Conjunctival pillar tarsorrhaphy







Table 45.1

Indications for surgery

















Paralytic lagophthalmos
Exposure keratopathy
CN VII palsy
Failing/exposed corneal transplant
Neurotrophic cornea
Recalcitrant corneal infections
Debilitating corneal pain


Table 45.2

Preoperative evaluation





















Presence of Bell’s phenomenon
Degree of lagophthalmos
Corneal epithelial staining
Orbicularis strength
Anterior or posterior lamellar shortage
Prior eyelid, facial surgery or trauma
History of head and neck cancer treatment, especially involving facial nerve
Corneal sensation
History of thyroid eye disease/proptosis


Introduction


A conjunctival pillar tarsorrhaphy is suitable for treating corneal exposure that is refractory to medical management. The size and location of the conjunctival pillar can be customized for the degree of corneal exposure. Exposure of the medial cornea, in particular, is difficult to treat with permanent tarsorrhaphy ( Chapter 46 ) without significantly constricting the horizontal palpebral aperture. A conjunctival pillar tarsorrhaphy can be rapidly reversed in the clinical setting and is cosmetically superior to permanent lateral tarsorrhaphy.


Patients with a history of impending failure or recurrent penetrating keratoplasty with corneal exposure are particularly suited for conjunctival pillar tarsorrhaphy. The conjunctival pillar continually lubricates the corneal graft with blinking and routine eye movements while maintaining a normal vertical aperture to allow for instillation of topical medications and slit lamp examination. Recurrent corneal infections, viral, bacterial or protozoal, may be considered after failed medical management. Acquired or heritable causes of neurotrophic corneas are other indications for treatment.


The surgery involves raising a tarsoconjunctival flap from the upper eyelid and fusing this to the lower eyelid. The pillar can easily be severed in the clinical setting with topical anesthesia and no disfiguring sequela.




Surgical Technique





Figures 45.1A and 45.1B


Assessment of corneal exposure

Examination of this patient discloses lagophthalmos. Her history is significant for upper eyelid blepharoplasty performed elsewhere resulting in an anterior lamellar deficiency ( Figure 45.1A ). This corneal exposure resulted in ulceration and perforation necessitating a penetrating keratoplasty. With elevation of the upper eyelid, there is dense corneal vascularization and thinning of the inferonasal cornea ( Figure 45.1B ). With the insufficiency of anterior lamella, placement of an upper eyelid weight would not be expected to improve the corneal exposure and the patient did not favor a cosmetically displeasing permanent medial tarsorrhaphy.

May 16, 2019 | Posted by in Reconstructive surgery | Comments Off on Conjunctival pillar tarsorrhaphy
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