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In a dog bite to the eye, swelling of the lids can hide injury to the tarsal plate.
A girl of 2 was brought to casualty after being bitten on the face by a labrador. On examination she had a deep laceration on the left side of the nose starting from the nasion and running down to the left lower eyelid just below the medial canthus (Figure 1). The lower eyelid was so swollen that the lid margins could not be properly assessed. An ophthalmologist in a distant hospital was reluctant to examine the eye until the oedema had subsided. Under general anaesthesia the vertical laceration of the upper eyelid was found to divide the tarsal plate completely. The nasolacrimal duct was intact. After a thorough washout of the lacerations, the nasal and other lacerations were repaired. A stay suture was inserted first at the lash margin and held by an artery clip without being tied. Once the edges of the laceration and the lid were under control, the cornea was protected by a shield and the tarsal plate was repaired with fine soft absorbable, 7/0 Vicryl, interrupted sutures inserted from the cutaneous side. The bites included the orbicularis but spared the palpebral conjunctiva. The knots were placed towards the skin, which was subsequently closed with 6/0 Vicryl. The stay suture was removed and the lid margin was sutured with 7/0 Vicryl. Recovery was uneventful and three weeks postoperatively the girl had an acceptable scar (Figure 2).
Eyelids are complex structures and discovery of a previously unidentified injury can cause serious difficulties during the repair.1 When a residual defect requires further intervention under anaesthesia, this not only adds to parental distress but also increases the likelihood of a poor long-term result. In the past, because of their reputation for infection, these injuries were often left open and repaired after an interval but primary closure is now favoured because of its better cosmetic results. This, however, demands periocular examination of a thoroughness difficult to achieve in children without anaesthesia. In addition, these injuries should ideally be assessed by an ophthalmic surgeon before surgery, but not all hospitals can offer rapid access to such specialists.
According to Mcheik et al.,3 the incidence of dog bite in children decreases with increasing age. However, in our experience the peak is in those aged 6–10. Of the 24 children admitted to our unit in 2003 for treatment of dog bites 3 were aged 0–5, 15 aged 6–10, and 6 aged 11–16. Median age was 9, M/F ratio 2/1. In the published work, there is a strong emphasis on canalicular injuries.4 Damage of the sort described here, with full-thickness laceration of the eyelid, has received little attention, yet unless these bites are repaired with proper technique and appropriate suture material the patient may be left with a notched lid margin, a kinked tarsal plate and long-term friction injury to the cornea.5 Upper lid repairs are particularly demanding technically since the tarsal plate is wider, the cornea lies just underneath, and involvement of the levator muscles presents a risk of ptosis. The strongest structure in the lid is the tarsal plate, and the key to good surgical repair is restoration of its integrity.