MANAGEMENT OF EYELID BURNS

Maviii E., Kayikcioglu A.

Plastic and Reconstructive Surgery Department, Hacettepe University, Ankara, Turkey

SUMMARY. Management of eyelid bums requires great care in the protection of the cornea. A 38-year-old male patient with severe ectropion was evaluated 8 months after a burn accident and treated by dermabrasion, overgrafting and cornea transplantation.

Introduction
A large percentage of patients admitted to hospitals with burns involving the face also have burns of the eyelids (Huang, 1978). Reflex blinking of the eyelids in response to heat or smoke often protects the cornea and the eyelid margins.
Most eyelid burns are the result of exposure to fire, and not of direct contact with hot materials or chemicals. If the exposure is brief, a second-degree burn of the eyelid skin may result. A more intense heat of longer duration may cause a full-thickness burn of the eyelid skin (Burns, 1979; Converse, 1967; Huang, 1978; Miller, 1979).

Presentation of the patient
A 38-year-old male with second-third degree bums which affected 40% BSA, involving face, eyelids, neck, arms, hands and chest, was treated at our burns unit for 6 months. The third-degree burns on the arms, chest and anterior neck were Managed through debridement and skin grafting. The Opthalmology Department used , non-surgical methods, including artificial tears and moist,c6vering, in the eyes to prevent drying of the cornea. When the patient was referred to the Plastic Surgery Department 8 months after the burn injury, he had bilateral ectropion of the lower and upper eyelids. He had nearly complete loss of vision. His vision was limited to perception of light due to the opacity that had developed on both corneas. Cornea transplantation was contraindicated because of intensive vascularization of the sclera and the lack of the protective and lubricating action of the eyelids (Reim, 1989).
The right half of the nose was absent both in skin and cartilage. The nasal septum was exposed completely on this side. The left nostril was retracted upwards.

Fig. Ia. Pre-operative anterior view Fig. lb. Pre-operative lateral view. Fig. lc. Pre-operative anterolateral view.

Fig. 2. Intra-operative view of periorbital and nasal reconstruction after completion.

The patient underwent surgery for reconstruction of the eyelids and nose. In the first operation a forehead flap was used for nasal reconstruction, the donor site of the flap being covered with a split-thickness skin graft.
In the second operation the forehead flap was revised. The upper and lower eyelids were relaxed with horizontal incisions. The burn scars on the periorbital regions were covered only by a thin layer of epithelium. Unhealthy, fragile epithelium was removed with the use of a dermabrader. The upper and lower eyelids were then closed tightly with tarsorrhaphy sutures and the dermabraded periorbital areas were covered with split-thickness skin grafts. Two strips of hairy skin harvested from the scalp were placed on the defect created by the upper relaxing incisions for eyebrow reconstruction. After the operation, a remarkably good protective function of the eyelids was restored and, soon after, vascularization of the sclera reduced and the oedema subsided.

Fig. 3a. Late post-operative period, eyes open. Fig. 3b. Late post-operative period, eyes closed. Successful eyelid function despite a 3 mm closing defect of the right eyelid.

Two months later, the opacified left cornea of the patient was replaced with a cornea transplant by the Ophthalmology Department. The patient is now able to read his newspaper, with a vision of 4/ 10 (according to the Snellen chart) in the left eye. Right eye cornea reconstruction has been scheduled.

Discussion
The acute management of eyelid burns includes gentle eyelid and eyelash hygiene to prevent crusting. Topical ophthalmic antibiotic ointments and artificial tears should be applied frequently. The upper eyelid is responsible for moistening the cornea; when there is a deep upper eyelid burn the potential for corneal dehydration is therefore present. Patients with eyelid burns should be examined daily especially while asleep. When the patient is asleep the voluntary component of lid closure is lost and the cornea may be partially exposed even if it is completely closed in daytime (McCarthy, 1990). If nonsurgical measures of corneal protection are not adequate, surgical measures should be carried out as soon as possible. Although tarsorrhaphy has been advocated for corneal protection in the past it does not prevent lid retraction in the long term and is not an appropriate substitute for timely skin grafting (Miller, 1979). If skin grafts are applied in time there is no reason for corneal ulcers and opacities. Although there are numerous reports of eyelid burns and corneal transplantation in corneal opacities as separate entities, there are few descriptions in the literature concerning corneal transplantation in burned eyelids (Durand, 1990; Reim, 1989; Saparovskii, 1990). If the cornea is opacified owing to delay in the appropriate treatment, such as in our case, cornea transplantion cannot be performed unless the inflammatory process in the eye settles down. This inflammatory process is characterized by ulcerations on the cornea, intense vascularization of the sclera, and oedema of the conjunctiva (Reim, 1989). The condition of the eyes develops remarkably after tarsorrhaphy, but if there is tissue lossl as in deep burns, this procedure should always be followed by grafting. The grafting of the periorbital region should include not only the obvious defects but also the unhealthy epithelium -covered areas, to prevent contracting of the tissue in the long-term follow-up of the patients.

RÉSUMÉ. Le traitement des brúlures de la paupiére exige des soins trés méticuleux pour protéger la cornée. Les auteurs décrivent un patient ágé de 38 ans atteint d'ectropion grave qui a été traité, huit mois aprés 1'incident qui a provoqué la brúlure, moyennant la dermabrasion, la couverture avee greffe, et la transplantation de la cornée.

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