The Management of Eyelid Burns

doi:10.1016/j.survophthal.2009.02.009

Survey of Ophthalmology

Volume 54, Issue 3, May–June 2009, Pages 356-371

https://doi.org/10.1016/j.survophthal.2009.02.009 Get rights and content

Abstract

Eyelid involvement is common in facial burns. Ocular sequelae, including corneal ulceration, are usually preventable and secondary to the development of eyelid deformities, exposure keratopathy, and rarely, orbital compartment syndrome. Early ophthalmic review and prophylactic ocular lubrication is mandatory in burns involving the eyelids. Early surgical intervention, often requiring repeat procedures, is indicated if eyelid retraction causing corneal exposure occurs. Permanent visual impairment is rare with such prompt management. No binding aphorisms exist regarding the tissue used for eyelid reconstruction, with each case requiring an individual approach based on available skin. This review article covers the principles of ophthalmic management in addition to intermediate and long-term management of eyelid burns.

Introduction

Facial burns are a common sequelae of thermal trauma,⁴⁴ and ocular involvement is relatively common, occurring between 7.5% and 27% of patients admitted to burn units.⁶ The loss of an eye primarily from a thermal injury is rare.⁴² This is due to protective mechanisms such as the blink reflex, Bell phenomenon, and protective movements of the head and arms to avoid the source of a burn. The initial corneal or ocular surface injury can be quite trivial compared to the injury sustained to the eyelids.⁴² Most ocular sequelae, including corneal ulceration, occur secondary to the development of eyelid deformities after the initial burn injury. Secondary complications such as exposure keratopathy, secondary infection, and orbital compartment syndrome are potentially preventable by appropriate early and sustained management.

Controversies exist regarding the role of prophylactic ocular lubrication, excision and debridement of eschar, temporary suture and surgical tarsorrhaphy, timing of surgery for eyelid contraction, and the role of full and split-thickness skin grafts in eyelid reconstruction.

We review the current literature regarding the management of eyelid burns, and in particular the role of the ophthalmologist and oculoplastic surgeon in the care of these patients. The management of ocular surface or corneal defects, chemical injuries, and their secondary ocular complications are beyond the scope of this article.

Section snippets

Epidemiology

The authors manage the surgical care of patients at the regional Burns Centre at the Queen Victoria Hospital, East Grinstead, UK. By far the most common thermal burn is the scald burn from hot water and the most common place to sustain this is at home. Children, the elderly, and the disabled are most prone to burn injury as the result of their impaired mobility and immature or impaired mental function.⁸ Seizures and unconsciousness secondary to cardiac or vascular events are also major causes

Pathophysiology of Thermal Burns

Burn injury results in the release of multiple inflammatory mediators that result in vasodilatation, pain, and edema. Exudation from the wound is greatest in the first 24 hours, athough this may continue for days. The associated edema may also take days to resolve.

The depth of burn depends on the intensity of heat exposure, the duration of exposure, and the thickness of epidermis and dermis.⁸ Periocular skin is thin with no subcutaneous fat, resulting in deeper burns than a similar exposure to

Epidermal burns (first-degree burns)

This corresponds to the zone of hyperemia in Jackson's model. Severe sunburn is the most common first-degree burn. By definition, this affects only the epidermis, and blistering is not common. Pain is due to local vasodilator prostaglandins, and healing is usually complete within a week. Undamaged keratinocytes regenerations within skin adenexae, and scarring does not occur.

Partial-thickness burns (second-degree burns)

Partial-thickness burns involve the dermis and epidermis. This corresponds to the zone of stasis in Jackson's model.

Principles of Ophthalmic Management

Most ocular sequelae, including corneal ulceration are potentially preventable and are secondary to the development of eyelid deformities because of inadequate or delayed treatment of the initial burn injury. The role of the ophthalmic and oculoplastic surgeon is therefore vital in the early management of these patients.

Conclusion

Eyelid involvement is common in facial burns. Most ocular sequelae, including corneal ulceration, are thought to be preventable. Prompt ophthalmic consultation and prophylactic ocular lubrication are mandatory in burns involving the eyelids. Early surgical intervention, often requiring repeat procedures, is indicated if eyelid retraction causing corneal exposure occurs. There are no hard and fast rules regarding the tissue used for eyelid reconstruction, and each case needs an individual

Method of Literature Search

Literature search was based on a Medline search with Pubmed (Embase, ophthalmic literature) including the keywords thermal eyelid burn, eyelid burn, burns of ocular adenexae, masquerade procedure, eyelid grafting, lagophthalmos, tarsorrhaphy. There was limitation by date from 1940 to 2006. Articles were restricted to those in English and other-language publications with English abstracts. References within these articles were also obtained for review.

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Cited by (54)

Management of multi-surface ocular burns caused by molten iron
2023, Trauma Case Reports
Ocular thermal burns are medical emergencies that require immediate intervention before the standard management protocol, which involves obtaining a detailed history and performing an ophthalmic examination. In this case report, we report the clinical manifestations of ocular burns caused by molten iron and the steps taken for good clinical outcomes. The patient presented with an inferior epithelial defect and limbal and lower lid ischemia at four hours post-injury. Over the course of treatment, due to non-resolving epithelial defect and increased superior lid notching, amniotic membrane transplantation (AMT) and lid repair by pentagon wedge excision were performed. Following AMT, the corneal surface completely healed with residual opacity and neovascularization. Additionally, limbal ischemia was significantly reduced with the restoration of normal lid anatomy. Corneal burns initiate a cascade of inflammatory reactions disrupting the balance between pro- and anti-angiogenic factors, leading to corneal neovascularization. The eyelid damage can lead to necrosis of tissues with eschar formation and eventually quantitative tissue loss. Therefore, timely intervention is the key to the successful management of ocular burns.
TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface
2023, Ocular Surface
Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed.
Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, “sick” building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases.
A systematic review was conducted to answer the following research question: “What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?” Dry eye disease is associated with air pollution (from NO₂) and soil pollution (from chromium), but not from air pollution from CO or PM₁₀.
Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.
Ocular-periocular burns in a tertiary hospital: Epidemiologic characteristics
2023, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
In cases of lagophthalmus due to cicatricial eyelid changes, skin grafting and conjunctival flap were performed as early as possible. Severe full-thickness burns required excision of the affected tissue and early skin grafting.13 In severely damaged full-thickness eyelids, a conjunctival flap was mobilized from the remaining upper and lower eyelids (usually the bulbar conjunctiva) and sutured to close the surface of the eye.
Ocular burns are ophthalmic emergencies that can cause devastating injuries. This study aimed to analyze the epidemiology, complications, and management of ocular-periocular burns.
A total of 193 patients with ocular-periocular burns were admitted to our tertiary hospital from January 2018 to December 2020. The demographic characteristics of the patients, injury variables, complications, and treatments were evaluated.
There were 142 male (73.6%) and 51 female (26.4%) patients with a mean age of 32.53±17.75 years. The average total body surface area was 12% (range, 1–80%). Injuries were most common at work (52.3%) and home (36.3%). Thermal burns were the most common injuries (74.6%), followed by chemical (14.5%) and electrical burns (10.9%). Alkaline agents (75.0%), mainly sodium hydroxide and lime, were common in chemical burns. Superficial lid burns were significantly higher in the thermal group (p < 0.001), and grade III-IV corneal burns were significantly higher in the chemical group (p < 0.001). Various complications were developed in 50 (13%) eyes. Medical treatment only was performed in 318 (82.4%) eyes, and additional surgical treatment was performed in 64 (17.6%) eyes; however, 54 (14.0%) underwent more than one surgery. The most common complications were corneal scars (7.3%), limbal deficiency (4.1%), and ectropion (3.9%). The most frequent procedures performed were amniotic membrane transplantation (AMT) (11.9%) and tarsorrhaphy (6.7%).
Chemical burns, limbal and conjunctival ischemia, and full-thickness eyelid defects had a poor prognosis. The degree of limbal deficiency and ınjury of intraocular structures were found to have a great influence on the outcome of their visual acuity.
Treatment of upper eyelid third-degree burns by dispersed implantation of very small autologous columnar skin grafts: A pilot study of a new method
2022, Burns
This retrospective study compared the effectiveness of dispersed implantation of very small autologous columnar skin (SCS) grafts and full-thickness skin grafts (FTSGs) for treating upper eyelid third-degree burns.
Fourteen patients and 26 eyes with granulation tissue formed by third-degree upper eyelid burns were enrolled in the study from August 2017 to June 2020. The experimental group of 6 patients with 11 eyes was treated with SCS grafts. The control group of 8 patients with 15 eyes was treated with FTSGs. The survival rate of the grafts, healing time, SCS diameter, upper eyelid movement distance (ULMD), visual analogue scale (VAS) score for patient satisfaction, and Vancouver Scar Scale (VSS) score were evaluated.
The difference in the survival rate between the two groups was not statistically significant (P = 0.06). The ULMD and VAS scores in the experimental group were higher than those in the control group (P < 0.05). The healing time was longer in the experimental group than in the control group (P < 0.05). The VSS scores of the donor site and the skin grafting site in the experimental group were lower than those in the control group (P < 0.05).
Unlike classical skin grafts, SCS implantation surgery can restore the appearance of the upper eyelid, and there is no obvious scar at the donor site. This can be a viable alternative to traditional FTSGs with potential benefits
Surgical repair of the sequelae of simultaneous burns of the four eyelids
2019, Presse Medicale
Case report of Wolfe grafting for the management of bilateral cicatricial eyelid ectropion following severe burn injuries
2018, Annals of Medicine and Surgery
Citation Excerpt :
Reconstruction of the cicatricial ectropion following face burns should have priority in planning and management of further treatment, although usually that is hard to obtain in case of large affected skin areas [7]. Incision and skin release without eschar excision is recommended by some authors [3], while others suggest that escharectomy is necessary for successful skin grafting and prevention of contracture [7,8]. If the orbicularis oculi been viable, it should be freed completely to avoid subsequent ectropion and scaring [4].
Eye lid reconstruction followed by severe, extensive body and facial burns represents a surgical challenge due to difficulties to obtain proper, healthy skin graft, tissue ischemia and necrosis.
We present a reconstructive lid surgery of cicatricial bilateral lower eyelid ectropion in a case of 31-year-old man who sustained thermal injuries, affecting more than 60% of total body surface area, causing severe, deep dermal burns. Reconstruction was made using the technique of skin cantus-to-cantus incision, contracture release, orbicularis liberation and lid elevation; and oversizing free full-thickness skin graft (FTSG) (Wolfe technique) from the left inguinal region, as the only healthy skin on the entire body surface. Residual lower left lid laxity was addressed by pentagonal wedge resection, not interrupting marginal arcade vessels, thus minimizing ischemia.
Method of choice of the graft type has been much debated question; however, significantly less reoccurrence rate of ectropion was observed using FTSG. Time of grafting should be balanced to avoid excess granulation and, thus scaring caused by delayed grafting time, or poor graft adherence caused by premature grafting. An interruption of the marginal arcade vessels should not be performed due to already severe ischemic process and increased risk for lid necrosis.
Major issues when addressing cicatricial ectropion followed by severe burns are: right donor site selection, appropriate graft thickness with the least possible disturbance of the affected place vascularisation, followed by immediate grafting after debridement of scaring and unhealthy tissue, with generous preservation of the orbicularis muscle.

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: The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. The authors wish to thank Jean-Louis deSousa for creating all line drawings.

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Major ReviewThe Management of Eyelid Burns

Abstract

Introduction

Section snippets

Epidemiology

Pathophysiology of Thermal Burns

Epidermal burns (first-degree burns)

Partial-thickness burns (second-degree burns)

Principles of Ophthalmic Management

Conclusion

Method of Literature Search

Am J Ophthalmol

Burns

Clinics Plastic Surg

Burns

Burns

Br J Plastic Surg

Br J Plast Surg

Br J Plast Surg

Br J Plastic Surg

Burns

J Br Plast Surg

Acute and reconstructive management of the burned eyelid

Clin Plast Surg

Tarsorrhaphy, clinical experience from a cornea practice

Cornea

Early release of third-degree burns prevents eye injury

Plast Reconstr Surg

Physiological response to crystalloid rescuscitation of severe burns

Ann NY Acad Sci

Eyelid trauma repair

Ocular complications of thermal injury: a 3-year retrospective

J Trauma

The management of thermal burns of the lids and globes

Ann Ophthalmol

Burn Care and Therapy

Management of periocular post burn scarring in the epileptics

J Coll Physicians Surg Pak

Single-hair transplantation by Choi's procedure

Int J Cosmetic Surg Aesth Dermatol

Repair of severe burn ectropion of the eyelids

Plast Reconstr Surg

Using lower eyelid fascial slings for recalcitrant burn ectropion

Ann Plast Surg

Secondary correction of the burned eyelid deformity

Plast Reconstr Surg

The early treatment and reconstruction of Eyelid burns

J Trauma

Eyebrow transplantation

Dermatologic Surg

Management of periorbital burns

Semin Ophthalmol

Major Review
The Management of Eyelid Burns