Case History:
A 39 y.o. Hispanic male with a history of Wegener’s Granulomatosis diagnosed in 1999 presented to the oculoplastic surgery clinic with diplopia and pain OD. The Wegener’s Granulomatosis involves his kidneys, lungs, sinuses and orbit. Past surgical history related to this disease includes a lung lobectomy, ethmoidectomy, uncinectomy, frontal sinusotomies, and maxillary antrostomy. He has been treated with multiple anti-inflammatory medications as well as immune modulators, some of which he no longer tolerates. His past ocular history is significant for multiple orbital floor reconstructions using titanium mesh implants twice, which became infected, extruded and had to be removed. His right lower eyelid completely scarred down to the inferior orbital rim and he had lost the normal architecture of the eyelid margin and posterior lamella. In addition, his globe became fixed with restricted upgaze and hypoglobus. In the presence of severe right lower eyelid retraction and a fixed globe, his cornea was exposed and he did not have an adequate Bell’s reflex for protection beneath the upper eyelid.
Given the multiple failures of previous reconstructions secondary to persistent orbital inflammation, options at this point were limited. Surgeries considered at this point included a permanent tarsorrhaphy to protect the globe and relieve the patient’s pain or a release of scar with reconstruction using preferably autografts to minimize the risk of rejection and extrusion.
The decision for eyelid reconstruction was made intraoperatively after the patient was placed under general anesthesia and more thorough manipulation of the globe and lid could be performed for evaluation. This approach was chosen in order to enable the patient to utilize his good seeing right eye.
Surgical Approach:
The right lower eyelid was first released from the underlying inferior orbital rim. Again, the margin was non-existent. Skin and orbicularis was fused with the periosteum lining the inside of the orbital floor. This skin muscle flap was dissected off of bare bone over the inferior rim. Next, we released the scarring of the globe that was limiting upgaze by performing a 180 degree conjunctival peritomy and using a hang-back suture on the inferior rectus muscle. The normal anatomical configuration of the conjunctiva was also lost as the bulbar conjunctiva was fused with the periorbita with complete lack of an inferior fornix. An amniotic membrane graft was used to reconstruct the inferior fornix, draping it from the area of the peritomy on the bulbar conjunctiva, looping it down into the fornix. Ambio5, manufactured by IOP Inc. was used because it was thicker than other amniotic membrane and held its shape better in this difficult reconstruction. A scleral patch graft was then used to line the inferior orbital rim to prevent scarring of the skin-muscle flap back to the bone. Next, our attention was turned to vertically lengthening the right lower eyelid. A full length Hughe’s tarsoconjunctival flap graft was used to reconstruct the central portion of the lower lid. Still there was horizontal shortening. An ear cartilage graft or hard palate graft could have been considered at this point, but that would include an additional donor site for the patient increasing morbidity. As well, a hard palate graft would introduce mouth bacteria into the orbit and this patient was already susceptible to multiple infections. We turned to a synthetic product, tarSys.
TarSys is a relatively new bioengineered eyelid spacer graft manufactured by IOP Inc. and made specifically for eyelid retraction repair. The biologic composition is similar to tarsal plate. It is compatible with superficial mucosa and integrates with the host tissue. TarSys is an eight layer, decellularized membrane consisting of collagen types I, III, and VI and is derived from a porcine source.
After hydration of the graft, we cut the sheet of tarSys in half and flanked the Hughe’s tarsoconjunctival flap. We then anchored the medial and lateral stumps of tarSys to the remaining soft tissues in these areas.
Advantages of tarSys are that the product has similar consistency to native tarsus. It is easy to work with and can be easily cut into the appropriate shape and size. Sutures are very easy to pass through the implant. TarSys takes at least 20 minutes to hydrate. In a case where the surgeon is sure to use the product, the hydration time would not be a factor, but if you are undecided, then this will add a bit to your operating time.
So far the implant has been well tolerated in our patient who is prone to rejection of synthetics. It has been only 2 weeks since his surgery, but he remains comfortable and is ecstatic that an eyelid reconstruction was attempted at this point.
TarSys has so far proven to be a likeable option for posterior lamellar reconstruction of eyelids. Since it is not lined with a mucous membrane, I would recommend that it be used in temporal and medial locations, rather than directly overlying the cornea, unless the surgeon decides to line the implant with a mucous graft or amniotic membrane graft. This will minimize the risk of a corneal abrasion. Other options for posterior lamellar replacement include hard palate grafts, an option I often use since it is an autograft and risk of rejection is eliminated. As well, ear cartilage can be used. The disadvantage to these approaches is the increased morbidity from having another donor surgical site, as well as increased surgical time to harvest the autografts. Many patients wish to have synthetic products used for their eyelid reconstructions to avoid a large donor site that takes healing time in the mouth. Alloderm is a collagen framework from donated skin that can be used in posterior lamellar reconstruction, but can resorb with time. Enduragen is another product used for eyelid reconstruction, also consisting of porcine dermal collagen, making it another xenograft.
Each of the above mentioned grafts are possibilities when reconstructing the eyelid. TarSys adds to the armamentarium of products that can be used not only for basic eyelid retraction cases, but in difficult reconstructions as well. Another advantage to this product has been the reliability and responsiveness of the company, IOP Inc. I placed a call to a representative of the company the day before surgery. The product was ordered, FedExed and arrived to my operating room by the next morning on time for the surgery. This type of responsiveness is key, especially when difficult cases arise and surgical decisions may not be made until late in the game.