Introduction

Permanent tarsorrhaphy may be considered when maximal medical therapy has failed to treat corneal exposure. Paralysis of the facial nerve and, specifically, the zygomatic branch of cranial nerve 7 (CN VII) results in denervation of the orbicularis oculi muscle which is essential for eyelid closure and maintenance of a healthy and clear ocular surface.

Possible causes of CN VII palsy include infections, trauma, skin cancers, salivary gland carcinomas, and other head and neck cancers. Occasionally, the facial nerve will be intentionally sacrificed during the excision of malignant head and neck cancers. Unknown causes should be investigated with assistance from primary care and/or neurologic consultation.

Non-paralytic indications for tarsorrhaphy include lower eyelid retraction secondary to thyroid-related orbitopathy (TRO) and post-blepharoplasty surgery. Stability of the exophthalmos and optic nerve status should be evaluated before considering tarsorrhaphy in a patient with TRO as progressive disease can increase intraorbital pressure and may preclude auto-decompression. Ideally, management of TRO should include consideration of orbital decompression ( Chapter 64 ) and eyelid retraction repair ( Chapter 17 ) if indicated. For the cosmetic patient, lateral tarsorrhaphy is the least favorable choice, and lower eyelid retraction repairs should be considered first ( Chapter 34 , Chapter 35 , Chapter 36 ).

Prior to considering tarsorrhaphy, initial management should consist of frequent ocular surface moisturization with lubricating drops and ointments, taping of the eyelids and use of moisture chambers. The presence of corneal anesthesia (cranial nerve 5; CN V) in conjunction with CN VII palsy puts the patient at significant risk of rapid corneal decompensation and warrants more aggressive management.

If the facial nerve paralysis is permanent and the ocular surface is compromised, several surgical options are available. The first consideration is upper eyelid loading with a weight ( Chapter 19 ). Placement of an eyelid weight provides a good balance between function and form. A conjunctival pillar tarsorrhaphy ( Chapter 45 ) can be fashioned to protect the ocular surface, particularly when a penetrating keratoplasty was previously performed. Finally, permanent tarsorrhaphy may be considered in recalcitrant cases. Lateral tarsorrhaphy of one-third of the eyelid provides excellent protection of the ocular surface, but at the cost of obstructing portions of the lateral visual field as well as the aesthetic changes to the eyelid. In patients with poor visual potential and non-compliance with ocular lubrication and eyelid taping, lateral tarsorrhaphy can be very protective of the ocular surface. Tarsorrhaphy may also be considered for debilitated patients as a protective measure. The surgery can be performed medially, but this causes more significant vertical palpebral shortening and conjunctival pillar tarsorrhaphy may be more appropriate.

The surgery involves dividing the anterior and posterior lamellar of the upper and lower eyelids, followed by fusion of the tarsal plates and anterior lamella. To allow for reversibility, a segment of epithelialized eyelid margin is kept intact at the lateral canthus. When severing the tarsorrhaphy, this can be performed sequentially with 1–2 mm increments at a time while carefully monitoring corneal status. After severing, the eyelid margin epithelizes well with minimal aesthetic consequences.