4 · Mechanical, surgical adjuncts & fibrosis modulators
Tarsorrhaphy · punctal occlusion · botulinum-induced ptosis
Review — modulators of corneal healing › 4 · Mechanical, surgical adjuncts & fibrosis modulators › Tarsorrhaphy · punctal occlusion · botulinum-induced ptosis
Tarsorrhaphy · punctal occlusion · botulinum-induced ptosis
Eyelid closure (suture/glue), punctal plugs or cauterization, chemodenervation of the levator muscle (botulinum toxin A)
Oxford II–IV
Moderate
Present · established
Mechanism of actionMechanical/physiological: tarsorrhaphy & botulinum-induced ptosis reduce exposure/evaporation and blink-related micro-trauma, cover the ocular surface and increase tear film contact time (protection of the neurotrophic epithelium). Botulinum toxin acts as a reversible “temporary tarsorrhaphy.” Punctal occlusion: ↑tear film volume/residence time, ↓MMP/inflammatory load.
IndicationsPersistent epithelial defect (PED), neurotrophic keratopathy, exposure keratopathy (facial palsy, lagophthalmos), severe aqueous-deficient dry eye, complex post-graft cases.
Route & dosageLateral/central tarsorrhaphy (temporary with glue/suture, or permanent); collagen punctal plugs (temporary) or silicone plugs/cauterization; botulinum toxin ~2.5–7.5 U into the levator muscle (ptosis develops within days, lasting ~4–12 weeks, repeatable).
Level of evidenceOxford III–IV (case series, long-standing practice; a few controlled series for botulinum toxin); punctal occlusion in dry eye: Oxford II · Scale: Moderate.
| FDA | Surgical procedures; punctal plugs cleared (510(k)). Botulinum toxin approved (other indications) — protective ptosis is off-label. |
|---|---|
| EU MA | CE-marked plugs; botulinum toxin under marketing authorisation (other indications). |
| France / USA / Asia | Available everywhere; botulinum-induced ptosis and its anti-melt use are an established off-label practice. |
Key studies: botulinum-induced ptosis for corneal protection (Eye) — PMID 3446541 ; botulinum toxin vs temporary tarsorrhaphy for PED — PMID 22553562 ; StatPearls neurotrophic keratitis — PMID 28613758.