Sealing of the gap between the conjunctiva and tenon capsule to improve symblepharon surgery

Management of symblepharon with Gore-tex as a novel treatment option for ocular chemical burns

PURPOSE

To assess the clinical outcomes of symblepharon release in patients with ocular surface chemical injury using Gore-Tex as a novel treatment option.

METHODS

This was a retrospective analysis of 23 eyes of 22 chemical injury patients done during a period of January 2014 to December 2021 at a tertiary eye care centre in South India. All patients underwent symblepharon lysis along with Gore-Tex application over the sclera with minimum 1 year follow up. The patients were assessed for demographic details, visual acuity, intraocular pressure, anterior and posterior segment details, photographic documentation, preoperative diagnosis, previous surgical details in recurrent cases, surgical procedures, final visual acuity, surgical outcomes, and complications. The clinical outcomes were assessed and outcomes were defined as success, partial success, or failure.

RESULTS

The median age was 17 years (IQR, 12-39 years). Among them 10 eyes with symblepharon had grade 3 length, 12 eyes grade 3 width and 12 eyes had grade 3 loss of palisades of Vogt. The success was achieved in 52.2% of the patients; partial success in 34.8% and 13.3% had failure. The mean duration of recurrence was 6.75 ± 3.6 months. Failure was noted in young patients with mean age 9.75years and with grade 3c symblepharon. There was no sight threatening complications noted.

CONCLUSION

The study showed very good results with Gore-Tex as a novel treatment option for chemical injury patient with symblepharon formation. It can be easily employed to prevent the symblepharon recurrence of various ocular surface disorders.

Outcomes of the TissueTuck Surgical Technique for Recurrent Pterygium

PURPOSE

The objective of this study was to evaluate the clinical outcomes of the TissueTuck technique in the treatment of eyes with recurrent pterygium.

METHODS

A retrospective review was performed on patients with recurrent pterygium who underwent surgical excision, followed by the application of cryopreserved amniotic membrane, using the TissueTuck technique between January 2012 and May 2019. Only patients with at least 3 months of follow-up were included for analysis. Baseline characteristics, operative time, best-corrected visual acuity, and complications were assessed.

RESULTS

A total of 44 eyes of 42 patients (age 60.5 ± 10.9 yrs) with single-headed (84.1%) or double-headed (15.9%) recurrent pterygium were included for analysis. The average surgical duration was 22.4 ± 8.0 minutes, and mitomycin C was administered intraoperatively in 31 eyes (72.1%). During a mean postoperative follow-up of 24.6 ± 18.3 months, there was only 1 case of recurrence (2.3%). Other complications include scarring (9.1%), granuloma formation (20.5%), and corneal melt in 1 patient with preexisting ectasia (2.3%). Best-corrected visual acuity significantly improved from 0.16 Logarithm of the Minimum Angle of Resolution at baseline to 0.10 Logarithm of the Minimum Angle of Resolution at the last postoperative follow-up ( P = 0.014).

CONCLUSIONS

TissueTuck surgery with cryopreserved amniotic membrane is safe and effective for recurrent pterygium cases with a low risk of recurrence and complications.

Decellularized Porcine Conjunctiva in Treating Severe Symblepharon

This prospective study aimed to evaluate the effectiveness of decellularized porcine conjunctiva (DPC) in the management of severe symblepharon. Sixteen patients with severe symblepharon were enrolled in this study. After symblepharon lysis and Mitomycin C (MMC) application, tarsus defects were covered with residual autologous conjunctiva (AC), autologous oral mucosa (AOM), or DPC throughout the fornix, and DPC was used for all the exposed sclera. The outcomes were classified as complete success, partial success, or failure. Six symblepharon patients had chemical burns and ten had thermal burns. Tarsus defects were covered with DPC, AC, and AOM in two, three, and eleven cases, respectively. After an average follow-up of 20.0 ± 6 months, the anatomical outcomes observed were complete successes in twelve (three with AC+DPC, four with AC+AOM+DPC, and five with AOM+DPC) (75%) cases, partial successes in three (one with AOM+DPC and two with DPC+DPC) (18.75%) cases, and failure in one (with AOM+DPC) (6.25%) case. Before surgery, the depth of the narrowest part of the conjunctival sac was 0.59 ± 0.76 mm (range, 0-2 mm), tear fluid quantity (Schirmer II tests) was 12.5 ± 2.26 mm (range, 10-16 mm), and the distance of the eye rotation toward the opposite direction of the symblepharon was 3.75 ± 1.39 mm (range, 2-7 mm). The fornix depths increased to 7.53 ± 1.64 mm (range, 3-9 mm), eye movement was significantly improved, and the distance of eye movement reaching 6.56 ± 1.24 mm (range, 4-8 mm) 1 month after the operation; the postoperative Schirmer II test (12.06 ± 2.90 mm, range, 6-17 mm) was similar to that before surgery. Goblet cells were finally found in fifteen patients by conjunctival impression cytology in the transplantation area of DPC, except for one patient who failed. DPC could be considered an alternative for ocular surface reconstruction of severe symblepharon. Covering tarsal defects with autologous mucosa is necessary for extensive reconstruction of the ocular surface.

Cryopreserved Amniotic Membrane Using the TissueTuck Technique: A Sutureless Approach for Pterygium Surgery

PURPOSE

The purpose of this study was to evaluate the clinical outcomes of the TissueTuck technique in the management of pterygium.

METHODS

This was a single-center, retrospective review of patients with primary or recurrent pterygium that underwent surgical excision followed by application of cryopreserved amniotic membrane (AM) using the TissueTuck technique. All patients underwent surgery between January 2012 and May 2019. Patient profile, surgical time, complications, and rates of pterygium recurrence were analyzed.

RESULTS

A total of 582 eyes of 453 patients (328 female patients; 65.1 ± 13.9 years) were included for analysis and initially presented with primary (92%) pterygium. The average duration of pterygium excision surgery was 14.7 ± 5.2 minutes (median: 14, range: 4-39 minutes) with mitomycin C administration in 257 (45%) eyes. At the last follow-up of 30.2 ± 22.2 months (median: 24.5, range: 3-94 months), BCVA significantly improved from logMAR 0.23 at baseline to logMAR 0.19 ( P < 0.0001). Recurrence rate was 2.3% but only 0.7% (2/274) in those cases with primary, single-headed pterygium without mitomycin C treatment. Other postoperative complications in that cohort included granuloma (7.9%), scarring (3.8%), and diplopia in extreme lateral gaze (2.5%). The AM remained secured to the ocular surface throughout the postoperative period.

CONCLUSIONS

The TissueTuck surgical technique with cryopreserved AM can be performed in minimal time and result in a low recurrence and complication rate after pterygium surgery.

Challenges in the management of bilateral eyelid closure in Stevens-Johnson Syndrome

Purpose

Observations

Conclusion and importance

Long-term follow up of oral mucosa autograft sutured to the sclera in severe symblepharon

Purpose

To evaluate the clinical outcomes and complications of oral mucosa autograft (OMAU) sutured to the sclera to treat symblepharon after severe chemical or fireworks burn.

Methods

Our surgical technique for OMAU sutured to the sclera is presented along with clinical data and outcomes of 7 symblepharon carriers. Our surgical technique was performed unilateral in all cases. An OMAU with a mean length of 3 cm and 2 cm wide was sutured to the bare sclera 1-3 mm behind the limbus. Amniotic membrane transplant was placed covering the rectus muscles and bare sclera proximal to the limbus. The fornix was secured into the skin with deepening bolster sutures. A temporary tarsorrhaphy was performed, and a symblepharon ring was placed on top of a bandage contact lens.

Results

There were no cases of intraoperative complications. Three years postoperatively, all patients had perfect integration of the OMAU and there were no cases of symblepharon's recurrence. Two patients developed mild superior entropion and 2 patients developed mild strabismus (one esotropia and another exotropia).

Conclusion and Importance

OMAU sutured to the sclera after symblepharon release caused by severe ocular burns, results in excellent cosmetic and anatomical outcomes with no recurrence.

Update on the application of amniotic membrane in immune-related ocular surface diseases

Immune-related ocular surface diseases, a group of diseases in which immune dysregulation damages the ocular surface, can induce uncontrolled inflammation and persistent epithelial defect, thus leading to the most severe forms of acute keratoconjunctivitis, dry eye disease, epithelial keratitis, stromal ulceration, and corneal perforation. As these diseases are often refractory to treatments, they have a threatening impact on the vision and life quality of patients. This review summarizes the current literature regarding the clinical application of sutured and self-retained cryopreserved amniotic membrane (AM) in treating Stevens-Johnson syndrome/toxic epidermal necrolysis, ocular graft-versus-host disease, Sjögren's syndrome, Mooren's ulcer, and peripheral ulcerative keratitis. Current evidence supports the safety and effectiveness of AM, especially self-retained cryopreserved AM, in decreasing ocular surface inflammation, promoting corneal epithelial and stromal healing, improving visual acuity, and preventing sight-threatening complications. Future studies are still required to validate the above findings and explore the varied application methods of AM to improve the clinical efficacy in maintaining ocular surface health.

A rabbit model for assessing symblepharon after alkali burn of the superior conjunctival sac

Symblepharon due to chemical burns affects ocular surface health, and there are currently no satisfactory treatments. To improve our understanding of symblepharon, an appropriate animal model is urgently needed. We established a rabbit model of superior conjunctival sac alkaline burn to evaluate symblepharon severity. Alkali burns were induced in rabbits by contacting the superior conjunctival sac with 2 N NaOH-soaked semicircle filter paper (10 mm diameter) for 60 s, 90 s or 120 s. Clinical and histological features were examined, symblepharon severity was evaluated via conjunctival sac depth (grade I - IV) and volume measurements (grade a-d) post-injury at 4 weeks. With increasing alkali burn duration, corneal perforation and symblepharon severity increased. The 60 s group manifested a sub-conjunctiva scar. The 90 s group featured localized adhesion. The 120 s group was characterized by extensive scar hyperplasia and adhesion. The rabbit model exhibited stable and reliable symblepharon following an alkali burn of the superior conjunctival sac. For further research, 90 s is a suitable duration for conjunctival sac burn. The volume measured using conjunctival sac casting was considered when developing a successful evaluation system for symblepharon severity.

Amniotic Membrane Grafts to Reduce Pterygium Recurrence

PURPOSE

To demonstrate the long-term outcome of pterygium surgery with adjunctive amniotic membrane transplantation (AMT) and intraoperative mitomycin C (MMC) in a large case series.

METHODS

Medical records were retrieved for this noncomparative retrospective study of all patients who had pterygium excision with adjunctive AMT and intraoperative MMC, from October 2010 to June 2016 with at least 6 months of follow-up.

RESULTS

There were a total of 556 eyes of 535 patients (291 males and 244 females) with average age of 51.9 ± 13 years who had pterygium excision (527 primary and 29 recurrent). For an average follow-up period of 17.3 ± 0.8 months (range 6-74 months), corneal recurrence occurred in 20 eyes (3.6%) and conjunctival recurrence in 12 (2.2%) in a total of 32 eyes (5.8%). Eleven eyes (2%) underwent reoperation. Other complications included granuloma (0.5%), diplopia (1.1%), and steroid-induced ocular hypertension (4.3%).

CONCLUSIONS

Adjunctive use of AMT and short exposure of MMC can reduce recurrence after pterygium surgery. The procedure is less tedious and less time consuming, resulting in early recovery while saving the conjunctiva for future surgeries.

[New approaches to ocular surface reconstruction beyond the cornea]

BACKGROUND

Reconstruction of the conjunctiva is an essential part of ocular surface reconstruction. Clinically applied and experimentally tested tissue- and stem-cell-based approaches are presented and evaluated.

MATERIALS AND METHODS

Current literature and our own results will be presented.

RESULTS

Autologous conjunctiva, mucous membrane of the mouth or nose, and amniotic membrane are routinely used for conjunctival reconstruction. Limitations are limited availability, involvement in autoimmune diseases, donor heterogeneity, and degradation in an inflamed environment. Experimentally tested matrices as tissues made from extracellular matrix proteins, synthetic polymers, temperature-sensitive culture dishes, and decellularized conjunctiva have been tested in vitro and partly in vivo. To replace conjunctival cells, cells of conjunctiva and mucous membrane of mouth and nose have been evaluated and show progenitor cell properties as well as secretory capacity (goblet cell differentiation).

CONCLUSIONS

Although different matrices are available for conjunctival reconstruction there is-due to specific limitations of existing tissues-a need for the development of new therapies for conjunctival replacement. Matrices produced in the laboratory have already been partly investigated in vivo and may thus be clinically applicable in the near future. Adult mucous membrane cells show many properties of conjunctival epithelium after expansion in vitro and thus are a promising cell source for conjunctival tissue engineering. Other stem cells sources require further evaluation.