsoconjunctival bridge flap from the upper eyelid to cover Tarsus and conjunctiva of the lower lid. Upper eyelid are incised horizontally 4 mm proximal to the eyelid margin. At least 4 mm of tarsus must be left for lid stability and to prevent the complication of upper lid entropion. A tarsal conjunctival flap is raised by dissecting the tarsus and conjunctiva away from the levator aponeurosis and Müller muscle. The bridge flap is advanced into the defect of the lower eyelid and its edges are sutured to the remnants of the medial and lateral tarsus of the lower eyelid. If the lower eyelid defect involves either the medial or lateral canthal angle, the tarsoconjunctival flap must be fixated appropriately either to the lateral orbital tubercle or to the posterior lacrimal crest. A full-thickness skin graft from upper eyelid or retro auricular region is placed over the anterior surface. The flap is separated at 4-6 weeks. [31]

    Another method to reconstruct this defect is by a free tarsoconjunctival graft. This composite graft is harvested from the upper eyelid tarsus of the opposing eyelid or from the alternate upper eyelid. A marginal 4-mm strip of tarsus is left in the donor eyelid. Edges of the free tarsoconjunctival graft are sutured to the edges of the lower eyelid defect. Conjunctiva at the inferior border of the free tarsoconjunctival graft is sutured to the palpebral conjunctiva. The anterior lamella is reconstructed by a local musculocutaneous flap.
  4. Defects involving the entire lower eyelid: May be reconstructed using a Mustarde cheek rotation flap. Incision begins at the lateral canthal angle, extends upward onto the temple, and swings posteriorly just anterior to the ear and then inferiorly across the mandible. Establishing good vertical height to this flap is important so the correct position of the lateral canthal angle can be achieved postoperatively. The posterior lamella of this flap must be reconstructed with a free tarsoconjunctival graft, a nasal septal cartilage graft, or with mucosal grafts.

Upper eyelid defects [29],[30]

  1. Defects involving up to 1/3 of the eyelid can be repaired by direct closure by a pentagonal wedge excision technique and layered closure.
  2. Defects involving up to 1/3to 1/2 of the eyelid can be corrected by Tenzel semicircular flap as in the lower lid.
  3. Defects involving more than 1/2 of the lid can be reconstructed by Sliding tarso conjunctival flap which is a variation of modified Huges procedure described for lower eyelids. Only the medial and lateral defects can be reconstructed. It is not suitable for central defects. The remaining tarsus is used as structural support (posterior lamella), and a skin graft or local musculocutaneous flap is used for the anterior lamella. As in any eyelid reconstruction, canthal attachments must be secure and in proper position.
  4. Large central defects of the upper eyelid: Can be reconstructed by Cutler-Beard procedure which uses a full-thickness segment of lower eyelid tissue that is passed under an intact bridge of the lower eyelid margin and is sutured into the defect in the upper eyelid. This also occludes vision for 6-8 weeks and must be divided in a second stage. It is, therefore, not suited for patients sighted only in the involved eye or of amblyogenic age.
  5. Free tarsoconjunctival graft: This is taken from the patient's contra lateral upper eyelid and is sutured in place with edges parallel to the edges of the defect. A vascularized anterior lamella is provided from adjacent tissue.

Palpebral aperture stenosis
"Port hole" deformity is due to cicatricial eyelid margins and exaggerates scar contracture in full-thickness eyelid burns. This deformity is also seen after extensive eyelid grafting for contracture and lagophthalmos. After correcting the upper and lower eyelid tissue deficit, a simple incisional release is adequate.

Eyebrow deformities

Depending upon the depth of the burn, loss of eyebrows may be partial or complete. A full-thickness composite graft of hair bearing skin from the temporo-parietal region of that side is an ideal choice of treatment. The thickness should not exceed 5 mm or alternatively 1 mm strips are used in a staged manner owing to the scarred recipient site. The flaps should be cautiously thinned to avoid damage to the hair follicles. Another method is to use the pedicled temporal flaps based on a branch from temporal artery. The eyebrow should be placed more medially due to subsequent contraction that pulls the graft laterally. Recent advances in micro graft techniques of hair transplantation produces natural eyebrow profile. The patient's gender influences the choice of procedure. In female patients makeup and eyebrow pencil can camouflage a missing eyebrow. In men, who require a thick bushy eyebrow a flap procedure may be preferable [Figure 18]a, b and [Figure 19]
Figure 18: (a) Post burn loss of right eyebrow. (b) Eyebrow reconstruction done with islanded flap based on superficial temporal artery

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Figure 19: Composite grafts from the scalp to reconstruct both the eyebrows

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Canalicular obstruction

Direct lacrimal damage is rare. But burns around the medial canthus may involve the puncta and canaliculi. In early stages, daily punctal probing with re-evaluation every 1-2 days with fluorescein dye disappearance test and repeat punctal dilatation if necessary. In later stages, punctoplasty and canaliculoplasty are the options. The incidence of asymptomatic punctal or canalicular stenosis is uncertain. However, in the presence of severe ocular surface injury and dry eye, there is a benefit of reduced tear flow.

  Conclusion Top

The final outcome of an eye burn depends on the cause of the burn, the depth of the injury, which structure (s) of the eye were involved, whether other parts of the body were burned, and the development of complications. With eye burns of any type, close follow-up care is important during the first several weeks to prevent scarring, exposure keratitis and other sequelae of ocular and periocular burns. Primary prevention and patient counseling on proper eye protection, first aid measures, and initial management is essential because most of the ophthalmic complications can be avoided with these measures.

The medical team working in the burn casualty must emphasis on the first aid measures in all facial burn patients like irrigation of the eyes, trimming of the charred eyelashes, use of artificial tears, padding of the eyes, and topical antibiotics. A thorough ophthalmological examination in the first 24 hours of burn injury must be made mandatory. Consequent eye examinations must be made to look for any adverse consequences and any intervention made as early as possible to prevent adverse outcomes in these patients.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19]

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