Abstract
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.
1
Introduction
Symblepharon is defined as adhesions between the palpebral and the bulbar conjunctiva and can result from several conditions as conjunctival chronic inflammatory diseases (ocular cicatricial pemphigoid, Steven-Johnson), trauma, infections or burns (chemical or thermal). The adhesions can occur in small areas or obliterating the entire fornix, deforming the position of the lids, leading the eyelashes to touch the ocular surface. Despite the etiology, association has also been reported between symblepharon with ocular dryness and limbal stem cell deficiency (LSCD).
Although symblepharon is easily diagnosed, treatment remains challenging and currently, there is no standardized surgical treatment for symblepharon. Usually the treatment involves symblepharon lysis and a conjunctival autograft, , , oral mucosa autograft (OMAU), , nasal mucosa autograft, , OMAU associated or no to the skin graft, , amniotic membrane transplant (AMT), , keratolimbal allograft, ex vivo cultivated cadaveric limbal allograft, or combining different techniques. Currently, there is no standardized surgical treatment for symblepharon.
The aim of the present study is to present our technique to treat severe symblepharon using OMAU sutured to the bare sclera, and evaluate the clinical outcomes and complications.
2
Materials and methods
This retrospective case series evaluated the outcomes and complications of a surgical technique for symblepharon using OMAU. The study was approved by the Institutional Review Board of the King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia; and adhered to the principles of the Declaration of Helsinki. Six eyes with mainly inferior symblepharon and one eye with superior symblepharon were included. All eyes were severe cases caused by chemical or fireworks burns and treated using a technique of symblepharon release and interposing OMAU sutured to the bare sclera. Only severe cases of chemical or fireworks burns were included. Data was retrieved from electronic medical records. Data was collected on patient demographics, laterality of the symblepharon, eye conditions, symblepharon etiology complications and outcome after surgery. Severity of the symblepharon was grading following the Kheirkhah scale and LSCD following the global consensus.
2.1
Surgical technique
All eyes underwent the surgical procedure by one surgeon (HMO). Surgeries were performed under general anesthesia. The symblepharon was released from the affected areas starting from the limbus, using 6900 blade (Miniature Blade Round Tip, Surgistar, USA) and Westcott scissors. All adherences sites and tenon capsule were removed until reaching the fornix. The extraocular muscles were identified and exposed using 4-0 Silk to guarantee no damage, remaining surrounding fibrous tissue were removed. Then, the bare area requiring the graft was measured. The graft was prepared to be 20% larger than the recipient area to address possible contraction. The buccal donor area was the inferior lip. After surgical field was prepared with Povidone-iodine Topical Solution 10%, submucous Xylocaine 2% with adrenaline 1:200000 was injected to decrease bleeding and facilitate the dissection of the mucous from the subside tissues. A retractor clamp specially designed for the procedure was used for better exposure of the donor area. A full-thickness OMAU in an elliptical fashion distant 1 cm from the red portion of the inferior lip using a number 15 blade and scissors was excised. After removal, the donor area was sutured using 4-0 Vycril in uninterrupted sutures. Minor salivary glands and submucous fat were removed from the internal surface of the OMAU, then mild trimming was performed with scissors. OMAU was preserved in BSS until was grafted. AMT was placed over the bare sclera covering the rectus muscles, then was sutured using 9-0 Vycril in interrupted sutures. The OMAU with the epithelium face up was sutured to the bare sclera 1–3 mm behind the limbus with a mean length of 3 × 2 cm using uninterrupted Vycril 8-0 sutures. The deepest fornix was anchoring to the skin with Nylon 6-0 and bolsters. The gap between the OMAU and the deepest fornix was also sutured with 8-0 Vycril. AMT filled also the gap adjacent to the limbus, covering the cornea and secured with interrupted 9-0 Vycril. A bandage contact lens (BCL) was adapted over the cornea and a symblepharon ring was placed above all. A temporary tarsorrhaphy was performed on the lid margin with 6-0 nylon (see Surgical Video of patient 1, Supplemental Digital Content 1).
The following is the supplementary data related to this article:
2.2
Postoperative medication and follow up
Neomycin/polymyxin/dexamethasone drops (Alcon, USA) tapering for 1 month, then Loteprednol etabonate drops (Bausch Lomb, USA) for 3 months on a tapered schedule were prescribed. Preoperative inflammation was also controlled during 3 months prior to surgery with Loteprednol etabonate drops. The tarsorrhaphy was removed 3–5 days after surgery. The symblepharon ring, BCL and bolsters were removed after 2 weeks. Slit lamp examination was performed at 7, 30, 90, 180 days, 1, 2 and 3 years postoperatively.
2.3
Outcomes
Surgery was considered as a complete success when the anatomical depth of the fornix was restored and no further surgery was required for symblepharon correction. Excellent integration was defined as restoration of a smooth ocular surface with no gaps between the surrounding conjunctiva and the OMAU.
3
Results
The patients were between 6 and 56 years old, six patients had unilateral burns (4 chemical burns and 2 fireworks induced burns) and one patient sustained bilateral chemical burn. One patient did not have previous surgery (patient 6). Four patients had undergone symblepharon release with AMT. Two other patients had undergone 5 previous surgeries. Symblepharon severity was classified as IIIc 2+ in all cases except patient 2 (IIc 2+). Inferior fornix was affected in all patients except patient 7 who had a superior fornix injury. The caruncula was compromised in all of them except patient 1. The symblepharon reached 1–4 mm into the cornea in all patients, except patient 2. Almost all patients had 360° LSCD (Stage III) except patient 1 who had inferior LSCD between 4 and 8 o’clock hours (Stage IA). Table 1 shows the ocular characteristics and outcomes for each patient.
| Eye No. | Age (y) | G | Cause | Eye | Pre-OP VA | Previous surgery, No. | Extension of symblepharon/LSCD | Severity grading | OMAU size (cm) | Outcome | EOM/POP Complication | Follow-up (months) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 6 | M | CB 2015 | OS | F&F | SR + AMT 1x | 3′0–9′0 (180°)/4′0–8′0 (90°) | IIIc 1+ | 2×1 | CS/EI | Full/Mild nasal entropion SE | 36 |
| 2 | 17 | F | CB 2013 | OS | HM | SR + AMT 1x | 3′0–11′0 (240°))/360° | IIc 2+ | 3X1 | CS/EI | Mild ET/none | 42 |
| 3 | 14 | M | F 2011 | OD | 20/400 | SR + AMT 2x; ER; 2x; CLAU 1x; | 1′0–11′0 (300°)/360° | IIIc 2+ | 3X2 | CS/EI | Full/none | 38 |
| 4 | 56 | M | CB 2015 | OS | HM | SR + AMT 1x | 3′0–9′0 (180°)/360° | IIIc 2+ | 2X 2 | CS/EI | Full/none | 44 |
| 5 | 22 | M | F 2014 | OS | HM | SKG 2x; SCG 1x; SR + AMT 2x | 3′0–11′0 (240°)/360° | IIIc 2+ | 3X1 | CS/EI | Mild XT/Mild entropion SE | 36 |
| 6 | 30 | F | CB 2015 | OU (OD) | HM | None | 11′0–7′0 (240°)/360° | IIIc 2+ | 3X1 | CS/EI | Full/none | 36 |
| 7 | 18 | M | CB 2014 | OS | CF | SR + AMT 1x | 7′0–5′0 (300°)/360° | IIIc 2+ | 3×2 | CS/EI | Full/none | 42 |
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