Eyelid bridging suture as a temporary eyelid closure technique for a patient undergoing intraocular surgery with full-thickness eyelids defect

INTRODUCTION

Eyelids are the natural protective mechanism for the eyes, which gives both structural and functional support.^[1] An injury to the eye by chemical or mechanical may cause eyelid defects and deformation, which in turn affects the ocular structure [Figure 1 a-d]. Patients with eyelid defect along with intraocular disease is a very challenging situation to undergo intraocular surgery as a good eyelid cover is essential for the surgery to become successful and also to avoid anaesthesia and other surgery-related complications such as exposure to keratitis. In this case, we describe a new approach to temporarily appose both the upper and lower deformed eyelids with the help of 5-0 silk as a bridging suture (eyelid bridging suture technique) to protect the cornea from exposure keratitis in a patient with extensive subluxated cataractous lens to undergo an intraocular procedure, i.e. intracapsular cataract extraction (ICCE) with scleral fixation of intraocular lens (SFIOL).

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Figure 1:

(a) The full-thickness defective upper and lower eyelids and exposure of the cornea through it. (b) The diffuse hazy cornea with scarring in the inferior 2 mm of the cornea. Anterior chamber shows the shallow depth with subluxation of cataractous approximately 270°. (c) No punctate or corneal abrasion on fluorescein staining except a pooling of dye in the inferior cornea. (d) The complete uprolling of the cornea under the remnant of the upper eyelids on attempted closure (Bell’s phenomenon).

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CASE REPORT

A 40-year-old male presented with decreased vision in his left eye after sustaining an injury in a roadside accident 10 years ago. He underwent multiple eyelid reconstruction surgeries in an outside hospital at the same time. He also stated that he was informed about his lens dislocation in the left eye because of the trauma, and surgery for the same was denied because of the adverse surgical outcome. On examination, best-corrected visual acuity (BCVA) for the left eye was hand movement close to the face with accurate projection of rays in all four quadrants, and intraocular pressure (IOP) was normal. The left eye examination showed that there was a full-thickness defect in both the upper and lower eyelids with exposure to the cornea through the defective eyelids [Figure 1a]. There was a scar of approximately 2 mm in the inferior part of the cornea, and there was also diffuse mild corneal haziness due to a diffuse superficial nebulomatous corneal scar [Figure 1b]. There was no epithelial defect or punctate staining because of the exposure to keratitis on fluorescein staining, except for a pooling of fluorescein dye in the inferior part due to the irregular surface of the cornea [Figure 1c]. The pupil was completely mydriatic because of the trauma. The anterior chamber was shallow because of the extensive subluxation of the cataractous lens of approximately 270° [Figures 1b and 2a]. Posterior segment examination showed that the retina was attached, but a scar was seen in the macular region. There were also a few inferior grey vitreous haemorrhages seen in the vitreous. The left eyeball showed good Bell’s phenomenon [Figure 1d], i.e. it rolled up completely below the upper eyelid remnants when attempting closure. There was an epiphora because of the complete absence of the punctum; the Schirmer test showed more than 15 mm in <1 min. The right eye examination was normal. In view of the fact that the anterior chamber has a cataractous lens, which may further damage the endothelium and also to prevent cataract-related complications in the future, cataract surgery is desirable in this situation, but immediate post-operative care is difficult in this case as the anaesthetised ocular muscle with defective eyelids are unable to cover the cornea until the local anaesthesia effect wears off. Several factors led us to proceed with the cataract surgery despite the challenges, including the absence of corneal abrasion preoperatively, sufficient lacrimation, and a positive Bell’s phenomenon. To protect the cornea from exposure to keratitis during the immediate post-operative period, we thought of closing both eyelids using a silk suture passing through the skin. Tarsorrhaphy was not ideal in this situation, as there is no palpable tarsal plate in the eyelids, and attempting tarsorrhaphy may further deform the eyelids. We tried to approximate the eyelid margins using our fingers, which was successful in completely closing the eyelids. Hence, we decided to go for cataract surgery to remove the extensive subluxated cataractous lens (ICCE) plus trans sutured fixated IOL (TSFIOL) along with eyelid bridging sutures under the peribulbar block with guarded visual prognosis.

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Figure 2:

(a) The intraoperative image of the subluxated cataractous lens from the surgeon’s left lateral view. (b) The partial-thickness scleral flap made at 12’O and 6’O clock and sclerocorneal tunnel made at 3’O clock. (c) The extraction of subluxated cataractous lens using Wire Vectis. (d) The scleral fixation of the intraocular lens was implanted and sutured at the scleral bed. (e) The anterior chamber was formed using the air bubble which gives good wound sealing. (f) The bridging suture was applied using a 5-0 silk suture which was passed into the skin between the upper and lower eyelids and then tightened and the knot was made. (g) A total of four sutures were required to completely close the eyelid. (h) The schematic diagram of the bridging sutures applied to the defective eyelids.

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Surgical procedure

The surgery (ICCE plus TSFIOL plus bridging suture) was performed in two parts [Figure 2a-h] [Video 1]: Part 1: Performing the intraocular procedure, i.e. ICCE plus TSFIOL as described by Lewis^[2] and Part 2: Eyelid bridging suture was applied through the skin using 5-0 silk suture.

Video 1:

Video 1:The important steps for eyelid bridging suture.

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Part 1: Under peribulbar anaesthesia, localised peritomy was done at 12’O and 6’O clock for partial-thickness scleral flap and at 3’O clock for sclerocorneal tunnel (the surgeon sitting in a left lateral position). Partial-thickness scleral flap was made at 12’O and 6’O clock and sclerocorneal tunnel was done at 3’O clock and entry into the anterior chamber was made through keratome [Figure 2b]. After injection of viscoelastic material, a subluxated cataractous lens was extracted using Wire Vectis followed by anterior vitrectomy [Figure 2c]. 9-0 polypropylene suture was passed through 12’O and 6’O clock at scleral bed, and sutural loop was taken out through the sclerocorneal tunnel. The sutural loop was cut into two ends and was tied to the scleral fixed intraocular lens (SFIOL). SFIOL was inserted into the anterior chamber, and the sutures were sutured at the scleral bed [Figure 2d]. The viscoelastic was finally removed using the cutter. The sclerocorneal tunnel was sutured. Anterior chamber was formed using the air bubble, which gave good wound sealing. Scleral flap and peritomy were closed using fibrin glue [Figure 2e].

Part 2: The bridging suture was applied using a 5-0 silk suture, which was passed through the skin between the upper and lower eyelids and then tightened and the knot was made [Figure 2f]. Initial suture was applied in the lateral and second suture was applied in the medial. Two more sutures were required to close the eyelid completely [Figure 2g and h]. The IOP was assessed digitally after passing each suture to rule out the tightness of the suture. Bandage contact lens was also applied which could help the uniform tear film distribution on the cornea.

On post-operative day (POD) 1, there was no sign of infection on both eyelids, and the bridging suture was removed. On POD 30, BCVA (with plano) was improved to counting finger 2 m [Figure 3a] with normal IOP. There was no sign of exposure to keratitis, and SFIOL was in place. [Figure 3b and 3c] There was no deformation of the eyelids. The low visual acuity gain could be due to a macular scar or a hazy cornea.

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Figure 3:

(a) The status at the post-operative day 30, the eyelids have no surgically induced deformation, (b) cornea which is similar to pre-operative status with scleral fixation of intraocular lens in place without any punctate or (c) corneal abrasion on fluorescein staining.

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DISCUSSION

There are various techniques described in the literature for the temporary disclosure of the eyelid for the treatment of corneal abrasions and to prevent exposure to keratitis such as temporary tarsorrhaphy,^[3] drawstring temporary tarsorrhaphy,^[4] temporary eyelid closure applique,^[5] application of cyanoacrylate glue,^[6] botulinum injection,^[7] pressure patch,^[8] and simple taping.^[8] All the abovementioned techniques are described mostly in the normal eyelid anatomical structures. Adhesive techniques^[5,6,8] using simple taping, pressure patching and temporary eyelid closure applique require at least normal upper eye without any defect. Sutural techniques^[3,4] like tarsorrhaphy, drawstring temporary tarsorrhaphy which requires tarsal plate and tarsal for the suture to be passed. Application of both the above-described sutural and adhesive methods is not possible in our case because of both upper and lower eyelid full-thickness defects and also with the absence of tarsal margins. Our approach to approximate both the defective eyelids using ‘eyelid bridging suture technique’ is a simple procedure as it involves just a basic sutural principle and also does not elevate the IOP which was assessed using a digital method. The skin is an elastic tissue which can be easily pulled a little by the sutures and hence closing the eyelid remnants with the suture passed through the skin does not give too much external pressure on the globe.

When we reviewed the literature, we found a similar purpose of sutural technique ‘bridging suture’^[9] is being performed in orthopaedics for bridging and closing the tendon and ligament injury. Inoue et al.^[10] have done a similar kind of rectangular bridging suture intraocularly to prevent the SFIOL from iris capture. Our eyelid bridging suture is a modification of the horizontal mattress suture,^[11] which is applied for wound closure, but ours is intended to temporarily oppose the deformed eyelids.

Indication of the eyelid bridging sutures are (i) Significant length full-thickness eyelid defect which may not be able to cover the cornea under the anaesthetic effect during the immediate post-operative period.

Prerequisites of eyelid bridging sutures in a patient with full-thickness eyelid defect who is undergoing for intraocular procedures are as follows: (i) Good Bell’s phenomenon, (ii) no pre-operative corneal abrasion or exposure keratitis, (iii) normal Schirmer’s reading, (iv) presence of adequate length of eyelids with palpebral conjunctiva to cover the cornea, (v) pre-operative assessment of approximating the upper and lower eyelids using examiners fingers, (vi) repeatedly assessing the IOP by a digital method after passing each bridging suture, (vii) preferably, intraoperative anterior chamber formation to be done using the air bubble which gives the good sealing under external pressure to the eyeball,^[12] (viii) application of bandage contact lens post-surgery further protects the cornea by redistributing the tear films all over the cornea and (ix) postoperatively, a patient needs to be in supine position so that air bubbles remain in the anterior chamber and also prevents the pupillary block.

CONCLUSION

Intraocular surgery under local or general anaesthesia is a challenging situation in a patient with full-thickness eyelid defects because of the risk of exposure to keratitis. ‘Eyelid bridging suture’ is a simple temporary eyelid closure technique that could be performed in a patient with full-thickness eyelid defects who is undergoing intraocular surgery. Careful examination of the patient to meet the prerequisite of this surgery is mandatory to avoid untoward complications.