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The Drawstring Temporary Tarsorrhaphy Technique
John Kitchens, MD;
John Kinder, MD;
Thomas Oetting, MD
Arch Ophthalmol. 2002;120:187-190.
ABSTRACT
Tarsorrhaphy 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 temporary
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.
Tarsorrhaphy is used to close the eyelids to facilitate the healing
of various corneal epithelial disorders or to prevent corneal exposure and
its inherent complications. A temporary form of tarsorrhaphy is used when
closure of the eyelids is needed for shorter periods. With any tarsorrhaphy
technique, one must allow for future and sometimes frequent examination of
the eye and for administration of topical medication.
A variety of temporary techniques have been proposed. These include
the use of pressure patching, cyanoacrylate, botulinum toxin to the levator
muscle, and a variety of suture techniques. Each of these techniques comes
with advantages and disadvantages. Techniques (Table 1), such as gluing the eyelid shut and lateral tarsorrhaphy,
are easy to perform and allow for excellent healing but make examination difficult.
Injection of botulinum toxin into the levator muscle is technically more difficult
and more expensive but allows for easy examination of the eye. Our proposed
drawstring technique allows for complete closure between examinations, yet
permits easy opening of the eyelids for examination or application of medicine.
Like most temporary tarsorrhaphy techniques, the drawstring technique can
be performed in any setting.
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Options for Temporary Tarsorrhaphy
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METHODS
The central pretarsal area of both the upper and lower eyelids is anesthetized
with lidocaine (1% epinephrine; 1:100 000) using a 3-mL syringe and a
30-gauge needle. The area is then prepared with povidone iodine and sterile
drapes are applied. Sterile bolster material is created by cutting a Foley
catheter into 2 semicircular strips. One of these strips is then cut into
two 2-cm sections and one 1-cm section. The bolsters help prevent the suture
from damaging eyelid tissue. These pieces also aid in everting the eyelid
to prevent trichiasis. The 1-cm bolster acts to close the drawstring when
placed against the 2-cm bolster of the lower eyelid (Figure 1 and Figure 2).
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Figure 1. Open drawstring tarsorrhaphy.
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Figure 2. Closed drawstring tarsorrhaphy.
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A double-armed 6-0 prolene suture on a cutting needle (P-3) is first
passed completely through one of the 2-cm bolsters about 2 mm from the end.
The same needle arm is then passed 3 to 4 mm from the upper eyelid margin
into the tarsus, exiting the eyelid margin at the gray line (through the arcus
marginalis). The needle should then enter the gray line of the lower eyelid
in the same position relative to the medial palpebral fissure, exiting the
lower eyelid 2 to 3 mm inferior to the eyelid margin. The other needle arm
of the 6-0 prolene suture should then be placed through the upper-eyelid bolster
in a similar fashion to the lower eyelids but displaced laterally. Both needles
are then passed through the second 2-cm bolster, which is placed adjacent
to the lower eyelid. Tightening of the suture at this point should allow complete
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
separated from the larger lower eyelid bolster, which allows the eyelid to
be examined 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 were performed. Neurosurgeons
repositioned frontal fractures to provide increased orbital volume. Unfortunately,
the patient had significant corneal exposure, eventually 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 infiltrates
resolved and the tarsorrhaphy was removed.
CASE 2
A 75-year-old man with adult-onset diabetes for 20 years developed a
postoperative sterile corneal ulcer after cataract extraction by phacoemulsification.
Central thinning was as much as 80%. A drawstring temporary tarsorrhaphy was
performed in the clinic minor room. The patient's sterile ulceration 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. Fortunately, the patient's cornea stabilized to the point that allowed
penetrating keratoplasty to be performed several months later (Figure 3 and Figure 4).
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Figure 3. Case 2. Temporary tarsorrhaphy
closure.
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Figure 4. Case 2. Temporary tarsorrhaphy
closed.
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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 retinopathy with neovascular glaucoma of his right
eye. The patient underwent cryoablation in the operating room to treat his
proliferative diabetic retinopathy. 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 improved 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 effective but can have a high incidence of
dehiscence and may deform the eyelid margin.2
The permanent technique (including intermarginal tarsorrhaphy) may lead to
damage to the eyelid margin and resultant trichiasis.3
Pressure patching provides a noninvasive option but is dependent on patient
placement and compliance.1 A variety of temporary
techniques have been proposed. Cyanoacrylate temporary tarsorrhaphy has an
unpredictable time course. This technique lasts from 1 to 15 days (average
of 6 days).4 It also does not allow for easy
observation without the need for reapplication of the agent. Botulinum toxin
injection can provide temporary eyelid closure, but it provides variable results5; may cause hypotropia6;
and is expensive.7 A variety of other temporary
techniques have been proposed that use sutures to close the eyelids.7-9 Several of these require
additional measures to close the eyelids or fail to provide adequate access
to the eye.
In summary, the drawstring temporary tarsorrhaphy is a useful tool in
the treatment of persistent epithelial defects. It allows easy access to the
eye for examination and for the administration of topical medications. Additionally,
it can be performed easily in virtually any setting.
AUTHOR INFORMATION
Accepted for publication September 19, 2001.
Corresponding author and reprints: Thomas A. Oetting, MD, UIHC, Department
of Ophthalmology, 200 Hawkins Dr, Iowa City, IA 52242-1091
(e-mail: thomas-oetting{at}uiowa.edu).
From the Department of Ophthalmology, University of Iowa Hospitals
and Clinics, Iowa City, Iowa (Drs Kitchens and Oetting); and Eye Consultants
Inc, Cape Girardeau, Mo (Dr Kinder). The authors have no proprietary or financial
interest in any of the products mentioned.
REFERENCES
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1. Wagoner MD, Steinert RF. Temporary tarsorrhaphy enhances reepithelialization after epikeratoplasty. Arch Ophthalmol. 1988;106:13-14.
2. Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG, ed. Plastic Surgery. Vol
2. Philadelphia, Pa: WB Saunders. 1990:1590-1591.
3. Missotten L. Lasting temporary tarsorrhaphy. Bull Soc Belge Ophtalmol. 1979;185:27.
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4. Donnenfeld ED, Perry HD, Nelson DB. Cyanoacrylate temporary tarsorrhaphy in the management of corneal epithelial
defects. Ophthalmic Surg. 1991;22:591-593.
ISI
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5. Kirkness CM, Adams GW, Dilly PN, Lee JP. Botulinum toxin A-induced protective ptosis in corneal disease. Ophthalmology. 1988;95:473-480.
ISI
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6. Wuebbolt GE, Drummond G. Temporary tarsorrhaphy induced with type A botulinum toxin. Can J Ophthalmol. 1991;26:383-385.
PUBMED
7. Rapoza PA, Harrison DA, Bussa JJ, Prestowitz WF, Dortzbach RK. Temporary sutured tube tarsorrhaphy: reversible eyelid closure technique. Ophthalmic Surg. 1993;24:328-330.
PUBMED
8. Hallock GG. Temporary tarsorrhaphy "zipper." Ann Plast Surg. 1992;28:488-490.
PUBMED
9. Dryden RM, Adams JL. Temporary nonincisional tarsorrhaphy. Ophthal Plast Reconstr Surg. 1985;1:119-120.
PUBMED
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