Tarsorrhaphy, the surgical fusion of the upper and lower eyelid margins, is performed to reduce the exposed surface area of the cornea. It is among the safest, most effective, and most underutilized procedures for healing difficult-to-treat corneal lesions. Tarsorrhaphy is most commonly performed to protect the cornea from exposure caused by inadequate eyelid coverage, as may occur in dellen, neurotrophic cornea, thyroid eye disease, or facial nerve (cranial nerve VII) dysfunctions such as Bell palsy. It can also be used to aid in the healing of indolent corneal ulceration, as is sometimes seen with tear film deficiency, herpes simplex or herpes zoster infection, or stem cell dysfunction.
Tarsorrhaphies are classified as lateral (Fig 13-10), medial, or central according to the position of the adhesion of the palpebral fissure. BCSC Section 7, Oculofacial Plastic and Orbital Surgery, discusses eyelid anatomy and surgical technique for tarsorrhaphy in detail. Because the cosmetic effect of a lateral tarsorrhaphy is significant, patients may be reluctant to undergo this procedure and should be counseled on its therapeutic benefits.
Tarsorrhaphy may be temporary (Frost suture) or permanent. The Frost suture, a surgical procedure involving use of a transtarsal plate suture to keep the eyelids closed but entailing no intramarginal adhesion, can be employed to partially occlude the eyelids for up to 2–3 weeks. If closure of more than 3 weeks is desired or if the length of time is uncertain, then permanent but reversible adhesion is induced by denuding the eyelid margin. Plastic stints or bolsters can be used to protect the eyelids from tight sutures, allow the suture tension to close the eyelids the desired amount, and reduce patient discomfort due to the sutures (see Fig 13-10).
Figure 13-10 Lateral tarsorrhaphy. A, A strip of eyelid margin is shaved over the gray line. B, One or two mattress sutures (double-armed 4-0 polypropylene with cutting needles) are passed through the upper and lower eyelids to secure the tarsorrhaphy. Sutures are threaded through bolsters (#40 silicone band) and tied. Each suture end should be placed through the skin of the upper eyelid approximately 5 mm above the lash line, traverse the upper tarsal plate, exit through the denuded wound surface of the upper eyelid margin, enter through the denuded wound surface of the lower eyelid margin, traverse the lower tarsal plate, and exit through the skin of the lower eyelid approximately 5 mm from the lash line.
(Reproduced with permission from Hersh PS. Ophthalmic Surgical Procedures. 2nd ed. New York: Thieme Medical Publishers; 2009:253.)
A tarsorrhaphy can be released under local anesthesia in the office. After infiltration of local anesthetic, a muscle hook is placed under the tissue, and a hemostat is placed (for 5 seconds) across the adhesion to be released. A blade or scissors are used to incise the tarsorrhaphy adhesion parallel to the upper and lower eyelid margins. If the status of the corneal exposure is uncertain, the tarsorrhaphy can be opened in stages, a few millimeters at a time. If the tarsorrhaphy has been performed properly, eyelid margin deformity is minimal.
Alternatives to tarsorrhaphy
Injection of onabotulinumtoxinA into the levator palpebrae superioris muscle to paralyze its function can cause pharmacologic ptosis and, similar to a surgical tarsorrhaphy, can impart a protective effect that lasts up to 6 months. Application of cyanoacrylate adhesive (discussed earlier in this chapter) to the eyelid margins may also enable temporary closure of the eyelids. However, both techniques have endpoints that are out of the control of the treating surgeon.
Tape may also be used to temporarily close the eyelids, but tape rarely lasts longer than 24 hours. Use of moisture-retaining eyewear (also called moisture chamber glasses) is another temporary measure that may be used to minimize desiccation and help protect the ocular surface. These devices are available commercially or may be constructed with plastic wrap and taped over the eyelids.
Reddy UP, Woodward JA. Abobotulinum toxin A (Dysport) and botulinum toxin type A (Botox) for purposeful induction of eyelid ptosis. Ophthalmic Plast Reconstr Surg. 2010; 26(6):489–491.
Sonmez B, Ozarslan M, Beden U, Erkan D. Bedside glue blepharorrhaphy for recalcitrant exposure keratopathy in immobilized patients. Eur J Ophthalmol. 2008;18(4):529–531.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.