The Drawstring Temporary Tarsorrhaphy Technique

SURGICAL TECHNIQUE The Drawstring Temporary Tarsorrhaphy Technique

John Kitchens, MD; John Kinder, MD; Thomas Oetting, MD

arsorrhaphy is used for the treatment of severe ocular surface disorders and cases of ocular exposure. Temporary tarsorrhaphy has been shown to aid in the healing of corneal epithelial defects.1 A variety of temporary techniques have been suggested that allow closure for epithelial healing but also allow access to the eye. The drawstring Ttemporary tarsorrhaphy uses rubber bolsters and 6-0 prolene sutures passed through the eyelid margin. This modification of the temporary tarsorrhaphy allows for complete closure of the eyelids while providing easy opening and closing. In addition, this technique is easy to perform in almost any setting. Arch Ophthalmol. 2002;120:187-190

Tarsorrhaphy is used to close the eyelids to niques, the drawstring technique can be facilitate the healing of various corneal epi- performed in any setting. thelial disorders or to prevent corneal exposure and its inherent complications. A METHODS temporary form of tarsorrhaphy is used when closure of the eyelids is needed for The central pretarsal area of both the up- shorter periods. With any tarsorrhaphy tech- per and lower eyelids is anesthetized with nique, one must allow for future and some- lidocaine (1% epinephrine; 1:100000) us- times frequent examination of the eye and ing a 3-mL syringe and a 30-gauge needle. for administration of topical medication. The area is then prepared with povidone A variety of temporary techniques iodine and sterile drapes are applied. Ster- have been proposed. These include the use ile bolster material is created by cutting a of pressure patching, cyanoacrylate, botu- Foley catheter into 2 semicircular strips. linum toxin to the levator muscle, and a One of these strips is then cut into two 2-cm variety of suture techniques. Each of these sections and one 1-cm section. The bol- techniques comes with advantages and dis- sters help prevent the suture from damag- advantages. Techniques (Table), such as ing eyelid tissue. These pieces also aid in gluing the eyelid shut and lateral tarsor- everting the eyelid to prevent trichiasis. The rhaphy, are easy to perform and allow for 1-cm bolster acts to close the drawstring excellent healing but make examination when placed against the 2-cm bolster of the difficult. Injection of botulinum toxin into lower eyelid (Figure 1 and Figure 2). the levator muscle is technically more dif- A double-armed 6-0 prolene suture ficult and more expensive but allows for on a cutting needle (P-3) is first passed easy examination of the eye. Our pro- completely through one of the 2-cm bol- posed drawstring technique allows for sters about 2 mm from the end. The same complete closure between examinations, needle arm is then passed 3 to 4 mm from yet permits easy opening of the eyelids for the upper eyelid margin into the tarsus, examination or application of medicine. exiting the eyelid margin at the gray line Like most temporary tarsorrhaphy tech- (through the arcus marginalis). The needle should then enter the gray line of the lower From the Department of Ophthalmology, University of Iowa Hospitals and Clinics, eyelid in the same position relative to the Iowa City, Iowa (Drs Kitchens and Oetting); and Eye Consultants Inc, Cape Girardeau, medial palpebral fissure, exiting the lower Mo (Dr Kinder). The authors have no proprietary or financial interest in any of the eyelid 2 to 3 mm inferior to the eyelid mar- products mentioned. gin. The other needle arm of the 6-0 prolene

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 suture should then be placed through Options for Temporary Tarsorrhaphy the upper-eyelid bolster in a similar fashion to the lower eyelids but dis- Technique Insertion Closure Examination Duration placed laterally. Both needles are then Lateral tarsorrhaphy Skilled, cheap Partial Difficult Indefinite passed through the second 2-cm bol- Cyanoacrylate glue Simple, cheap Complete Impossible 1 wk ster, which is placed adjacent to the Botulinum toxin Skilled, expensive Complete Easy 3-6 mo lower eyelid. Tightening of the su- Standard bolster Simple, cheap Complete Skilled 2-4 wk ture at this point should allow com- Drawstring Simple, cheap Complete Easy 2-4 wk plete closure of the eyelid. The next step is to create the drawstring. The 2 suture arms are passed through the 1-cm bolster. The needles are then removed and the 2 ends of the suture are tied, leaving 2 to 3 cm of slack in the suture to allow the lower-eyelid bolsters to be loosened and the eyelid opened. The suture can now be pulled to bring the drawstring together and bring the 2 large bolsters down on the eyelids to accomplish closure. The smaller bolster locks down the drawstring to keep the eyelid in place. To open the drawstring, the smaller bolster is sepa- rated from the larger lower eyelid bolster, which allows the eyelid to be ex- amined or to receive treatment. The suture can be cleaned with 2% povidone iodine.

REPORT OF CASES

CASE 1 A 30-year-old man was seen in the emergency department following severe head trauma and bilateral retrobulbar hemorrhages from a motor vehicle crash. Bilateral lateral canthotomies and cantholyses Figure 1. Open drawstring tarsorrhaphy. were performed. Neurosurgeons repositioned frontal fractures to provide increased orbital volume. Unfortunately, the patient had sig- nificant corneal exposure, eventu- ally resulting in a corneal ulcer. The drawstring tarsorrhaphy was performed in the intensive care unit setting. The intensive care nurses were able to open the tarsorrhaphy to apply the necessary antibiotic drops. After 3 weeks, the tarsorrhaphy was replaced but was not associated with inflammation. After 4 weeks, the patient’s infil- trates resolved and the tarsorrhaphy was removed.

CASE 2 A 75-year-old man with adult-onset diabetes for 20 years developed a post- Figure 2. Closed drawstring tarsorrhaphy. operative sterile corneal ulcer after

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 cataract extraction by phacoemulsi- fication. Central thinning was as much as 80%. A drawstring temporary tarsorrhaphy was performed in the clinic minor room. The patient’s sterile ul- ceration was aggressively treated with topical steroids, antibiotics, and by discontinuing topical nonsteroidal medication. The patient’s wife was able to open and then close the drawstring to apply his frequent medications. The drawstring tarsorrhaphy was changed approximately eevery 3 to 4 weeks during the course of the following several months. Fortu- nately, the patient’s cornea stabilized to the point that allowed penetrating keratoplasty to be performed several months later (Figures 3 and 4). Figure 3. Case 2. Temporary tarsorrhaphy closure.

CASE 3

A 70-year-old man was seen in the clinic with a long-standing history of a persistent corneal epithelial defect, primary open-angle glaucoma, and proliferative diabetic retinopa- thy with neovascular glaucoma of his right eye. The patient underwent cryoablation in the operating room to treat his proliferative diabetic reti- nopathy. While in the operating room, a drawstring tarsorrhaphy was performed. The patient’s wife was able to use the drawstring to open his eye to administer multiple essential glaucoma medications and postoperative anti-inflammatory medications. The drawstring also allowed for adequate postoperative examinations and provided better healing for the epithelial defect. His defect im- proved modestly while the tarsorrhaphy was in place for 2 months.

COMMENT

Tarsorrhaphy is useful in the treatment of persistent corneal epithelial defects. Several techniques have been proposed to provide protection to the corneal surface. Each has its own advantages and disadvantages. Permanent tarsorrhaphy is effec- tive but can have a high incidence of dehiscence and may deform the eye- lidmargin.2 Thepermanenttechnique (including intermarginal tarsorrhaphy) may lead to damage to the eyelid margin and resultant trichiasis.3 Pressure patching provides a nonin- vasive option but is dependent on pa- Figure 4. Case 2. Temporary tarsorrhaphy closed.

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 tient placement and compliance.1 A the treatment of persistent epithelial lids and associated structures. In: McCarthy JG, variety of temporary techniques have defects. It allows easy access to the eye ed. Plastic Surgery. Vol 2. Philadelphia, Pa: WB Saunders. 1990:1590-1591. beenproposed.Cyanoacrylatetempo- for examination and for the adminis- 3. Missotten L. Lasting temporary tarsorrhaphy. Bull rary tarsorrhaphy has an unpredict- tration of topical medications. Addi- Soc Belge Ophthalmol. 1979;185:27-28. able time course. This technique lasts tionally, it can be performed easily in 4. Donnenfeld ED, Perry HD, Nelson DB. Cyanoac- from 1 to 15 days (average of 6 days).4 virtually any setting. rylate temporary tarsorrhaphy in the manage- It also does not allow for easy obser- ment of corneal epithelial defects. Ophthalmic Accepted for publication September 19, Surg. 1991;22:591-593. vation without the need for reappli- 2001. 5. Kirkness CM, Adams GW, Dilly PN, Lee JP. Botu- cation of the agent. Botulinum toxin Corresponding author and re- linum toxin A-induced protective ptosis in cor- injection can provide temporary eye- prints: Thomas A. Oetting, MD, UIHC, neal disease. Ophthalmology. 1988;95:473-480. lid closure, but it provides variable re- 6. Wuebbolt GE, Drummond G. Temporary tarsor- 5 6 Department of Ophthalmology, 200 rhaphy induced with type A botulinum toxin. Can sults ; may cause hypotropia ; and is HawkinsDr,IowaCity,IA52242-1091 expensive.7 A variety of other tempo- J Ophthalmol. 1991;26:383-385. (e-mail: thomas-oetting@uiowa .edu). 7. Rapoza PA, Harrison DA, Bussa JJ, Prestowitz WF, rary techniques have been proposed Dortzbach RK. Temporary sutured tube tarsor- 7-9 that use sutures to close the eyelids. rhaphy: reversible eyelid closure technique. Oph- REFERENCES Severaloftheserequireadditionalmea- thalmic Surg. 1993;24:328-330. sures to close the eyelids or fail to pro- 8. Hallock GG. Temporary tarsorrhaphy “zipper.” Ann 1. Wagoner MD, Steinert RF. Temporary tarsorrha- Plast Surg. 1992;28:488-490. vide adequate access to the eye. phy enhances reepithelialization after epikerato- 9. Dryden RM, Adams JL. Temporary nonincisional Insummary,thedrawstringtem- plasty. Arch Ophthalmol. 1988;108:13-14. tarsorrhaphy. Ophthalmic Plast Reconstr Surg. porary tarsorrhaphy is a useful tool in 2. Jelks GW, Smith BC. Reconstruction of the eye- 1985;1:119-120.

Fractal Fundus. Created by Patrick J. Saine, MEd, CRA, Dartmouth-Hitchcock Medical Center, Lebanon, NH.

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