Autologous advanced tenon grafting combined with conjunctival flap in scleromalacia after pterygium excision

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 All the patients who underwent a DTF graft in an unpublished new indication over the study period (May 2020-October 2023) were included.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.

Spontaneous intraocular lens extrusion through Gundersen conjunctival graft after multiple failed keratoplasties: A report of two cases

PURPOSE

To report the occurrence and the outcomes of 2 cases of spontaneous extrusion of 3-piece intraocular lens (IOL) through a Gundersen conjunctival flap performed for tectonic purposes after multiple failed penetrating keratoplasties (PKs).

METHODS

A 70-year-old woman (Patient #1) with severe dry eye disease who had undergone cataract surgery with posterior chamber 3-piece IOL implantation, multiple PKs and Gundersen conjunctival flap in her left eye presented with partial extrusion of the optic and the inferior haptic of the IOL through the conjunctival flap. Inferior symblepharon and keratinization of the entire ocular surface were also present. A 64-year-old diabetic man (Patient #2) with history of cataract surgery with a posterior chamber IOL implantation, multiple PKs for keratoconus and Gunderson conjunctival flap in his right eye presented with partial extrusion of IOL optic through the conjunctival flap.

RESULTS

Patient #1 refused a further surgery and IOL was removed at the slit lamp. Currently, 3 months after IOL extrusion, corneal perforation self-sealed, visual acuity of light perception is maintained, and the patient does not complain any symptoms of ocular discomfort or pain. In Patient #2, tectonic PK combined with IOL removal and anterior vitrectomy was performed. Currently, 1 month postoperatively corneal graft is clear, intraocular pressure is normal, and patient's vision is counting fingers.

CONCLUSIONS

In both cases, IOL extrusion occurred spontaneously through a Gunderson conjunctival flap. Including the underlying Tenon's capsule in the conjunctival graft could increase its tectonic support, potentially avoiding this complication.

Scleral thinning causes, diagnosis, and management: A narrative review

INTRODUCTION

Sclera forms the outer fibrous coat of the eye and provides structural integrity for the housing of intraocular contents. Scleral thinning is a serious progressive condition which can lead to perforation and worsening visual functioning. This review aims to summarize the anatomical consideration and causes of scleral thinning, diagnosis, and the various surgical approaches available to treat scleral thinning.

MATERIALS AND METHODS

The narrative literature review was conducted by senior Ophthalmologists and researchers. PubMed, EMBASE, Web of Science, Scopus, and Google Scholar databases were searched for relevant literature from infinity till March 2022. Terms of the search referred to 'sclera' or 'scleral thinning' or 'scleral melting', and were combined with 'treatment', or 'management' or 'causes'. Publications were included in this manuscript if they offered information about the nature of these topics. Reference lists of relevant literature was searched. There were no limits on type of article to be included for this review.

RESULTS

Scleral thinning arises from diverse congenital, degenerative, immunological, infectious, post-surgical, and traumatic etiologies. It is diagnosed upon slit-lamp examination, indirect ophthalmoscopy, and optical coherence tomography. Conservative pharmacological treatment of scleral thinning may include anti-inflammatory drugs, steroid drops, immunosuppressors, monoclonal antibodies, and surgical treatments including tarsorrhaphy, scleral transplantation, amniotic membrane transplantation, donor corneal graft, conjunctival flaps, tenon's membrane flap, pericardial graft, dermis graft, cadaveric dura mater graft, and other autologous and biological grafts.

CONCLUSION

Scleral thinning treatments have developed dramatically in recent decades and the rise of alternative grafts for scleral transplantation procedures or use of conjunctival flaps have taken center stage in surgical management. This review adds a comprehensive summary of the scleral thinning with attention to the positive and negative features of new treatments alongside previous mainstay management strategies.

Topical Erythropoietin for Treatment of Scleral Necrosis

PURPOSE

To investigate the safety and efficacy of topical erythropoietin for the treatment of scleral necrosis.

METHODS

This study enrolled eight consecutive patients with scleral necrosis due to previous ocular surgery, rheumatoid arthritis-associated necrotizing anterior scleritis, and thermal and chemical burns. Conventional treatments failed to heal avascular scleral lesions in all eyes. Patients were treated with topical erythropoietin (3000 IU/mL) four times a day.

RESULTS

The mean patient age was 37.6 ± 15.5 years. The interval between the development of scleral necrosis and initiation of topical erythropoietin was 25.6 ± 12.0 days. The necrotic sclera completely healed within 31.9 ± 16.9 days in all patients. The avascular lesions did not recur, and there was no evidence of side effects during the study.

CONCLUSION

Our results showed that topical erythropoietin could be safely used to manage scleral necrosis. Randomized clinical trials are needed to further explore the efficacy of this intervention in patients with avascular scleral lesions.

Hitch suture assisted tuck in Tenon's Patch Graft for management of Corneal Perforations

PURPOSE

To describe a novel modification of tuck-in Tenon's patch graft (TPG) using temporary horizontal mattress sutures and fibrin glue to hitch the graft in the management of corneal perforations.

DESIGN

Ambispective interventional case series.

METHODS

Modified technique of autologous TPG was used to seal corneal perforations measuring 3-5 mm, using horizontal mattress sutures to hitch the graft in a lamellar pocket, followed by application of fibrin glue. The horizontal mattress sutures were removed after the reformation of the anterior chamber. The primary outcome measure was a well formed anterior chamber in the post-operative period and the secondary outcome was epithelization time.

RESULTS

The surgery was performed in 22 eyes. The mean age was 43.86 ± 16.02 (26-66) years, with 14 males and eight females. The etiologies of corneal perforation included dry eye (n = 10), neurotrophic keratitis (n = 6), trauma (n = 2), chemical injury (n = 2) and exposure (n = 2). The mean size of the perforation with the thinned-out area was 4.3 mm (range 3-5 mm). The mean duration of epithelialization was 14.31 ± 2.63 days (7-21 days). No intraoperative complications were observed. All eyes had a well-formed anterior chamber in the immediate postoperative period. Postoperatively, two eyes had graft pseudoectasia due to a thick graft and supra tenon haemorrhage each; one eye each had graft thinning with the formation of pseudopterygium and graft melting.

CONCLUSION

Tenon's patch graft, along with the use of temporary horizontal mattress sutures and fibrin glue, is an effective modification of the technique for managing corneal perforations measuring 3-5 mm.

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.

Topical Erythropoietin as a Novel Treatment for Necrotizing Scleritis After Pterygium Surgery: A Pilot Study

PURPOSE

To share our initial experience with the innovative use of topical erythropoietin for the treatment of necrotizing scleritis manifesting immediately after pterygium excision surgery.

METHODS

This study enrolled 3 patients who developed necrotizing scleritis immediately after undergoing pterygium excision. All cases with pterygium were primary, and topical mitomycin C and conjunctival autografts were used at the time of surgery. Noninvasive therapy that included ophthalmic lubricants and topical and systemic corticosteroids failed to improve the avascular scleral lesions. The patients were prescribed erythropoietin-containing drops (3000 U/mL) every 6 hours in addition to topical antibiotics and lubricant. The effect of topical erythropoietin on the healing process of avascular scleral lesions was investigated, and its ocular and systemic side effects were evaluated.

RESULTS

The mean age of the participants was 69.0 ± 14.8 years, and 2 of the 3 eyes belonged to male subjects. The time between pterygium surgery and presentation to our clinic was 33.0 ± 14.7 days. There were no infectious causes or underlying systemic diseases in any of the cases. After treatment with topical erythropoietin for an average of 34.3 ± 20.3 days, the lesions were completely vascularized in all 3 eyes without any ocular or systemic adverse effects. The patients were followed up for an average of 126 ± 94 days after discontinuation of erythropoietin. There was no evidence of recurrence during the last examination in any of the eyes.

CONCLUSIONS

Topical erythropoietin might be a safe and an effective method for treating cases of necrotizing scleritis that manifests immediately after pterygium surgery.

Clinical presentation and management of corneal fistula

Purpose

To describe the clinical features and management of corneal fistula in patients of healed keratitis.

Methods

Medical records of all patients of healed keratitis presenting to the cornea clinic from November 2016 to September 2017 were reviewed. Eightcases of corneal fistula (six true fistulas, two closed fistulas) were identified. Six patients were managed with autologous tenon patch graft while two patients were managed medically. Various risk factors and treatment outcomes of corneal fistulisation were evaluated.

Results

The patients included two patients of failed therapeutic keratoplasty (with resolved graft infection) and six patients of healed keratitis. The age of the patients ranged between 10 and 60 years. Five of the patients were male while three were female. The size of the fistula measured between 1 and 2 mm. A surrounding cystic area of diameter ranging between 1 and 4.5 mm was seen in all the patients. In all of the patients, the treating physician missed the diagnosis. Complete healing was noted at 6–8 weeks in all the patients who underwent tenon graft. One patient refused to undergo any surgery and was lost to follow-up. In another case, surgery was deferred due to uncontrolled hypertension and he developed anterior staphyloma subsequently.

Conclusion

Corneal fistula can often be missed in an apparently healed perforated corneal ulcer. Tenon patch graft is an effective technique for the management of corneal fistula.

Tenon patch graft for corneal fistula: a rare entity treated by a simple technique

A 50-year-old patient presented with dull aching pain with some discomfort in his right eye for the past 2 weeks. History revealed the patient had a past episode of infective keratitis managed medically in a local hospital. The last follow-up record suggested a diagnosis of healed keratitis with corneoiridic scar. On examination, the patient had visual acuity of hand movement and a corneoiridic scar of 7×7 mm with an inferotemporal translucent cystic area measuring 3×4 mm in size with underlying uveal tissue visible. Seidel test was found to be positive confirming leakage. For this, a tenon patch over the area of defect along with anterior chamber formation was done. On postoperative day 1, the graft was well attached and anterior chamber was formed with no leak on Seidel test. Intraocular pressure was 16 mm Hg.

Tenonplasty for closing defects during sclerocorneal surgery-A brief review of its anatomy and clinical applications

To provide insight into the clinical anatomy of Tenon's capsule and to describe a technique to manage sclerocorneal defects using autologous Tenon's tissue. A thin layer of Tenon's capsule harvested from the patient's own eye is used to seal the defect and act as a scaffold. The Tenon's flap is spread over the defect and held in place by Vicryl sutures. A bandage contact lens is then placed on the eye. Tenon's capsule is composed of thick fibrous tissue with smooth muscle fibers and a thin posterior capsule of orbital fat. It is rich in fibroblasts, which can accelerate wound healing and eventually lead to robust scarring without risk of immunogenicity and without cost. Tenonplasty uses easily-available autologous Tenon's tissue in patients with sclerocorneal defects to preserve globe morphology. The technique is a feasible alternative not limited by the availability of graft tissue. Clin. Anat. 31:72-76, 2018. © 2017 Wiley Periodicals, Inc.