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Role of Temporary Tarsorrhaphy Using Super Glue in the Management of Corneal Disorders

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Role of Temporary Tarsorrhaphy Using Super Glue in the Management of Corneal Disorders Original Article Role of Temporary Tarsorrhaphy Using Super Glue in the Management of Corneal Disorders Muhammad Moin, Irfan Qayyum, Anwar Ul-Haq Ahmad, Mumtaz Hussain Pak J Ophthalmol 2009, Vol. 25 No. 3 . .. .. See end of article for Purpose: To evaluate the safety and efficacy of temporary tarsorrhaphy using authors affiliations super glue in the management of corneal disorders. … ……………………… Material and Methods: A retrospective chart review of 46 consecutive patients who underwent superglue tarsorrhaphy from June 1997 to June 1998 was Correspondence to: performed. All patients were managed at the Institute of Ophthalmology, Mayo Mohammad Moin hospital, Lahore. This study included patients with painful non healing corneal Department of Ophthalmology ulcers, exposure keratopathy (secondary to moderate proptosis), dry eyes (to Mayo Hospital reduce surface area of evaporation) and post-operative patients with conjunctival Lahore flaps ± scleral grafts (to help take up of the graft). Patients with corneal perforations, endopthalmitis or panophthalmitis were excluded from the study. Temporary tarsorrhaphy was done using super glue technique in which the upper eyelashes were glued to the lower lid skin. The degree of lid closure was calculated according to the pre-existing corneal pathology. Patients were followed up on a weekly basis for one month to check for reduction of pain, improvement of corneal pathology and duration of tarsorrhaphy. Results: There were 50 eyes of 46 patients included in the study who underwent super glue tarsorrhaphy for various corneal pathologies. There were 36 males and 10 female patients with an average age of 40 years (range 10-60 yrs). Thirty two eyes had keratitis (fungal, bacterial, disciform, dendritic), 5 had a persistent epithelial defect, 4 had exposure keratopathy secondary to moderate proptosis, 5 had conjunctival flap alone or combined with a scleral graft and 4 had dry eyes. In cases of keratitis the tarsorrhaphy remained intact for 2-3 weeks, in patients with proptosis it remained intact for 2 weeks and in cases of dry eyes and conjunctival graft it remained intact for 2-3 weeks. The most common complication seen in the majority of patients was loss of a few lashes after spontaneous opening of the tarsorrhaphy in 2-3 weeks time. Three patients required early opening of the tarsorrhaphy which was done by cutting the eyelashes. No patient had spillage of the glue onto the cornea. Received for publication Conclusion: Temporary tarsorrhaphy using super glue technique is a quick, January’ 2009 painless and effective outdoor procedure in providing temporary relief in the … ……………………… management of different keratopathies, dry eyes and exposure keratopathy. arsorrhaphy is the fusion of upper and lower indolent corneal ulceration sometimes seen with tear eyelid margins. It is one of the safest and most film deficiency, or 5th nerve dysfunction (neurotrophic effective procedures for healing the corneal lesion). T 1 lesions which are usually difficult to treat . It can also be performed to protect the cornea from exposure Tarsorrhaphy may be temporary or permanent. 3 caused by inadequate eyelid coverage, as may occur in Temporary can be done with sutures ; while in Graves’s disease or facial nerve dysfunction such as in permanent raw tarsal edges are created to form a Bells palsy2. It can also be used to aid in healing of lasting adhesion. It may be total or partial, depending 139 on whether only a portion of the palpebral fissure is RESULTS occluded. Finally, they are classified as lateral, medial There were 50 eyes of 46 patients included in the study or central, according to the location on the eyelid. We who underwent super glue tarsorrhaphy for various analyzed the results of temporary tarsorrhaphy by corneal pathologies. There were 36 males and 10 using superglue (Cyanoacrylate). female patients with an average age of 40 years (range 10-60 yrs). Forty two patients underwent unilateral MATERIAL AND METHODS tarsorrhaphy while 4 patients had bilateral tarsorrhaphy. Bilateral tarsorrhaphy was done in 2 A retrospective chart review of 46 consecutive patients patients with dry eye and 2 patients with bilateral who underwent superglue tarsorrhaphy from June proptosis. The tarsorrhaphy remained stable for at 1997 to June 1998 was performed. All patients were least 2-3 weeks with spontaneous opening of the lids managed at the Institute of Ophthalmology, Mayo afterwards. hospital, Lahore. Temporary tarsorrhaphy was done Out of 50 eyes 32 had infective keratitis (Fig. 1, 2), using super glue technique. This study included 5 had a persistent epithelial defect, 4 had exposure patients with painful non healing corneal ulcers, keratopathy secondary to moderate proptosis, 5 had exposure keratopathy (secondary to moderate conjunctival flap alone or combined with a scleral proptosis), dry eyes (to reduce surface area of graft and 4 had dry eyes. Out of the 32 eyes having evaporation) and post-operative patients with infective keratitis 10 had fungal keratitis, 15 had conjunctival flaps ± sclera graft (to help take up of the bacterial keratitis, 4 had disciform keratitis and 3 had graft). Patients with corneal perforations, dendritic keratitis. In cases of infective keratitis the endopthalmitis or panophthalmitis were excluded tarsorrhaphy was done only after control of active from the study. stage of the keratitis. The aim of the treatment was to A detailed history was taken to document the help in the healing phase of the keratitis. Patients with cause and severity of corneal pathology in each case. persistent epithelial defect underwent tarsorrhaphy Pre-operative examination included best corrected after having the epithelial defect for at least 5 days. visual acuity (BCVA), a detailed corneal examination Proptosis was bilateral in 2 cases (thyroid eye disease) for epithelial defect, ulcer or exposure keratopathy, while 2 patients had unilateral proptosis (one with anterior segment examination for hypopyon and orbital inflammatory disease and one post orbitotomy measurement of proptosis in selected cases. Patients patient). Tarsorrhaphy done in patients with thyroid were followed up on a weekly basis for one month. eye disease was a precursor to permanent procedure Post-operative data included grading of pain, changes to check for its efficacy. It was done in orbital in corneal pathology (improvement of epithelial inflammatory disease (OID) and post orbitotomy defect, ulcer, exposure keratopathy or dry eyes), patients to resolve inferior conjunctival prolapse duration of superglue tarsorrhaphy and document- associated with chemosis (Fig. 3, 4, 5). There were 3 tation of any complications. Pain at presentation was cases of conjunctival flaps done for descematoceles taken as a baseline and following the procedure it was and 2 cases of conjunctitval flaps with scleral grafts for graded as worse, same or improved. perforated corneal ulcers which were done as a last The procedure included instillation of topical resort to save the shape of the eyeball until a donor proparacaine (Alcaine, Alcon Labs Tx) in the cornea was available (Fig. 6, 7). Tarsorrhaphy was conjunctival sac. This was followed by meticulous done along with the conjunctival procedure to drying of the skin and application of super glue improve its success. The 2 patients with dry eyes (cyanoacrylate) on the lower lid skin beneath the underwent this temporary procedure bilaterally to eyelashes. The patient was warned about a feeling of check if decreasing the palpebral fissure with warmth on application of the super glue. Then the permanent tarsorrhaphy would be of any help to these patient was asked to close his eyelids tightly. This patients (Fig. 8, 9). In cases of keratitis the resulted in adhesion of the eyelashes to the lower lid tarsorrhaphy remained intact for 2-3 weeks, in patients skin producing an effective tarsorrhaphy. If there was with proptosis it remained intact for 2 weeks and in insufficient adhesion of the lashes it could be re- cases of dry eyes and conjunctival graft it remained enforced with more superglue. The degree of lid intact for 2-3 weeks. closure was calculated according to the corneal Eighty four percent of the eyes had relief of pain pathology. after the tarsorrhaphy. However, 2 patients had 140 aggravation of pain after the tarsorrhaphy (patients non healing corneal ulcer, lagophthalmos, dry eye with keratitis) and 5 patients did not feel any syndrome, keratitis, kerato-conjuctivitis, proptosis, difference after the tarsorrhaphy (4 patients with chemical burn, thyroid ophthalmopathy, impending keratitis and 1 patient with proptosis). There was perforation secondary to trauma, persistent epithelial aggravation of pain in 2 patients with keratitis because defect and autoimmune (Steven Johnson Syndrome, the tarsorrhaphy had been done before achieving Mooren's ulcer)4. Botulinum toxin is also used to favorable response to topical medications in order to induce ptosis in some cases. But botulinum toxin may prevent corneal perforation in very large corneal not be available universally because of constraints of ulcers with marked central thinning. In these cases the cost and expertise. Moreover, the induced ptosis is tarsorrhaphy was opened early by cutting the matted variable in its onset and duration, and there are risks eyelashes at the base and treatment changed associated with the injection. accordingly. The tarsorrhaphy complications are usually failure The most common complication seen in the of the lid adhesion
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