SURGICAL PROCEDURE Performing a tarsorrhaphy

Saul Rajak Figure 1a. Alignment and threading of bolster bolster. The sutures are tied over Oculoplastic Fellow: South Australian the bolster (e.g. plastic tubing or Institute of Ophthalmology, Royal small cotton wool balls) to prevent Adelaide Hospital, Adelaide, Australia. Honorary lecturer: International Centre them cutting into the skin. They can for Health, London School of Hygiene be made from paediatric butterfly and Tropical Medicine, London, UK. cannulas or other similar sterile Juliette Rajak plastic tubing. Cut each bit of Illustrator: Brighton, UK. tubing lengthwise to prepare a bolster ‘gutter’. 3 Pass a double-armed Dinesh Selva non-absorbable suture (e.g. silk, Professor of Ophthalmology: prolene or nylon 4-0, 5-0 or 6-0) South Australian Institute of straight through one of the 2cm Ophthalmology, Royal Adelaide bolsters, 2 mm from the end. Hospital, Adelaide, Australia. 4 Line up the bolster in the middle of What is tarsorrhaphy? the upper lid and pass the same Tarsorrhaphy is the joining of part or all of needle into the upper skin the upper and lower so as to 3–4 mm above the lid margin, partially or completely close the eye. through the tarsal plate and out of Temporary tarsorrhaphies are used to help the grey line of the lid margin. The the heal or to protect the cornea grey line is the slightly darker line in during a short period of exposure or the middle of the lid margin that is disease. Permanent tarsorraphies are between the anterior and posterior used to permanently protect the cornea lamellae of the lid. from a long-term risk of damage. A 5 Pass the same needle into the grey permanent tarsorrhaphy usually only into short-term (temporary) and line of the lower lid, into the tarsal closes the lateral (outer) eyelids, so that long-term (permanent) tarsorrhaphies. In plate and out of the skin 2–3 mm the patient can still see through the central both cases the procedure almost always below the lower eyelid margin. opening and the eye can still be examined. involves using a suture to join the lids. 6 Align the lower lid bolster centrally, Other techniques that are occasionally and pass the needle through it a few What are the indications used are botulinum toxin tarsorrhaphy millimetres from one end. for tarsorrhaphy? (the upper lid levator muscle is paralysed 7 Pass the other needle of the suture To protect the cornea in the case of: with the toxin), or the use of cyanoacr- through the upper bolster – upper lid • inadequate eyelid closure, for example ylate glue to join the lids and placing a – lower lid –lower bolster in the same due to facial nerve palsy or cicatricial weight (usually gold) in the upper lid. way as the first needle, 2mm from the other end of each of the bolsters. (scarring) damage to the eyelids caused We will describe two simple procedures: by a chemical or burns injury 8 Pass both needles through the • an anaesthetic (neuropathic) cornea • A temporary central tarsorrhaphy with shorter length of bolster, 2mm from that is at risk of damage and infection a drawstring that allows it to be each end of the bolster (Figure 1a). repeatedly opened and closed for • marked protrusion of the eye (proptosis) Figure 1b. Using sutures and bolsters to examining the eye. causing a risk of corneal exposure close the eye • poor or infrequent blinking, for example • A permanent lateral tarsorrhaphy that in patients in intensive care or with leaves the central lids open, allowing severe brain injuries. the patient to see and the eye to be examined. To promote healing of the cornea in patients with: The drawstring temporary central • an infected , which is tarsorrhaphy (Figures 1a and 1b) taking a long time to heal This simple suture tarsorrhaphy will be • non-healing epithelial abrasions. effective for 2–8 weeks. Other indications include: 1 Anaesthetise the central area of both • To prevent conjunctival swelling (chemosis) the upper and lower eyelids with an and exposure after ocular surgery injection of a few millilitres of local 9 Slide the two lower lid bolsters • To retain a conformer or other device, for anaesthetic (e.g. lidocaine 1–2% or upwards to close the eye. The smaller example in children with anophthalmia bupivacaine 0.5%). If anaesthetic bolster ‘locks’ the lid closed (Figure 1b). or adults after evisceration or enucleation. with adrenaline is available it will 10 To separate the lids, pull the smaller reduce operative bleeding. bolster down and the lids will easily open. What are the different 2 Clean the area with 5% povidone types of tarsorrhaphy? iodine. Leave the iodine for a few If a single armed suture is being used, the The techniques for joining part or all of minutes. During this time prepare needle can be passed from the lower the upper and lower lids can be divided two x 2cm bolsters and one x 1cm bolster back up to the upper bolster.

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CEHJ89_OA_Revise.indd 10 01/06/2015 16:15 The permanent tarsorrhaphy Figure 2a. Splitting the anterior and posterior inserted into the upper lid. Repeat this (Figure 2a–f) lamellae with a second suture. The upper and lower lids will not stay ‘stuck’ 5 Close the anterior lamella together when the sutures of a (eyelid skin) (Figure 2e). Insert a temporary tarsorrhaphy lose their needle drawing a 4-0 to 6-0 sized tension after a few weeks. In a thread into the skin of the permanent tarsorrhaphy, some upper lid, 2–3 mm above the of the lid margin is debrided lid margin and bring it out of the which allows the lids to stick anterior lamella of the upper together as they heal. lid margin. Pass the Permanent tarsorrhaphies needle directly across are almost always only into the anterior lamella lateral so that the patient can of the lower lid margin still see out of the central eyelid and out of the skin 2–3 mm opening and the eye can still be below the lid margin. Tie the examined. They should last at suture. Repeat this with several least 3 months (and sutures placed 3 mm apart until the sometimes forever). skin is closed over the closed controlled with a few minutes of posterior lamella. The steps of a permanent pressure. Cautery can be used if lateral tarsorrhaphy are: When you have finished the procedure available. note the following two things (Figure 2f): 1 Anaesthetise the upper 3 Excise 1 mm of the posterior and lower lids as above. lamella (Figure 2b). This removes the • If you have neatly joined the lateral 2 Split the anterior and posterior epithelium of the lid margin and will third of the upper and lower eyelids, lamellae (Figure 2a). Use a number enable the lids to stick together when there will still be an opening that the 11 blade if available (or otherwise a they heal. patient can see through. The opening number 15 blade) to cut along the grey 4 Close the posterior lamella (Figures will obviously be narrower horizontally, line of the lateral third of the upper and 2c and 2d). Pass the needle of an but it will also be narrower vertically, lower lids to a depth of 2 mm. This will absorbable 5-0 or 6-0 suture into the which will give more protection to the separate the anterior and posterior posterior lamella of the upper lid and cornea in the open area. lamella. Continue the split inferiorly then bring it out a little bit further • In this procedure, the anterior lamella (lower lid) or superiorly (upper lid) for along the upper lid posterior lamella. and eyelashes are undamaged – about 5 mm using either a blade or Pass the needle into the posterior therefore if the tarsorrhaphy is opened spring scissors. Make sure you keep lamella of the lower lid in line with the at a later date, the lid will look almost the split parallel to the tarsal plate so point of emergence on the upper lid. normal. These tarsorrhaphies often last that the eyelid neatly separates into Pass the needle so that it emerges forever, but if they need to be divided anterior and posterior lamellae. The from the posterior lamella of the lower this can be done by injecting some local eyelid is likely to bleed and this can be lid in line with where the needle was first anaesthetic and cutting the sutures.

Figure 2b. Excising 1 mm of the posterior Figure 2c. Closing the posterior lamella Figure 2d. Closing the posterior lamella lamella (side view)

Figure 2e. Closing the anterior lamella

Figure 2f. After the procedure

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