Two bolsters of the surgeon's choice of size and material (plastic tubing, red robin catheter, cotton wool balls, etc.) are prepared. If it is anticipated that the suture will be removed within 2 weeks and there is no skin compromise, bolsters may not be necessary. Allen, R. “Lateral tarsorrhaphy.” Oculoplastics Surgery Techniques. University of Iowa Health Care. Ophthalmology and Visual Sciences Video Library.

silk sutures are passed through the upper eyelid at the level of the meibomian gland orifices and the eyelid is everted over a speculum. Allen, R. “Pillar tarsorrhaphy.” Oculoplastics Surgery Techniques. University of Iowa Health Care. Ophthalmology and Visual Sciences Video Library. To retain a prosthesis, Boston Keratoprosthesis, or other device in patients with anophthalmia or after evisceration or enucleation Ellis MF, Daniell M. An evaluation of the safety and efficacy of botulinum toxin type A (BOTOX) when used to produce a protective ptosis. Clin Exp Ophthalmol. 2001;29(6):394–399.The anterior lamella of the lower lid is then sutured to the anterior lamella of the upper lid using absorbable or permanent 5-0 to 6-0 suture in an interrupted fashion. [1] [13] Tzelikis PF, Diniz CM, Tanure MA, Trindade FC. Tarsorrafia: aplicações em um Serviço de Córnea [Tarsorrhaphy: applications in a Cornea Service]. Arq Bras Oftalmol. 2005 Jan-Feb;68(1):103-7. Portuguese. doi: 10.1590/s0004-27492005000100019. Epub 2005 Mar 30. PMID: 15824813. After washing and preparing the eye thoroughly within the lid margins and fornices, the glue gel of choice is applied along closed lateral eyelid margins using the standard applicator tip supplied with the gel. Using the same applicator tip, the gel is spread medially along the eyelid margins to achieve the desired amount of closure. The glue is allowed to dry for 15 – 20 seconds. Once dry, the eyelids stay closed for approximately 2 weeks. [5] [16] Some report longer lasting closure with a recent study in a pediatric population reporting that cyanoacrylate glue tarsorrhaphies last an average of 4.5 weeks (range 0.5-13 weeks). [17] It can be reversed by cutting the eyelashes following the application of lidocaine gel. Donnenfeld ED, Perry HD, Nelson DB. Cyanoacrylate temporary tarsorrhaphy in the management of corneal epithelial defects. Ophthalmic Surg. 1991;22591- 593.

The needle is then passed through the meibomian gland orifices of the upper lid margin and retrieved 3-4 mm above the upper lid margin and engages the upper bolster.Prior to the procedure, a full ophthalmic examination should be performed and documented. A thorough slit lamp biomicroscopic examination should document corneal pathology and the size and location of any defects or corneal ulcers. Careful examination of the palpebral conjunctiva using double eversion to look for foreign bodies or keratinization should also be performed. External examination of eyelid abnormalities, the degree of lagophthalmos, and assessment of corneal sensitivity are critical in determining what type of tarsorrhaphy is appropriate (permanent vs. temporary) and deciding on the extent of tarsorrhaphy (lateral vs. medial vs. central vs. total) to be performed. The length of tarsorrhaphy to be performed is determined by gently pinching the upper and lower eyelids together with forceps or manually to achieve desired closure. A medial tarsorrhaphy is another useful technique when applicable. This technique is modified to avoid damage to the canaliculi and involves making a V-shaped incision peripheral to the canaliculi to the upper and lower lids. The medial tarsorrhaphy is advantageous in that it does not interfere with peripheral vision. Lagophthalmos due to facial nerve palsies (neurogenic exposure keratopathy), cicatricial damage to the eyelids, anorexia nervosa, leprosy, Ramsay Hunt Syndrome Type 2, orbital tumors, and thyroid eye disease [1] [7] [8] [9] The 4-0 silk everting sutures are removed, and the eyelids are inspected to ensure appropriate closure. [3] [14]

A #15 Bard-Parker blade is used to cut through the skin and orbicularis adjacent to the canaliculus.

Scissor - Stevens Tenotomy, Curved, Length 11cm

Khairy H. Botulinum toxin A-induced ptosis: A safe and effective alternative to surgical tarsorrhaphy for corneal protection. Journal of the Egyptian Ophthalmological Society. 2014;107(1):20-22. doi:10.4103/2090-0686.134937.