Tarsorrhaphy - Purpose, Indications, Contraindication, Results, and Complications

Introduction

Tarsorrhaphy is a surgical procedure to protect the cornea where the eyelids are sutured together. Depending on the requirement, it can be temporary or permanent. It is a favorable procedure performed post-operatively to promote epithelium healing. Botulinum toxin is used for temporary tarsorrhaphy. It is an alternative to conventional surgeries, which provides similar protection to conventional suture tarsorrhaphy.

What Is the Classification of Tarsorrhaphy?

Tarsorrhaphy is classified into different types:

• Partial or complete.

• Permanent or temporary.

• Short-duration tarsorrhaphies without sutures.

• Temporary suture tarsorrhaphies.

• Permanent suture tarsorrhaphies.

What Is the Purpose of Tarsorrhaphy?

Lids in the eye are mainly used for protection. Till the complete healing, sewing the eyelids together helps protection of both eyes.

The conditions that require tarsorrhaphy include:

• Sjogren's syndrome, tears are reduced, and the cornea is at risk of damage, so tarsorrhaphy is done to provide protection.

• Bell's palsy, the facial nerve, weakens facial and eyelids muscles and in myasthenia gravis also, facial muscles are weakened. So tarsorrhaphy temporarily cures the situation.

• Graves thyroid disease, exophthalmos (eyes bulging out of their sockets) occurs. Lids cannot close properly in case of excess bulges, so tarsorrhaphy protects the eyes from damage.

• Eyelids become ineffective in enophthalmos. In this condition, the eye falls back into the socket. So tarsorrhaphy temporarily cures the situation. Tarsorrhaphy protects the eyes from the cornea's swelling until the condition resolves.

What Are the Indications for Tarsorrhaphy?

There are several indications in which tarsorrhaphy is indicated, including:

• Corneal ulceration is seen in herpes simplex virus or varicella-zoster infections.

• In case of severe dry eye.

• In the case of progressive corneal thinning.

• Keratoconjunctivitis (an inflammatory process that involves conjunctiva and cornea).

In Which Surgeries Tarsorrhaphy Is Indicated?

• To prevent conjunctival swelling after ocular surgery.

• After some surgeries to retain the prosthesis in the eye, tarsorrhaphy is indicated. For example, Boston keratoprosthesis (the most widely used artificial cornea).

• Tarsal kink repair (there is corneal ulceration because of in-turned eyelashes and eyelids, so this procedure is undertaken to repair the defect).

• Globe reconstruction surgery (surgical repair is done under general anesthesia).

Types of Tarsorrhaphy

• Permanent Lateral Tarsorrhaphy: An incision is given along the lateral lower lid of the desired length with a depth of two millimeters.

• Permanent Medial Tarsorrhaphy: A V-shaped incision peripheral to the upper and lower lids is a safe and effective technique.

• Pillar Tarsorrhaphy: In this procedure, tissue pillars are elevated and carried out above the superior border of the upper eyelid.

• Glue Tarsorrhaphy: It is a simple, non-invasive procedure. Tissue glue or cyanoacrylate gel is used as an adhesive.

• Neurotoxin Tarsorrhaphy: It is a safe and elective procedure to protect the cornea, and botulinum toxin is used.

• Temporary Bolster Tarsorrhaphy: In this procedure, cotton bolsters are placed between the suture and the skin before the suture is tied.

What Are the Contraindications for Tarsorrhaphy?

There is a certain contraindication for tarsorrhaphies but can be easily reversed if needed. These include:

• Active microbial infection (bacterial or fungal) keratitis.

• In the case of ulcer treatment and epithelial defect healing, partial tarsorrhaphy is indicated, but complete tarsorrhaphy is generally contraindicated.

• A bilateral, complete tarsorrhaphy is undesirable in the case of amniotic membrane device placement.

What Is the Patient Preparation Associated With Tarsorrhaphy?

Tarsorrhaphy is a minor procedure done under local anesthesia. Special preparation is not necessary. Eye drops and soft contact lenses are used to moisten the eyes.

What Are the Preoperative Considerations for Tarsorrhaphy?

• A full ophthalmic examination and biomicroscopic examination should be done before the procedure.

• Consider if any corneal pathology is present and evaluate the size and location of any defects or corneal ulcers if present.

• The palpebral conjunctiva should be carefully examined.

• Carefully look for any keratinization or any foreign bodies.

• External examination of eyelid abnormalities is done.

• Careful examination of corneal sensitivity is important to determine what type of tarsorrhaphy should be performed.

• The length of tarsorrhaphy is determined by gently pinching the upper and lower eyelid with forceps.

What Is the Normal Expected Result After Tarsorrhaphy?

After the tarsorrhaphy, there is a regain of normal moisture in the eye. Therefore, it prevents the eye from injury during the postoperative procedure by keeping it lubricated.

What Are the Postoperative Considerations for Tarsorrhaphy?

Certain points should keep in mind to take care of in postoperative periods:

• After surgery, antibiotic ointment is placed at regular intervals over the eyelids.

• The follow-up of patients is a must after surgery on day one, then after a week, and then at appropriate intervals.

• Rubbing of the eye is contraindicated.

• Wearing make-up is contraindicated till the physician approves.

• Without an ophthalmologist's permission, driving should be restricted.

• Peripheral vision loss occurs after lateral tarsorrhaphies, so patients should adjust their daily activities.

• Use topical drops for lubrication.

• Antibiotics should be given for preserving the corneal worsening, and appropriate treatment should be undertaken for the underlying disease.

What Are the Complications Associated With Tarsorrhaphy?

Like every surgical procedure, there are certain complications for tarsorrhaphy, including:

• There is a risk of bleeding, infection, and swelling.

• Surgeries risk damage to underlying or surrounding structures.

• Pyogenic granuloma (non-cancerous raised tumor skin and mucous membrane).

• Premature separation occurs, and reoperation is required in such cases.

• Skin breakdown and lid margin deformities can occur.

• In Pillar tarsorrhaphies, a type of unique complication occurs called ectropion (eyelid turned outwards).

• In neurotoxin tarsorrhaphies, pre-septal bleeding can occur.

• Superior rectus muscle damage can cause double vision called diplopia, which lasts up to nine months.

What Are the Advantages of Tarsorrhaphy?

• It is a simple procedure, and it is easy to perform.

• The results last for one to several weeks.

• Topical medication can be applied even after surgery.

• Allows inspection of the cornea.

What Are the Disadvantages of Tarsorrhaphy?

• Deep sutures result in corneal friction and cause ulcers in the cornea.

• Also, in complete tarsorrhaphy, monitoring is not possible.

• Finally, it causes physical obstruction, reducing the concentration of delivered medication.

Conclusion

Tarsorrhaphy is a minor surgical procedure of the eye that can be done alone or in combination with other surgical techniques to prevent the cornea from exposure. Postoperative complications can be prevented by proper care during surgery and after surgery.