Conjunctival Flap with Biodegradable Collagen Matrix Implantation for the Treatment of Scleromalacia after Periocular Surgery

Revisiting the Use of Deep Temporalis Fascia Grafts in Ophthalmology

PURPOSE

To report new indications for deep temporalis fascia (DTF) grafts in the ophthalmic field.

METHODS

Monocentric retrospective interventional case series study. All the patients who underwent a DTF graft in an unpublished new indication over the study period (May 2020-October 2023) were included. For each patient, gender, age, graft indication, outcomes, complications, and follow-up duration were collected. In most cases, the DTF graft was covered by a vascularized flap.

RESULTS

Eight patients underwent a DTF graft over the study period. The indications were: radiotherapy-induced scleral necrosis in three cases, tendinoplasty to replace the inferior rectus muscle tendon invaded by a locally advanced conjunctival carcinoma in one case, Ahmed glaucoma valve tube exposure in one case, intraocular lens with scleral fixation exposure in one case, orbital cerebrospinal fluid fistula (orbitorrhea) in one case, and post-traumatic complete corneal graft loss in one case. The DTF graft was successful in 87.5% of cases after a mean follow-up of 11.4 months. No complications were observed.

CONCLUSIONS

DTF graft is a highly versatile graft that can be easily harvested. New indications for DTF grafts may include the repair of radiotherapy-induced scleral necrosis, the creation of oculomotor tendon and the temporary packing of large ocular tissue loss in an emergency context. Further studies with a longer follow-up are needed to confirm our preliminary results.

Management of scleral melt

Scleral melting, while rare, can lead to significant ocular morbidity. Several possible risk factors for scleral melt have been identified, such as infection, autoimmune disease, trauma, and post-surgical state, and these may act in combination with each other. Treatment should be tailored according to the etiology and severity of the scleral melt. Medical management may be indicated, especially in cases of autoimmune-related melt; however, surgical procedures are often necessary due to compromised ocular integrity and limited penetration of medications into the avascular sclera. An understanding of the surgical options available and their operative outcomes is particularly important when choosing the appropriate treatment protocol for each patient.

Is the human sclera a tendon-like tissue? A structural and functional comparison

Collagen rich connective tissues fulfill a variety of important functions throughout the human body, most of which having to resist mechanical challenges. This review aims to compare structural and functional aspects of tendons and sclera, two tissues with distinct location and function, but with striking similarities regarding their cellular content, their extracellular matrix and their low degree of vascularization. The description of these similarities meant to provide potential novel insight for both the fields of orthopedic research and ophthalmology.

Long-term Outcome of Surgical Treatment with Various Reinforcement Material Grafts on Scleromalacia

Purpose: To investigate the long-term efficacy and stability of the use of various reinforcement material grafts on scleromalacia.Methods: This retrospective study was conducted on scleromalacia patients who underwent surgical treatment with reinforcement material grafts from January 2012 to March 2019. The choice of amniotic membrane, Tenon’s capsule, acellular sclera, or collagen matrix implanted in the area of scleromalacia was made based on disease severity. Amniotic membrane transplantation with a pedicular rotatory inferior conjunctival flap was performed to prevent having a bare sclera. The patient demographics, cause of scleromalacia, best-corrected visual acuity (BCVA), recurrence rate, postoperative complications, and restoration appearance were evaluated.Results: A total of 58 patients (58 eyes) were enrolled in this study. The mean age of patients was 65.7 ± 9.6 years, and 32 patients (55.2%) were women. The mean follow-up period was 28.1 ± 17.3 months. The most common cause of scleromalacia was pterygium operation (53 patients, 91.4%). The reinforcement materials were mainly amniotic membrane (31 patients, 53.4%) and acellular sclera (15 patients, 25.7%). There was no recurrence of scleromalacia or structural instability during the follow-up period. The preoperative and postoperative mean BCVA values were 0.24 ± 0.24 and 0.21 ± 0.23 logMAR, respectively. Wound dehiscence (three patients, 5.2%) and conjunctival cyst (three patients, 5.2%) occurred with the highest frequency.Conclusions: The use of the appropriate reinforcement material graft according to the severity of scleromalacia and amniotic membrane transplantation using a pedicular rotatory inferior conjunctival flap to prevent a bare sclera can be effective for treating scleromalacia, without long-term recurrence.

Necrotizing Scleritis After Cosmetic Conjunctivectomy With Mitomycin C

PURPOSE

To report cases of necrotizing scleritis, a sight-threatening complication that can result from cosmetic conjunctivectomy procedures.

DESIGN

Retrospective case series.

METHODS

The medical records of consecutive patients who underwent eye-whitening conjunctivectomy with mitoycin C (MMC) treatment performed by 1 surgeon in South Korea and were referred to the authors' clinic between January 2011 and December 2015 were reviewed. The patients in whom findings of necrotizing scleritis with active inflammation were detected in an avascular area of previous conjunctivectomy were included.

RESULTS

Of a total of 231 patients who had received cosmetic eye whitening, 4 patients who met the inclusion criteria were identified. The average length of time from cosmetic eye surgery to a diagnosis of necrotizing scleritis was 51 months and all patients had unilateral findings of necrotizing scleritis. There was no underlying systemic autoimmunity or infectious etiology in all cases. Three of these 4 patients were treated with a conjunctival flap; however, all 4 received systemic anti-inflammatory treatment with oral corticosteroids. The mean follow-up duration of the patients was 22.75 months.

CONCLUSIONS

Necrotizing scleritis is a severe complication that can arise after cosmetic eye-whitening conjunctivectomy with MMC. Because of the large area of the ocular surface that is treated in eye-whitening with MMC, the necrotizing scleritis that can ensue may be more extensive and severe than the surgically induced necrotizing scleritis following other periocular surgeries such as pterygium removal. Proper anti-inflammatory treatment and surgical intervention should be required for management of this complication.

Ologen Implantation versus Conjunctival Autograft Transplantation for Treatment of Pterygium

Purpose

To evaluate the effectiveness and safety of Ologen implantation versus conjunctival autograft transplantation for primary pterygium.

Methods

A retrospective case-series analysis. Thirty-one eyes of 29 patients were included in the Ologen group and 42 eyes of 35 patients in the autograft group. The patients were followed up for 1 year and evaluated for slit-lamp biomicroscopy, intraocular pressure, and adverse events. Recurrence rate, complications, and final appearance of the cases were evaluated prospectively.

Result

At 1 year after operation, 2 eyes recurred (6.5%) in the Ologen group and 4 eyes recurred (9.52%) in the autograft group. There was no statistically significant difference between both groups (P=0.157, χ² = 3.781). There was no occurrence of serious complications. Two eyes among the 31 eyes of the Ologen group were conjunctivitis; the incidence of complications was 6.45% (2 eyes). There was conjunctivitis in 3 eyes of the autograft group, 1 eye complicated with symblepharon, and 1 eye with conjunctival granuloma; the incidence of complications was 11.90% (5 eyes), and there was no statistically significant difference between both groups (P=0.094). The conjuntiva was less vascular and inflamed at 1 month postoperatively in the Ologen group than in the autograft group.

Conclusions

Ologen transplantation was technically easier, provided short operative time compared with conjunctival autograft transplantation, and preserved healthy conjunctiva with less complication and less recurrence; it may be a new, safe, and effective alternative for improving the short-term success rate of primary surgery.