35 EyeWorld Asia-Pacific | June 2025 CORNEA Such persistent corneal epithelial defects, Dr. Kim continued, by a variety of 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 if healing is a concern. Dr. Kim said there are a variety of treatments that should be tried, in most cases, before tarsorrhaphy, including aggressive lubrication, punctal occlusion, therapeutic bandage contact lens, autologous serum, and/or amniotic membrane. “It is at the ophthalmologist’s discretion, but my general rule is if an epithelial defect persists for more than 7–10 days despite aggressive 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—amniotic 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, temporarily 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 exhausted other options. “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 perforation, 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 tarsorrhaphy earlier as a more efficient solution. Dr. Rapuano said it’s important preoperatively to tell the patient that this will be an uncomfortable procedure but that we’ll use a lot of medications to minimize the pain. This, he said, prepares the patient mentally for the procedure, so they don’t feel overwhelmed or alarmed during the experience. 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 concurrent 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 medically, 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 enables ongoing examination and medication delivery. 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 permanent tarsorrhaphies can be reopened at the surgeon’s discretion. Some drawbacks to Botox tarsorrhaphy are that it doesn’t take effect immediately (often 1–3 days to kick in), and it’s unpredictable how long it will last, Dr. Rapuano said. He added that glue tarsorrhaphies can be problematic if the glue gets inside the eyelid and rubs against an already compromised cornea; it’s also unpredictable how long the glue will last.
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