|Year : 2015 | Volume
| Issue : 2 | Page : 61-63
Eyelid avulsion due to bull horn injury: A rare presentation
Pradnya Kamat, Pratik Doshi
Department of Ophthalmology, Goa Medical College, Goa
|Date of Web Publication||12-Nov-2015|
168, 8/2, Kamat Nursing Home, Upper Bazaar, Ponda Town, Goa
A 52-year-old female presented with a history of bull horn injury to the right eye. Examination revealed an avulsed flap of right lower eyelid starting from a point just lateral to the lacrimal punctum up to the lateral canthus without any other ocular or orbital damage. After a thorough assessment and cleaning, lid flap was sutured in layers. Postoperative antibiotic prophylaxis was given. Eyelid wound healed without complications.
Keywords: Avulsion, bullhorn, eyelid, gore
|How to cite this article:|
Kamat P, Doshi P. Eyelid avulsion due to bull horn injury: A rare presentation. Sudanese J Ophthalmol 2015;7:61-3
| Introduction|| |
Bull or cow horn injuries are not uncommon amongst agricultural workers. However, most of these injuries involve abdomen and perineum.  Bull horn injuries to head or face can be in the form of lacerations, fractures, palate injuries, blow out fracture of orbit, and eyeball injuries.  Ocular injuries due to bullhorn are uncommon and are almost always visually threatening open globe injuries with or without orbital fractures.  The literature search did not reveal any case of horn injury causing only eyelid avulsion without affection of the globe or any other orbital structures, and hence, we report this interesting case.
| Case report|| |
A 52-year-old female presented in the Emergency Department with a 4 h history of being hit by bull horn in the right eye while cleaning the shed. There was no history of a decrease in vision.
Examination revealed an avulsed flap of right lower eyelid starting from a point just lateral to the lacrimal punctum up to the lateral canthus [Figure 1]a. A small inferior sub-conjunctival hemorrhage was noted. The rest of the eye was unremarkable with best corrected visual acuity of 6/6 in both eyes. Fundus examination was within normal limits.
|Figure 1: (a) Colored photograph showing avulsed right lower eyelid flap without any tissue loss and an intact globe. (b) Colored photograph showing a well-apposed lid flap after suturing|
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Suturing of the avulsed flap was undertaken under local anesthesia after thorough wound cleaning with saline and 5% povidone-iodine solution. Lid flap was sutured in layers using absorbable 6-0 vicryl suture, and skin suturing was done using interrupted 3-0 silk sutures. Marginal sutures were taken and suture ends cut long and anchored to forehead skin [Figure 1]b. The patient was vaccinated against tetanus and was prescribed topical moxifloxacin eye drops 4 times per day and systemic antibiotics (amoxicillin-clavulanic acid and metronidazole) for 1-week. Skin sutures were removed after 1-week. Postoperative recovery was good with no signs of infection [Figure 2]. However, stenosis of lacrimal punctum was noted.
|Figure 2: Colored photograph after suture removal at 1-week. Note increased marginal tear meniscus (probably due to stenosed inferior lacrimal punctum)|
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| Discussion|| |
Bull or cow horn injuries are common amongst people dealing with animals. Although ocular injuries are uncommon, the knowledge of the mechanism of these injuries is essential in understanding the nature of the damage possible. The type of injury caused and the depth of wound depend on various factors such as position of the person being charged, the speed and direction of movement of the bull's head, reflex reaction of the person, and sharpness or pointing of the bullhorn.
Depending on the interplay of all these factors, a bull horn injury to orbit can result in either a closed globe injury or more commonly, an open globe injury either in the form of globe rupture or perforating wound.  Bull horn injuries have certain common characteristics such as muscular tearing, several wound paths, introduction of foreign bodies, discrepancy between the apparent and actual wounds, massive inoculation of germs, etc., that make detailed examination and assessment of wounds necessary prior to deciding about appropriate treatment.
Eyelid avulsion due to bull horn injury as a sole finding is extremely rare. It is usually the result of the blunt tangential impact on the side of the horn that leads to horizontal traction on the eyelid which causes avulsion at a weak point, usually at the medial or lateral canthal tendon. However, sometimes avulsions starting from other areas can occur.
Eyelid avulsions should be repaired by suturing only after a thorough assessment of the damage that is caused to the muscles, nerves, blood vessels of the eyelid, and more importantly lacrimal drainage system.  If the canalicular damage is found, repair by stenting should be undertaken prior to the repair of the avulsed lid flap.  Avulsed flap should be sutured in layers after thorough cleaning with an antiseptic solution. , When associated with lid margin lacerations, it requires precise suture placement and critical suture tension to avoid notching of eyelid margin which can disrupt tear pump function postoperatively. This can be accomplished by sutures for alignment through the lash line, Meibomian gland More Details plane and gray line, and keep ends long.  In our patient, stenting was not undertaken as the lacrimal punctum was found to be just medial to the avulsed flap on the day of injury. However, at 1-week follow-up a stenosed punctum was noted. Hence, we concluded that stenting must be considered in any case of avulsion injury in close proximity to the punctum.
Bull horn injuries are almost always contaminated by various microbes and stand a high-risk of local infection from the time of occurrence.  To prevent infection of the wound, it should be cleaned meticulously to remove any foreign body with copious saline wash and antiseptic solution like 5% povidone iodine (as it is safe for contact with ocular tissues). The patient should be treated with broad spectrum antibiotic and also receive tetanus vaccination. Martínez-Ramos et al. indicated that the antibiotic combination most often used is metronidazole and amoxicillin-clavulanic acid. Various other combinations can be used such as metronidazole and tobramycin (or amikacin) with or without ampicillin.  Whatever antibiotic combination is used, it is indispensable that it covers aerobic, both Gram-negative and Gram-positive, and anaerobic microorganisms.
In summary, a patient who has been gored by a bull must be considered initially as a patient with poly-trauma and assessed immediately in emergency services. Eyelid avulsion injuries should be sutured only after careful examination of the globe to rule out occult rupture and lacrimal drainage system damage. Canalicular stenting should precede repair of any eyelid avulsion in which line of avulsed flap passes close to the punctum or canaliculus. Finally, it is important that precautions are taken by people involved in cattle-related jobs to reduce the risk of injury to the eyes and in case of an eye injury, to present as early as possible to an ophthalmologist in order to improve the chances of visual recovery and decrease chances of infection.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]