|Year : 2021 | Volume
| Issue : 3 | Page : 469-470
Drawstring temporary tarsorrhaphy with tarsal internal fixation for corneal protection
Maria Miura1, Hidenaga Kobashi2, Hualei Zhai3, Joseph B Ciolino3
1 Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA; Juntendo University Graduate School of Medicine, Department of Ophthalmology, Tokyo, Japan
2 Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA; Department of Ophthalmology, Keio University, School of Medicine, Tokyo, Japan
3 Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
|Date of Submission||11-Jul-2020|
|Date of Acceptance||10-Feb-2021|
|Date of Web Publication||02-Jul-2021|
MD, Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, 02114, Juntendo University Graduate School of Medicine, Department of Ophthalmology, Tokyo
Source of Support: None, Conflict of Interest: None
For a 47-year-old woman presented with a persistent corneal ulcer that was refractory to antibiotic drugs and amniotic transplantation, we performed both drawstring temporary tarsorrhaphy with tarsal internal fixation of the upper lid. Two weeks postoperatively the epithelial defect was resolved. The eyelid did not exhibit any complications such as trichiasis or skin necrosis. A drawstring temporary tarsorrhaphy with tarsal internal fixation was an effective treatment for the protection of the ocular surface and can be used to treat persistent corneal epithelial defects and exposure keratopathy.
Keywords: Amniotic membrane, bolster, corneal epithelium, ocular surface, persistent corneal epithelial defects, tarsorrhaphy
|How to cite this article:|
Miura M, Kobashi H, Zhai H, Ciolino JB. Drawstring temporary tarsorrhaphy with tarsal internal fixation for corneal protection. Indian J Ophthalmol Case Rep 2021;1:469-70
|How to cite this URL:|
Miura M, Kobashi H, Zhai H, Ciolino JB. Drawstring temporary tarsorrhaphy with tarsal internal fixation for corneal protection. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:469-70. Available from: https://www.ijoreports.in/text.asp?2021/1/3/469/319988
Temporary eyelid closure is one of the treatments for persistent corneal epithelial defects or exposure keratopathy and a variety of techniques have been described., Pressure patching, cyanoacrylate lid apposition,, botulinum toxin to the levator muscle, and sutured lid apposition (tarsorrhaphy) have been used. Eyelid splints and pressure patching are for short periods of time, but typically result in incomplete eyelid closure. Gluing the eyelid shut and lateral tarsorrhaphies allow for excellent lid apposition but leave the clinician with a poor view of the ocular surface. Injection of botulinum toxin into the levator muscle of the upper lid results in upper lid ptosis. While it allows for easy examination of the cornea, the effect may persist after the cornea has healed. In addition, the apposition may be not enough in cases of exposure keratopathy attributed to ectropion or lower lid retraction. Temporary tarsorrhaphy is the way to appose the upper and lower lids surgically and various methods have been described., Frequently the suture exits skin of the lids and is tied over bolsters to prevent the suture from “cheese-wiring” or cutting through the skin. Internal fixation of the suture within the upper lid tarsus has been described as an alternative to upper lid bolsters. The drawstring temporary tarsorrhaphy allows the lids to be effectively closed and also opened temporarily for examination; it achieves closure by using two sets of sliding bolsters. In this report, we describe a modification that combines both the drawstring temporary tarsorrhaphy and tarsal internal fixation of the upper lid.
| Case Report|| |
A 47-year-old woman was treated for a non-healing corneal ulcer caused by an improper use of contact lenses. Cultures results showed coagulase-negative staphylococcus. The ulcer was treated for 12 days with fortified tobramycin and vancomycin, but a persistent epithelial defect remained. To promote re-epithelialization a ProKera (Bio-Tissue, Miami, FL) was placed, after the epithelial defect was considered sterile from results of the multiple cultures and the clinical findings and the antibiotic drops were discontinued. However, the epithelial defect persisted even after the amniotic membrane dissolved. Therefore, we performed a suture of amniotic membrane followed by a placement of a temporary tarsorrhaphy with an internal fixation along the upper lid and a drawstring with bolsters along the lower lid.
The lids were administered local anesthetic block and draped in a sterile fashion before the following technique. First, 2 cm x 2 cm sections were cut to serve as adjustable bolsters using 25-gauge butterfly intravenous tubing. A double-armed non-absorbable suture 5-0 silk suture on a cutting needle (16 mm, 1/2 circle) (Ethicon, Somerville, NJ) was passed perpendicularly through one side of the tubing about 3 mm from the lower eyelid margin [Figure 1].
|Figure 1: Schematic illustration of drawstring temporary tarsorrhaphy with the tarsal internal fixation technique: (a) frontal view; (b) cross-sectional image|
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Subsequently, the same suture was then passed through the second tubing. The same needle was passed 3 mm below the lower lid margin, through the tarsal plate, and exited just anterior to the grey line to avoid cornea touch. Tarsal internal fixation was performed through the upper lid. The same needle was inserted perpendicularly anterior to the grey line. It was advanced within the plane of the tarsal plate and parallel to the lid margin. Then, the needle was exited once more through the lid margin just anterior to the grey line. The same needle was passed into the grey line of the lower lid, into the tarsal plate and out of the skin 3 mm below the lower eyelid margin. The same suture was passed through the upper and lower tubing. The ends of the sutures were tied as a suspension “air-knot” with a length of approximately 20 mm. This suspension “air-knot” provides enough slack to allow the bolster tubing to be slid down the cheek and the eyelids opened for examination. The two bolster tubes (Surflo winged infusion set, Terumo, Tokyo, Japan) are slid upwards to close the eye. The lower bolster 'locks' the lid closed [Figure 2]. Two weeks after the placement of the tarsorraphy the epithelial defect was resolved. The temporary tarsorrhaphy was maintained in place for an additional 2 weeks to allow for additional healing of the corneal epithelium. After removing the tarsorraphy, the eyelid did not exhibit any complications such as trichiasis or skin necrosis.
|Figure 2: Postoperative photograph after the temporary tarsorrhaphy. The temporary tarsorrhaphy was maintained in place for an additional 2 weeks to allow for additional healing of the corneal epithelium. The eyelid did not exhibit any complications such as trichiasis or skin necrosis|
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| Discussion|| |
In this case report, we demonstrated that drawstring temporary tarsorrhaphy with the tarsal internal fixation technique. This technique is similar to that reported by Kitchens et al., which used 6-0 prolene suture on a cutting needle. In contrast, we used 5.0 silk suture to minimize rigidity and maximize flexibility for less likely to cause a corneal abrasion. And also a 1/2 circle cutting needle with 16 mm length allows the wide radius of this suture which enable the needle to pass through a larger section of the tarsal plate in order to minimize the risks of the suture “cheese-wiring” or cutting through the lid.
The needle should be placed 2-3 mm below the lower eyelid margin and come out through the grey line so that it passes into the lower tarsal plate. It should then go into the grey line of the upper lid margin and through the upper tarsal plate and then out of the grey line. By going through the tarsal plates, the suture is anchored into the lid and that there is less chance that the suture will “cheese-wire” through the lid skin. Finally, the suture will go into the grey line of the lower lid and then out 2-3 mm below the lower eyelid margin. Care should be taken to ensure that the location where the needle passes through the grey line of the lower lid and upper lid is aligned when the lids are closed. It may be helpful to mark the lid margins when the lids are closed because the lid margins rein a different location when the lids are open.
We did not encounter any eyelid necrosis or lash loss which had been reported by bolsters due to pressure on the marginal arcade vasculature. Previous studies used Foley catheter composed of latex, silicone as bolsters., We hypothesize that our tubing composed of polyvinyl chloride is less likely to cause pressure-related injury because of its flexible characteristics that allow it to conform to the natural curvature of the eyelids.
| Conclusion|| |
Drawstring temporary tarsorrhaphy with the tarsal internal fixation technique can be effective for the management of a persistent corneal epithelial defect. This technique may be an option to treat various pathologies related to ocular surface disease and corneal exposure. The drawstring temporary tarsorrhaphy over bolsters allows for complete closure of the eyelids while permitting easy opening of the eyelids for examination, corneal cultures, or application of medicine in a clinical setting.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]