CLINICAL CHALLENGES
Desperate Times, Desperate Measures
When all else fails, tarsorrhaphy may help dry eyes.
By Eric Schmidt, O.D.

Some patients whom we treat for ocular disorders need more aggressive or more protracted therapy, and a few require a unique approach to their problem. Here's an example.

The case

Ms. Smith was 70 years old, confined to a wheelchair because of severe rheumatoid arthritis and couldn't use her fingers. The only medication that gave her any relief was 30 mg of predni-sone per day to control the pain. She took furosemide (Lasix) and diltiazem HCl (Cardizem) also, for cardiac arrythmia.

Her eyes "constantly hurt and felt tired, hot and sore." Ms. Smith was also concerned that her vision was getting worse.

Five years earlier, after she had cataracts removed, I had treated Ms. Smith for dry eye so bad that she had suffered a corneal melt OD with subsequent scarring of that eye. She also developed a hypersensitivity to many preserved eyedrops. At that time, we were able to keep her eyes fairly comfortable by using non-preserved artificial tears q2h. Unfortunately, for the last 6 months her arthritis had worsened so that it was impossible for her to instill the drops herself. Her husband could instill them q.i.d., but this wasn't sufficient to keep her eyes adequately moistened or comfortable.

The exam

Ms. Smith's visual acuity (VA) was 20/80 OD, 20/40 OS with her 6-month-old eyeglasses. Her eyelids were almost completely closed even when I had her move her eyes for the Physiological H test. She could open them but said they felt even sorer then.

The slit lamp examination revealed a picture drastically different from when I saw her 5 years earlier. The cornea OD showed signs of extreme xerosis. There was 2+ stromal haze throughout, and multiple elevated areas. I saw two areas of corneal thinning, one of which was 90% thinned in the central portion. A moderately dense stromal scar had formed inferiorly, and corneal neovascularization was present into the pupil margin superiorly and inferiorly. This cornea stained heavily in focal spots with sodium fluorescein (NaFl) dye (see left).

The OS revealed a similar, but less dramatic picture of xerosis. The cornea OS was flat, with no elevations or ectasia and far less stromal haze. I did see mild incursion of limbal vessels into the superior cornea. Posterior chamber intraocular lens implants were visible OU and the posterior capsules were clear.

Corneal haze obscured my view into Ms. Smith's retina OD, but I could view a small pink disk with a cup-to-disk ratio of .2/.2 OU. I saw mild retinal pigment epithelium changes in both maculae. A small ring of peripapillary atrophy surrounded each nerve head.

Looking for moisture

Ms. Smith obviously had dry eyes, but I wanted to conduct additional tests to assess the severity of the condition. A Schirmer's test showed no wetting of the strip OD and only 2 mm OS. The right cornea stained positively with rose bengal dye; the left didn't.

The root of Ms. Smith's discomfort was indeed keratitis sicca. Little inflammation was associated with her dry eye. My first task was to increase wetting. More frequent drops were impossible given her physical constraints, so I chose occlusion of the puncta with silicone plugs.

I inserted 0.6 mm Freeman-type plugs into the lower puncta OU without complications. I asked Ms. Smith to use the artificial tears as often as she could and to use GenTeal ointment qhs. I scheduled a follow-up visit for 2 weeks.

Back too soon

Only 2 days later, Ms. Smith returned with eyes hurting "worse than ever before." Her eyelids were red and edematous, and the bulbar conjunctiva exhibited 2+ injection. She said that the soreness began shortly after I inserted the plugs.

My exam showed no anterior chamber reaction and normal intraocular pressure. The corneas appeared unchanged from her previous visit. Because this inflammation began after the plug insertion, I surmised that it was caused by a hypersensitivity reaction to the silicone. Thus, I removed both plugs and told her to use the artificial tears as often as possible.

I saw her again in 3 days. Now her eyes felt "better than they did on Friday." They were, of course, still extremely dry. I felt that her right eye was at great risk for further scarring and vision loss if this dryness persisted, but because of her severe rheumatoid arthritis and hypersensitivity to preservatives (as well as the silicone plugs), we had few remaining options.

What now?

Ms. Smith desperately needed increased surface wetting. I recommended electrocautery to permanently close the puncta. This wouldn't stimulate tear production but would allow the tears she had to remain in contact with the ocular surface longer.

I performed this procedure on her lower punctum OU using a fine-tipped, disposable cautery pen. I was hopeful that Ms. Smith would tolerate this because I wasn't introducing a foreign material onto her mucous membranes, making it unlikely that her body would reject it.

One week later, Ms. Smith's eyes felt a little better, though she said that they were still sore. Her Schirmer's test results improved to 3 mm OD and 5 mm OS, still woefully short of where they needed to be. I was still worried about the long-term prospects for her vision and corneal health, especially in her right eye. But what could I do for Ms. Smith?

One last attempt

Ms. Smith's VA was decreased to 20/100 OD because of corneal scarring and thinning. Normally, I'd recommend a corneal transplant, which could improve vision and yield a smoother surface that would wet better. But given the extreme dryness of Ms. Smith's eye, the risk for failure or rejection was higher.

Then it dawned on me that we could do a corneal transplant and concomitantly perform a partial lateral tarsorrhaphy. The tarsorrhaphy would inhibit evaporation, allowing the tears to stay on the eye much longer and protect the ocular surface.

Five weeks later, a corneal surgeon performed the transplant as well as the lateral tarsorrhaphy. He closed the lid aperture 35%, enough to protect the surface, yet still allow light to enter the pupil unobstructed.

Success!

It's been 14 months since Ms. Smith's surgery. At her last exam, her VA was 20/40 OD, 20/30 OS and she was happy. She uses non-preserved artificial tears t.i.d. and carboxymethylcellulose ointment (Celluvisc) qhs. I'd considered opening the tarsorrhaphy, but Ms. Smith said she was delighted with the way things were. We were both reluctant to make changes.

Unfortunately, the rheumatoid arthritis has progressed. Ms. Smith is bedridden, but she says, "At least I can read again."

Contributing Editor Eric Schmidt, O.D., is director of the Bladen Eye Center in Elizabethtown, N.C. E-mail him at KENZIEKATE@aol.com.