Severe cicatricial entropion repair using mucous membrane graft in Stevens–Johnson syndrome

Background:Severe cicatricial entropion in Stevens–Johnson syndrome (SJS) patients is difficult to treat and is associated with a higher recurrence rate. Also, entropion in the presence of lid margin mucous membrane graft (MMG) further complicates the surgical anatomy and approach.Purpose:To report a modified surgical technique of repairing severe upper eyelid cicatricial entropion in an SJS patient with history of lid margin MMG.Synopsis:Cicatricial entropion in patients with SJS is entirely different from trachomatous cicatricial entropion. The involvement of the lid margin with keratinization, tarsal scarring, persistent conjunctival inflammation, and unhealthy ocular surface affects the surgical approach and outcomes. Conjunctiva-sparing surgery with reconstruction of the lid margin using MMG, flattening and repositioning the anterior lamella, and covering the bare tarsus with MMG rather than leaving it raw are the necessary modifications in this technique from conventional anterior lamellar recession. The video demonstrates the surgical technique for harvesting and preparation of a labial MMG, the splitting of the anterior and posterior lamella of the lid margin, scar tissue release between the lash line and the tarsus, repositioning of the anterior lamella, and anchoring of the labial MMG.Highlights:Anterior lamellar recession combined with MMG wrapping the lid margin and bare tarsus offers good cicatricial entropion repair outcomes. Removal of fat and submucosa from the mucosal graft should be done for better cosmesis. Adequate separation of the scar tissues from the lash line and the tarsus is essential.Video link: https://youtu.be/6HsKgeZQCyY     

Cicatricial entropion and trichiasis in an urban Australian population

BACKGROUND: Cicatricial entropion and trichiasis may be caused by a variety of diseases, of which trachomatous entropion is the commonest worldwide. The spectrum of disease in the authors' community is quite different. The purpose of this study was to establish the aetiology of entropion and trichiasis in patients referred to a Melbourne-based subspecialty oculoplastics practice, excluding epiblepharon, congenital entropion and involutional entropion, and to compare the final diagnosis with the referring diagnosis. METHODS: All records of patients with cicatricial entropion and trichiasis presenting to the practice of one of the authors over the period 1990-2000 were analysed. Demographic data, referring diagnosis and final diagnosis were tabulated. RESULTS: The commonest final diagnosis was ocular cicatricial pemphigoid. In only a small proportion of cases was this diagnosis considered by the referring practitioners. In addition, two cases of undiagnosed conjunctival neoplasia presented with entropion and trichiasis. CONCLUSION: In all patients with entropion and trichiasis, a careful history and examination should be obtained and appropriate investigations performed to try and establish a firm diagnosis.     

应用自体硬腭黏膜修复睑板缺损

目的 观察自体硬腭黏膜修复睑板缺损的效果.方法 各种原因所致睑板缺损26例（26眼）.其中上睑10例,下睑14例,单眼上下睑2例.睑板完全缺损10只睑,缺损1/2～2/3者10只睑,缺损1/3～＜1/2者8只睑.取自体硬腭黏膜修剪后代替睑板修复眼睑缺损.结果 术后随访6～36月.16只睑外形及功能完全恢复,4只睑轻度睑内翻,3只睑轻度闭合不全,1只睑闭合不全为3 mm,4只睑轻度睑缘切迹.无严重并发症发生.结论 自体硬腭黏膜修复睑板缺损外形及功能均良好,自体硬腭黏膜是一种很好的睑板替代物.     

Cicatricial Pemphigoid and Dry Eye

Cicatricial pemphigoid is the most common of the immunobullous disorders causing conjunctival cicatrization and is an autoimmune disease in which the ocular component of the immunopathology is directed at the conjunctival basement membrane. The disease is usually bilateral and more common in females, with most cases occurring between 30–90 years, and most often in the seventh decade. The disease occasionally occurs in children. Tear deficiency is a major cause of symptoms, although loss of vision is usually due to surface failure before the onset of aqueous tear deficiency, which occurs late in the progression of the disease. Management of the dry eye must be integrated with the management of the other components of both the ocular surface disease and inflammation. Management requires plastic surgery for the lid and lash malposition, tetracyclines and lid hygiene for the accompanying blepharitis. For the dry eye, the use of lubricants without preservatives is important, to avoid toxicity, and lubricant ointment is helpful for the relief of symptoms in terminally dry eyes without the capacity for surface wetting. Contact lenses, either large limbal diameter rigid gas permeable or gas permeable scleral lenses, are useful for treating dry eye and improving vision in some patients. Control of the conjunctival inflammation is mandatory to prevent disease progression and usually requires systemic immunosuppressive therapy.     

自体硬腭黏膜移植联合眶周皮瓣修复全层眼睑缺损

目的：评价眼睑恶性肿瘤切除术后采用自体硬腭黏膜移植联合眶周皮瓣进行眼睑再造的临床效果。 方法：患者10例10眼行眼睑恶性肿瘤切除术后重度眼睑缺损,采用硬腭黏膜移植替代眼睑后层,即睑板和睑结膜层,利用眶周皮瓣修复眼睑前层。 结果：术后随访6~12mo,眼睑外观及功能基本恢复正常。硬腭黏膜移植片及转移皮瓣全部成活,无感染、移位、挛缩。 结论：自体硬腭黏膜移植联合眶周皮瓣转移修复全层眼睑缺损,效果肯定。     

儿童先天性下睑内翻合并倒睫的手术时机对眼内屈光发育的影响

目的:研究儿童先天性下睑内翻合并倒睫的手术对于眼内屈光发育的影响,进一步探讨患儿的最佳手术时机。方法:前瞻性队列研究。纳入2016-09/2018-06在我院确诊为先天性下睑内翻合并倒睫并接受下睑内翻矫正手术的患儿30例59眼。将其分为低龄组(2~3岁)10例20眼,中龄组(4~6岁)10例20眼和大龄组(7~12岁)10例19眼。所有患儿在全身麻醉下接受下睑皮肤眼轮匝肌切除术,合并内眦赘皮患儿同时接受内眦切开联合L型缝合术式,轻度下睑内翻不伴眼轮匝肌肥厚的患儿接受缝线术,术后3mo合并弱视及屈光不正者接受屈光矫正,随访6~12mo。测定三组患儿术前及术后6mo眼内屈光状态,视力发育情况及角膜地形图结果。结果:所有患儿术后下睑内翻矫正效果良好,无欠矫,外翻或眼睑角状畸形者。手术前后角膜散光(CC)三组患儿均有差异(P<0.05),视网膜检影总散光值(RC)、BCVA,低龄组和中龄组患儿有差异(P<0.05),大龄组无差异(P>0.05)。结论:先天性下睑内翻合并倒睫患儿在6岁以内接受手术矫正可以改善眼球散光值。4~6岁患儿术前顺规散光发病率高,应尽早接受手术治疗及屈光矫正。     

硬腭黏膜移植联合眶周表浅肌肉腱膜系统皮瓣重建全层眼睑缺损

目的:探讨利用自体游离硬腭黏膜植片替代后睑组织联合眶周表浅肌肉腱膜系统(SMAS)皮瓣转移修复缺损的前层眼睑皮肤,重建因肿瘤术后或外伤所致的全层眼睑缺损的临床疗效。方法:对16例≥眼睑全长1/2中重度全层眼睑缺损患者,全部用口腔硬腭黏膜植片替代睑板和结膜,再造后层眼睑;用眶周血供丰富的表浅肌肉腱膜系统(SMAS)皮瓣转移覆盖于硬腭黏膜上,替代缺损的眼睑皮肤肌肉层再造前层眼睑,其中10例采用眼轮匝肌单蒂皮瓣,3例为颞浅动脉皮瓣,2例为上睑皮肤轮匝肌双蒂皮瓣,1例为眉上皮瓣。手术操作中首先行硬腭黏膜移植,然后根据眼睑前层缺损的部位和范围设计眶周的SMAS转移皮瓣,手术完毕行睑缘缝合3～6mo后切开。结果:全部患者随访>12mo,硬腭黏膜植片及其转移皮瓣全部成活,无移位、感染和坏死等不良反应,无收缩,眼睑外观及功能改善满意。结论:硬腭黏膜联合SMAS皮瓣转移修复重建眼睑全层缺损,可以一次性修复眼睑缺损的皮肤、睑板、结膜,疗效肯定,具有较高的临床应用价值。     

The use of mucous membrane from the hard palate in the treatment of trichiasis and cicatricial entropion

I have discussed a technique for grafting hard palate mucous membrane to the lid margin as a treatment for trichiasis. Because of the resistance of this material to shrinkage and recurrence of trichiasis, it forms an excellent barrier to recurrence of trichiasis.     

Ocular Cicatricial Pemphigoid: A Review of Clinical Features,Immunopathology, Differential Diagnosis,and Current Management

Ocular cicatricial pemphigoid is a devastating autoimmune blistering disorder mainly affecting the conjunctiva but frequently associated with systemic mucosal findings. This article is an update of the pathogenesis, ocular findings, differential diagnosis, and approaches to treatment.     

Combined use of bulbar conjunctival pedicle flap and labial mucous membrane graft for porous orbital implant exposure: Long-term outcome

Implant exposure is the most common serious complication of porous orbital implants, and often requires surgical repair. This study aims to describe a new repair technique using a bulbar conjunctival pedicle flap and a labial mucous membrane patch graft, as well as to report its long-term results. A retrospective chart review was performed on all patients whose porous orbital implant exposures were repaired using this technique from 1995 to 2014. Twenty-three patients were included. The maximal defect dimension ranged from 2 to 18 mm. Sixteen patients (70%) also received a banked human scleral patch graft during their repair. The mean follow-up was 130 months (range 29–267 months). Eighteen patients (78%) were successfully treated with one repair surgery. At the final follow-up, 21 patients (91%) could comfortably wear a prosthetic eye, and 18 patients (78%) reported satisfactory cosmesis. Two patients (9%) developed small conjunctival cysts that were successfully excised. The combination of a bulbar conjunctival pedicle flap and a labial mucous membrane patch graft is a simple but effective technique in salvaging exposed porous orbital implants. Its long-term results are promising.     

Socket reconstruction with combined mucous membrane and hard palate mucosal grafts

OBJECTIVE: To evaluate the use of combined mucous membrane and hard palate mucosal grafts in the reconstruction of contracted eye socket. PATIENTS AND METHODS: Thirteen eyes of 13 patients with contracted sockets underwent socket reconstructive surgery with combined mucosal membrane and hard palate mucosal grafts. RESULTS: The average follow-up period was 33 months. Five of 13 patients required additional surgery after initial socket reconstruction. However, all patients who underwent socket reconstruction with hard palate mucosal grafts were able to wear a cosmetically acceptable ocular prosthesis postoperatively. CONCLUSION: Combined mucosal membrane and hard palate mucosal grafts can be effectively used in the reconstruction of contracted sockets.     

Eyelid mucous membrane grafts: a histologic study of hard palate, nasal turbinate, and buccal mucosal grafts

PURPOSE: To histologically evaluate the outcome of mucous membrane grafts to the eyelid. METHODS: Case series of 31 eyes from 24 patients who underwent transplantation of hard palate (25 eyes), buccal (1 eye), or nasal turbinate (5 eyes) mucosa to the posterior eyelid surface. These grafts were biopsied at 0.5 months to 84 months (mean, 20 months) postoperatively. They were examined with light microscopy and compared with either the donor mucosa from the same patient (2 patients) or the typical donor site histology (22 patients). RESULTS: Graft biopsies revealed general epithelial morphology that was quite similar to the respective donor sites in virtually all cases. Six (25%) of 24 hard palate graft biopsies, which were obtained at 8 months to 49 months (mean, 22 months) postoperatively, displayed orthokeratosis alternating with parakeratosis, while 12 (50%) demonstrated parakeratosis alone, and another 6 (25%) showed adjacent regions of parakeratotic and nonkeratinized epithelium. No hard palate grafts showed complete absence of keratinization after transplantation. Other significant findings included loss of goblet cells in nasal turbinate grafts and few submucosal glands remaining in any specimen. CONCLUSIONS: Full-thickness mucosal grafts typically maintain their native epithelial morphology following transplantation to the ocular surface. Submucosal glands usually do not survive transplantation, which could be the result of intentional thinning of the graft at the time of transplantation. Contrary to the opinion that hard palate graft epithelium usually undergoes metaplasia from keratinized to nonkeratinized within 6 months following transplantation to the eye, all hard palate grafts in this study remained orthokeratotic and/or parakeratotic.     

Split thickness buccal mucous membrane grafts and β irradiation in the treatment of recurrent pterygium

BACKGROUND—Pterygium is a common problem and after surgical removal may recur in up to 80% of cases, depending on the technique of primary excision. Recurrent pterygia can be aggressive and repeated excision may result in severe conjunctival scarring and shortening, resulting in insufficient conjunctiva to perform further grafting and lid surgery. When there is insufficient autologous conjunctiva, mucous membrane must be obtained from other sites. Full thickness buccal mucous membrane grafts have been described, but they may result in a beefy red appearance, with graft contraction and a poor tear film.
METHOD—The use of split thickness buccal mucous membrane grafts is described in three patients with recurrent pterygium, two in combination with lamellar keratoplasty. β Irradiation was used as adjuvant therapy in all cases.
RESULTS—In all three cases an acceptable cosmetic appearance was achieved, with no recurrence of the pterygium, and a good range of eye movements.
CONCLUSIONS—It is recommended that split thickness buccal mucosal grafts, combined with β irradiation, should be considered in complex cases of pterygium recurrence when there is insufficient autologous conjunctiva and conjunctival shortening with restricted eye movements.

Keywords: pterygium; split thickness buccal mucous membrane graft; β irradiation     

Ectodermal Dysplasia: Association with Anti-Basement Membrane Autoantibodies

ABSTRACT

Ectodermal dysplasia (ED) is a group of several genetic conditions with absence or dysgenesis of at least two ectodermal derivatives: teeth, skin and its appendages including hair, nails, eccrine and sebaceous glands. The most important clinical findings in patients with ED are hypodontia, hypotrichosis, and hypohidrosis, which can lead to episodes of hyperthermia. Few reports have focused on the progressive keratopathy in ED. Cicatrizing conjunctivitis associated with anti-basement membrane autoantibodies has been described. We report a series of three ectodermal dysplasia patients with an ocular phenotype typically seen in ocular mucous membrane pemphigoid; conjunctival immunohistopathology revealed anti-basement membrane autoantibodies in all of them, and systemic immunosuppression proved to be effective in improving symptoms and helping to stabilize ocular surface disease.     

Cicatricial ectropion: repair with myocutaneous flaps and canthopexy

BACKGROUND: To evaluate the effectiveness of myocutaneous upper eyelid flaps combined with canthopexy to treat cicatricial lower eyelid ectropion. METHODS: A prospective non-comparative case series undertaken in a private practice setting. Consecutive patients with moderate lower eyelid cicatricial ectropion and upper eyelid dermatochalasis underwent transfer of a bipedicle or monopedicle flap from the upper eyelid combined with canthopexy. The main outcome measures included the occurrence of complications, eyelid position and cosmesis. RESULTS: Sixty-two consecutive cases of cicatricial ectropion repair using myocutaneous flaps and canthopexy. After a mean follow up of 20 months, 58 (93.5%) of the cases had the lower lid punctum facing posterosuperior into the tear lake, showed lid globe apposition and satisfactory eyelid position. There was mild recurrence of cicatricial ectropion in four patients (6.5%). There were no cases of graft failure or granuloma formation. CONCLUSION: The use of a myocutaneous flap from the upper eyelid combined with a canthopexy suspension suture for repair of cicatricial ectropion may offer good eyelid position and function. This technique has the advantage of avoiding full thickness blepharotomy and was associated with a low incidence of early recurrence.     

A beginner‘s guide to mucous membrane grafting for lid margin keratinization: Review of indications,surgical technique and clinical outcomes

The posterior lid margin, where the mucocutaneous junction (MCJ) between the eyelid skin and tarsal conjunctiva is located, plays a critical role in maintaining the homeostasis of the ocular surface. Posterior migration of the MCJ leads to lid-margin keratinization (LMK), which has a domino effect on the delicate balance of the ocular surface microenvironment. This occurs most commonly following Stevens-Johnson syndrome/toxic epidermal necrolysis and is not known to regress spontaneously or with medical therapy. Over time, LMK causes blink-related chronic inflammatory damage to the corneal surface which may have blinding consequences. Lid-margin mucous membrane grafting (MMG) is the only definitive therapy for LMK. Timely MMG can significantly alter the natural course of the disease and not only preserve but even improve vision in affected eyes. Literature searches were conducted on PubMed, using the keywords “mucous membrane grafts,” “lid margin keratinization,” “Stevens-Johnson syndrome,” “toxic epidermal necrolysis,” “lid related keratopathy,” and “lid wiper epitheliopathy”. This review, which is a blend of evidence and experience, attempts to describe the indications, timing, surgical technique, postoperative regimen, and clinical outcomes of MMG for LMK. The review also covers the possible complications and pearls on how they can be effectively managed, including how suboptimal cosmetic outcomes can be avoided. The authors hope that this review will aid ophthalmologists, including cornea and oculoplasty specialists, to learn and perform this vision-saving surgery better, with the aim of helping their patients with chronic ocular surface disorders, relieving their suffering, and improving their quality of life.     

Chronic cicatrizing conjunctivitis: A review of the differential diagnosis and an algorithmic approach to management

Cicatrizing conjunctivitis constitutes a group of chronic local and systemic disorders that cause conjunctival scarring. A systematic approach is required to sift through the clinical history, examination, and laboratory investigations of patients to arrive at the correct diagnosis of the underlying cause. Establishing the etiology is critical, as the therapeutic approach changes based on the cause of conjunctival inflammation. Effective management of patients with the condition requires knowledge of multiple modalities such as systemic immunosuppressive therapy, use of scleral contact lenses, and surgery for ocular surface and vision improvement. We review the clinical features of this condition and present diagnostic and treatment algorithms to help simplify the complexities in its management. This review attempts to place all the relevant information on chronic cicatrizing conjunctivitis together in one place for the benefit of cornea and ocular surface specialists, general ophthalmologists, and ophthalmology residents.     

超声乳化术中的硬核处理：翻核劈裂法

目的探讨安全有效的处理硬核的方法。方法对３６例（３６眼）核硬度在Ⅳ级以上的白内障翻核劈裂法碎核。翻核劈裂法：连续环形撕囊后,在水分离过程中将晶状体核作１８０度翻转,使其后极部朝上,然后用劈裂刀将核劈成数块,再乳化吸除。结果术后１ｗｋ矫正视力全部达０．５以上,其中１０例（２８％）术后视力达１．０以上;术中术后并发症包括１例虹膜损伤,６例短暂性角膜水肿。结论结果提示翻核劈裂法为一种有效的处理硬核的方法