Eyeworld

86 | EYEWORLD | SPRING 2025 C ORNEA by Liz Hillman Editorial Co-Director About the physicians Christopher R. Dermarkarian, MD Assistant Professor of Ophthalmology Oculofacial and Orbital Surgery Duke University School of Medicine Durham, North Carolina Kourtney Houser, MD Associate Professor of Ophthalmology Duke University School of Medicine Durham, North Carolina D. Brian Kim, MD Professional Eye Associates Dalton, Georgia Christopher Rapuano, MD Chief of the Cornea Service Wills Eye Hospital Philadelphia, Pennsylvania lens, autologous serum, and/or amniotic mem- brane. "It is at the ophthalmologist's discretion, but my general rule is if an epithelial defect persists for more than 7–10 days despite ag- gressive medical therapy, one should consider a tarsorrhaphy to reduce the risk for corneal haze or stromal melt. The use of oral doxycycline and vitamin C is also advised to minimize stromal complications," he said. Dr. Houser said she'll outline what the options are leading up to this procedure—am- niotic membrane, punctal plugs, artificial tears, Oxervate (cenegermin-bkbj, Dompe)—but she said that patients who have thin corneas near perforation or persistently diseased corneas despite multiple treatments would benefit from tarsorrhaphy sooner. "If you could do a tarsorrhaphy for every epithelial defect, either medical or surgical, the corneas would absolutely love it," Dr. Houser said. However, "[patients] don't tend to like their eyelid being closed surgically or medically." Patient perceptions Closing the eye, either partially or fully, tempo- rarily or permanently, can be a "tough sell" for patients, Dr. Houser said, due to the functional and cosmetic issues it poses. As such, she said patients don't usually come on board with the procedure until they've tried everything else. "I think patients are usually not sold on it on the first visit unless they have something imminently vision threatening. So, if a patient comes in with a thin cornea with a risk of perfo- ration, I may suggest that we do a tarsorrhaphy on my first visit seeing them. Most patients are amenable to a tarsorrhaphy if you explain to them that they have a vision- or eye-threatening condition." With some of the treatments tried prior to tarsorrhaphy requiring more frequent visits, Dr. Houser said some patients, depending on their living or medical condition, may opt for tarsor- rhaphy initially as well. Dr. Rapuano said it's important preopera- tively to tell the patient that this will be an un- comfortable procedure but that we'll use a lot of T hree cornea specialists and one oc- uloplastics specialist agreed that in some cases, closing the eyelid with either a permanent or temporary tarsorrhaphy is among the best treat- ments for corneal healing; the procedure is, in many ways, "the cornea's best friend." On the flip side, it's not necessarily thought so by the patient—as Christopher Rapuano, MD, put it, "patients hate it"—and, as such, often requires trying multiple healing modalities prior to patients coming to terms with the procedure. "The biggest problem with a tarsorrhaphy," said Christopher R. Dermarkarian, MD, "is that you're going to lose either some or all of the field of vision. … You're limiting how much the patient can see. That is a big drawback to tar- sorrhaphy—patients lose their peripheral vision or their entire field of vision." Dr. Rapuano, Dr. Dermarkarian, Kourtney Houser, MD, and D. Brian Kim, MD, gave their perspectives on when tarsorrhaphy is beneficial, different types of tarsorrhaphy, and how to help patients understand that while they might not want the procedure initially, it could, in many cases, speed healing for visual recovery and, in more severe cases, save their eye. Why tarsorrhaphy? Dr. Kim shared that tarsorrhaphy protects the cornea because: 1) it limits corneal exposure to the environment, and 2) it limits corneal trauma from blinking. "The normal blink frequency is around 15–20 blinks per minute, and in the face of a persistent corneal epithelial defect or ulcer- ation, the continual and repetitive movement of the eyelid over the cornea can undermine corneal healing," he said. Such persistent corneal epithelial defects, Dr. Kim continued, can be caused from numer- ous conditions, such as herpes keratitis, Bells palsy, contact lens overwear, and cicatricial lagophthalmos after eyelid surgery. Dr. Rapuano said he'll also recommend a tarsorrhaphy after a corneal transplant when he has concerns about healing. Dr. Kim said there are a variety of treat- ments that should be tried, in most cases, before tarsorrhaphy, including aggressive lubrication, punctal occlusion, therapeutic bandage contact Tarsorrhaphy: the cornea's best friend continued on page 88

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