46 Tarsorrhaphy (Temporary and Permanent)
This chapter describes both the temporary and permanent options to join the upper and lower eyelids. Tarsorrhaphy may be indicated to protect the ocular surface, forestall eyelid retraction after surgery, or to maintain a conformer or prosthesis. Temporary tarsorrhaphies include different suture techniques, both adjustable and nonadjustable, that can be performed quickly and may be vital for treatment of acute ocular surface exposure. Permanent tarsorrhaphy options include intermarginal adhesions and minor flaps, when long-term management of corneal exposure is necessary. Even after a tarsorrhaphy is placed, continued monitoring is required to ensure appropriate ocular surface protection.
A tarsorrhaphy is the temporary or permanent joining of the upper and lower eyelids. Surgical closure of the eyelids is most frequently indicated to protect the cornea and ocular surface in the setting of exposure from lagophthalmos or eyelid malposition. Other indications include maintenance of a conformer or ocular prosthesis in the anophthalmic socket, and counter traction (e.g., Frost suture tarsorrhaphy) after eyelid surgery especially in the setting of a graft. A tarsorrhaphy may be placed medially or laterally for partial coverage and to preserve the central visual axis, or centrally to completely cover the eye when necessary.
A tarsorrhaphy is a powerful and relatively simple, usually reversible technique to provide immediate protection to the ocular surface. It is usually expedient and can often be completed in the office or at bedside with local anesthesia and no sedation. There are many tarsorrhaphy variations, including temporary and permanent, as well as partial and complete. A partial tarsorrhaphy closes the lateral and/or medial portion of the eyelids maintaining a central opening to preserve the visual axis and space for ocular examination. A complete tarsorrhaphy ensures closure of the entire palpebral aperture for maximal protection. An adjustable suture is a temporary measure that allows for repeated opening and closing of the eyelids that afford ocular examination and medication administration. 1 A Frost suture tarsorrhaphy provides counter traction postoperatively to forestall or correct eyelid malposition after some types of eyelid surgery.
Tarsorrhaphies can provide symptomatic relief, improved corneal protection, and expedited healing due to exposure. Suturing the eyelids together can be distressing for some patients and cosmetically unacceptable for others.
46.4 Key Principles
A successful tarsorrhaphy achieves the appropriate amount of eyelid closure. The decision for a temporary versus permanent tarsorrhaphy is based on the desired duration of ocular surface coverage. Tarsorrhaphies with or without bolsters should bring the upper and lower eyelids in tight apposition to cover the corneal surface or in cases of anophthalmia, to prevent extrusion of the conformer or prosthetic eye. 2 During the placement of a tarsorrhaphy, care should be taken to avoid damage that may cause scarring or trichiasis.
A tarsorrhaphy is indicated to protect and promote healing of the ocular surface in the setting of corneal exposure, infection, or poor healing. Other applications are to forestall eyelid retraction immediately following eyelid surgery (i.e. Frost suture tarsorrhaphy), as well as to help maintain a conformer, symblepharon ring, or an ocular prosthesis in the anophthalmic socket.
Temporary suture tarsorrhaphy is indicated when immediate protection of the cornea is needed due to inadequate eyelid closure. Suture tarsorrhaphy may be particularly useful when corneal sensation is impaired since the absence of pain or discomfort that normally induces volitional eyelid closure increases the risk for corneal damage and infection. Acting as a natural bandage, a tarsorrhaphy can promote healing of ocular surface disorders including persistent epithelial defects, corneal thinning, or postinfectious sterile corneal ulcers. When used for these indications, a temporary tarsorrhaphy can be customized to protect the affected area. Lastly, a tarsorrhaphy can stretch tissue to counteract wound contraction after eyelid surgery, especially when a skin graft or flap is utilized.
In cases where ocular exposure is expected to be long-standing (months to years), a permanent tarsorrhaphy can be considered. Generally, these are placed laterally and for persistent lagophthalmos from facial nerve palsy or in patients with central nervous system causes for poor or absent blink. Although the term “permanent” is used with these tarsorrhaphies, opening the eyelids in a reversal procedure is possible.
Tarsorrhaphies have a few contraindications and are readily reversed if needed. An active infected corneal ulcer is a relative contraindication for complete tarsorrhaphy since ongoing visualization of the ocular surface is necessary; however, a partial tarsorrhaphy may be beneficial for ulcer treatment in some cases. Once ulcers have been sterilized with antibiotic treatment, a tarsorrhaphy may be placed to encourage epithelial healing. Although not a definitive contraindication, placing a complete tarsorrhaphy over the only seeing eye in a monocular patient may be quite debilitating, although it may be necessary to preserve vision in the one functional eye. Similarly, bilateral, complete tarsorrhaphies are undesirable. In these cases, other modalities such as scleral contact lenses or amniotic membrane devices (e.g., Prokera) may be utilized to prevent occlusion of the visual axis.
46.7 Preoperative Preparation
Most types of tarsorrhaphy can be completed at the bedside, office, or operating room. Local anesthesia is administered in the upper and lower pretarsal eyelid in the location of suture placement. The area is then prepped and draped to maintain a sterile field.
Also important is a discussion with the patient or the health care proxy regarding the type of tarsorrhaphy that will be placed, specifically the appearance of the eyelid and how the vision will be affected by the tarsorrhaphy.
46.8 Operative Technique
46.8.1 Temporary Tarsorrhaphy
There exist several nonsurgical options for a temporary tarsorrhaphy. The least invasive options include closing the eyelids using adhesive (e.g., tape or Steri-Strips) with or without a pressure patch. However, this may require frequent replacement that could be uncomfortable or compromise the skin, and there is a risk of a corneal abrasion if the eyelid opens under the patch. Botulinum toxin can be injected into the upper eyelid to target the levator palpebrae superioris causing ptosis of the upper eyelid and improved eyelid closure. 4 , 5 This option can provide easy access for examination and administration of eye drops and will last weeks to months; however, the induced ptosis blocks the visual axis and may affect the superior rectus muscle causing vertical diplopia. A temporary tarsorrhaphy can also be created using cyanoacrylate glue, which can last approximately 1 to 15 days, averaging 1 week. 6 Care must be taken to avoid accidental application of glue to the ocular surface.
46.8.2 Suture Tarsorrhaphy
A temporary suture tarsorrhaphy can be used in patients who require only temporary closure of the eyelids or as a bridge until a definitive treatment (permanent tarsorrhaphy or other eyelid procedure) can be performed. Although most cases of idiopathic facial nerve palsy (i.e., Bell palsy) recover spontaneously without significant damage to the cornea, if significant exposure exists, suture tarsorrhaphy may be an ideal temporary solution.
After the upper and lower eyelids are injected with local anesthesia, a suture tarsorrhaphy can be achieved with a 4–0 or 5–0 monofilament nylon, polypropylene, or silk suture in a horizontal mattress fashion with or without bolsters to protect the skin (Fig. 46‑1). The suture passes should be placed with care so that the suture is not exposed through the posterior lamella or interpalpebral zone that could result in corneal abrasion. A lateral suture tarsorrhaphy can be placed in cases where partial eyelid closure and preserving the visual axis are desired. This can be helpful in patients who are dependent on the affected eye or in patients in whom a lateral tarsorrhaphy provides a sufficient amount of eyelid closure to treat the corneal exposure or issue. A medial suture tarsorrhaphy similarly preserves the visual axis and can be helpful with eyelid malposition in this zone; however, care must be taken to avoid damage to the canalicular apparatus.