Eyeworld

88 | EYEWORLD | SPRING 2025 C ORNEA medications to minimize the pain. This, he said, prepares the patient mentally for the procedure, so they "don't think something horrible is hap- pening" while it's being performed. He said that while tarsorrhaphy can be a difficult choice for some patients, many, after having it done, say they wish they had done it earlier. Types of tarsorrhaphy All the surgeons interviewed for this article said standard suture tarsorrhaphy is within the purview of any ophthalmologist. Dr. Houser said she'll perform some tarsorrhaphies herself and others she'll refer to oculoplastics. "Oculoplastic surgeons do eyelid surgery all the time. So especially if a patient has a con- current ectropion or other eyelid issue, I think it's good to have an oculoplastics colleague do it. But there are some patients in whom I want to do a tarsorrhaphy at the time of a high-risk corneal transplant or at the time of a transplant for perforation," she said. Depending on the type of tarsorrhaphy needed, Dr. Houser said they can be done med- ically, such as with Botox (onabotulinumtoxinA, AbbVie), or surgically. A temporary method that she uses in the operating room or clinic is a suture using a mattress stitch in a temporal position so the patient can still see out of the medial aspect of their eye. This also allows the physician to still examine the eye. Dr. Houser said for permanent tarsorrhaphy, she'll often refer the patient to oculoplastics because that specialty is available to her, though, depending on logistics, she does perform them herself. Dr. Rapuano said for a typical tarsorrhaphy, he uses black 4-0 silk on a double-armed needle and a foam bolster. He said he uses bolsters on the upper and lower lids, so the suture doesn't "cheese-wire" through the skin over time. He'll typically only close the outer third of the eyelid, but it closes about two-thirds of the eye, which facilitates healing and allows for examinations and for medications to be administered. He noted that even with permanent tarsorrhaphies, it can still be opened up later at the surgeon's discretion. Some drawbacks to Botox tarsorrha- phy are that it doesn't take effect immediately (often 1–3 days to kick in), and it's unpredict- able how long it will last, Dr. Rapuano said. He added that glue tarsorrhaphies can be problem- atic if the glue gets inside the eyelid and rubs against an already compromised cornea; it's also unpredictable how long the glue will last. Dr. Kim said since corneal fellowship, he has performed hundreds of surgical suture tar- sorrhaphies (both temporary and permanent), but a few years ago, a representative from Bio-Tissue showed him a technique using a rigid piece of tape. "I have since given it the name tape tarsorrhaphy, then Dr. Michael Mimouni and the University of Toronto Cornea Depart- ment modified it to a more accurate description, which we now call tape-splint tarsorrhaphy. 1 The tape-splint tarsorrhaphy has superseded my use of surgical temporary tarsorrhaphy, and it has been an invaluable tool because it is non-surgical, easily reversible, and the patient can apply it themselves," he said. Dr. Kim noted that tape tarsorrhaphy doesn't work for all situations. "If there is a deep set orbit or excessively oily skin, it may not effectively splint the eyelid. There can also be intolerance due to contact dermatitis from the tape adhesive. Other times, a more permanent and aggressive method needs to be considered for chronic corneal exposure with a surgical suture tarsorrhaphy or a Gunderson flap, but I think from a patient informed consent per- spective, the tape-splint tarsorrhaphy should be offered early in the process as a safe, non-surgi- cal option." Dr. Kim said when performing a temporary suture tarsorrhaphy, he always uses bolsters to protect the eyelid skin under the bolster. He also suggested using a slip knot to titrate tension. For permanent lateral tarsorrhaphy, Dr. Kim said his best pearl is when removing the anteri- or lamella of the eyelid margin, spare the lateral canthal area about 3–4 mm. "This is important because if and when you try and reverse the tar- sorrhaphy, you will avoid rounding of the lateral canthus and achieve a much better cosmetic result," he said. Dr. Houser said she doesn't use bolsters. "It's a great procedure, with or without bol- sters," she said. Dr. Dermarkarian, as an oculoplastics specialist, said permanent tarsorrhaphies are not a significant component of his practice, but he performs up to two a week. "I think anytime that people are asking for permanent tarsorrha- phy or a variation of the standard tarsorrhaphy, that is when they end up in my clinic for evalua- tion," he said. continued from page 86

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