Proptosis Reduction

Step 1.

Administer systemic analgesic and protect the cornea by applying a topical lubricant (eg, ophthalmic antibiotic ointment) immediately on presentation. Assess the patient’s general physical condition; when the patient is stable, induce general anesthesia. Evaluate the globe’s condition, particularly the cornea, to determine whether globe replacement or enucleation is indicated; check for intraocular muscle integrity, vision, hyphema, and pupillary light reflex. Clip and prepare eyelids and corneoconjunctival surfaces; remove debris from the cornea and conjunctiva with sterile saline or lactated Ringer’s solution.

Author Insight

To clean and prepare ocular surfaces and conjunctival fornices, use dilute povidone–iodine with saline to 0.5% (light brown, resembling weak tea). Swab lid margins and fornices (if accessible) with a sterile cotton-tipped applicator. Rinse the povidone–iodine solution from the eye with sterile saline or eye wash. Do not apply povidone–iodine scrub or other chemical preparations (eg, chlorhexidine) to ocular surfaces; doing so can cause corneoconjunctival ulceration.

Step 2.

A releasing lateral canthotomy allows eyelid margins to be lifted from behind the globe’s equator and returned to their normal anatomic position. Use scissors to make a full-thickness incision extending laterally from the lateral canthus, as if to extend the length of the palpebral fissure. Be generous with the incision (ie, ~1 cm). Using forceps, roll the eyelid margins into their normal orientation, facing forward and rostrally.

Step 3a. 

Place a temporary tarsorrhaphy to protect the globe from exposure. Preplace 2–4 partial-thickness horizontal mattress sutures in the eyelids across the palpebral fissure. This facilitates placement of remaining sutures in the correct tissue plane (partial thickness exiting the meibomian gland openings) and proper positioning of the lids over the globe. Pass the suture first through the stent and then through the skin of the eyelid ~5 mm from the eyelid margin (A),directing it toward and exiting along the lid margin at the level of the meibomian gland openings. Leave the suture material untied over the globe across the palpebral fissure.

Step 3b. 

Direct the needle through the meibomian gland openings on the opposite lid, exiting the skin ~5 mm from the lid margin; then reverse the entire procedure. Tie suture ends after all have been placed.

Author Insight

Using stents (typically small piece of rubber band or IV tubing) reduces skin tension from the suture material, limits the possibility of pull-through and subsequent breakdown of thetarsorrhaphy, and helps prevent pressure necrosis of the eyelids.

Step 3c.

Direct the needle through the meibomian gland openings on the opposite lid, exiting the skin ~5 mm from the lid margin; then reverse the entire procedure. Tie suture ends after all have been placed.

Author Insight

Using stents (typically small piece of rubber band or IV tubing) reduces skin tension from the suture material, limits the possibility of pull-through and subsequent breakdown of thetarsorrhaphy, and helps prevent pressure necrosis of the eyelids.

Author Insight

Proper placement of the horizontal mattress suture for the temporary tarsorrhaphy is critical. Suture should be snug enough to avoid any space between the upper and lower eyelids and prevent it from contacting the cornea, especially after periocular swelling begins to subside. 

Step 4.

Close the canthotomy before tightening the tarsorrhaphy sutures for ease of exposure. Close the canthotomy with a figure-of-eight suture to reappose eyelid margins at the lateral canthus. To prevent suture material from protruding through the palpebral conjunctiva and irritating the cornea, do not place the suture through the full thickness of the eyelid. Exit the suture through the meibomian gland openings. Close the remaining incision with simple interrupted sutures.

Author Insight

Placing the initial suture at the lid margins of the lateral canthotomy site allows proper realignment of the margin, thereby maintaining normal anatomic position and function of the eyelids.

Step 5a.

Once the tarsorrhaphy sutures are in place, place a lubricated scalpel handle over the cornea underneath the sutures. If possible, try not to press down on the cornea with the instruments.

Step 5b.

Draw up on the sutures simultaneously to bring the lids into a closed position over the globe.

Placing a flat, smooth implement between the sutures and the cornea prevents (1) the sutures from irritating the cornea and (2) forward movement of the globe while the eyelids are being pulled up.

Step 5c.

Tighten and tie each suture.

Author Insight

The medial canthus of the palpebral fissure is usually left open a few millimeters to allow topical medications to be applied to the ocular surface. Alternatively, one of the tarsorrhaphy sutures can be left with long tags that can be tied in a bow (rather than a knot) and can be opened and closed as needed to apply medication or check the globe’s status.

Step 6.

Postoperative systemic medical therapy should include broad-spectrum systemic antibiotics (especially if the injury was sustained during an encounter with another animal), systemic antiinflammatory medications (usually steroids in case optic neuritis is present), and analgesics in addition to topical broad-spectrum antibiotic ointments (q6h) and 1% atropine (q8–12h). The tarsorrhaphy sutures should remain in place as long as they are secure but for at least 2 weeks (sometimes up to 4 weeks). If lagophthalmos persists after suture removal, replace the sutures for a few more weeks, then remove the sutures sequentially, not all at once.

Temporary or permanent lateral strabismus is common after proptosis.

Author Insight

If exposure keratitis continues to cause problems, permanent partial lateral tarsorrhaphy or medial canthoplasty to shorten the palpebral fissure length and provide greater coverage for the globe may be indicated.