A Possible Alternative to Tarsorrhaphy?
Lynette Johns OD FAAO FSLS
Extreme and longstanding corneal exposure from either mechanical or neurogenic lagophthalmos may require tarsorrhaphy for corneal protection. A tarsorrhaphy is a surgical procedure that narrows the palpebral fissure by partially suturing the eyelids together. It can be performed in a variety of ways. While the procedure is therapeutic, it may limit peripheral visual field and also have cosmetic implications for the patient.
Prior to tarsorrhaphy, a variety of protective measures are utilized including aggressive and copious lubrication, punctal occlusion, bandage soft contact lenses, lid weights and even amniotic membranes. If left untreated, exposure and neurotrophic keratopathy can potentially lead to persistent epithelial defects, corneal ulceration and perforation (Figures 1 and 2). The use of scleral lenses in cases of exposure and neurotrophic keratopathy can lubricate and protect the exposed cornea, providing adjunctive therapy and, in some cases, an alternative to a tarsorrhaphy.
Figures 1 and 2
A 38-year-old male had a history of an acoustic neuroma resection that resulted in facial, trigeminal and acoustic nerve involvement on the right side. As a result, the cornea was left exposed from lagophthalmos and neurotrophic (keratopathy?). He arrived for a scleral lens fitting with a dense corneal scar and inferior neovascularization invading the visual axis, temporal tarsorrhaphy, and 20/100 acuity (Figure 3). He was successfully fit with a scleral lens, with best corrected visual acuity of 20/30.
Use of scleral lenses as an alternative to tarsorrhaphy has been reported in the literature.1 While scleral lenses have many benefits for these fragile corneas, there also must be a level of clinical vigilance with close observation of these patients. Daily wear of scleral lenses is very effective for lubrication and protection while awake; however, nighttime exposure poses additional risks. Some measures include nighttime goggles, tape tarsorrhaphy, and aggressive ointment lubrication. Nighttime ointment can cause issues with coating the lenses upon application if residual ointment remains. Sometimes, a tarsorrhaphy needs to be reversed to support scleral lens fitting. Lastly, and controversially, there is a question of using scleral lens extended wear to protect the cornea at all times.
Dr. Lynette Johns is an adjunct assistant professor and clinical attending in contact lenses at the New England College of Optometry.
She was formerly the senior optometrist at the Boston Foundation for Sight where she exclusively fit scleral lenses and managed complex corneal disease.
She is a fellow of the American Academy of Optometry and Scleral Lens Education Society as well as a member of the BCLA. She is a clinical and educational consultant to the GP and specialty soft lens division of Bausch + Lomb.