In this case, there were several indications for surgical intervention. First, this child was of amblyogenic age; partial obstruction of the visual axis as well as the likely corneal astigmatism induced by the hypertrophic mucous membrane graft would have been sufficient indications for surgical reduction of the graft tissue. However, it was also noted on examination that despite the size of the graft, the inferior fornix itself was visible upon pulling the left lower eyelid inferiorly—indicating that the tissue was not in ideal position. The extension/growth of the graft onto the corneal surface coupled with altered tear film quality (buccal tissue does not contain goblet cells) created constant irritation of the corneal surface. Finally, the hypertrophic graft had resulted in poor cosmesis for this child. It is unknown at what rate mucosal graft hypertrophy occurs and there is little data in the eye literature; however, mucosal graft columnar metaplasia and hypertrophy have been reported in the urology literature and are thought to be associated with exposure of mucosal tissue to air [1].

The patient underwent excision of most of the buccal mucous membrane graft, leaving behind a small amount of tissue in the inferior fornix. He also underwent lysis of symblepharon, placement of a symblepharon ring, and a temporary suture tarsorrhaphy to keep the symblepharon ring in place. The following month, the suture tarsorrhaphy and symblepharon ring were removed, revealing a thin layer of neovascular pannus on the inferior cornea and a new area of symblepharon formation inferiorly, although the inferior fornix remained formed. Within 3 months, he developed progressive symblepharon as well as ankyloblepharon formation; he subsequently underwent a fornix reconstruction procedure with lysis of symblepharon/ankyloblepharon, application of mitomycin C (MMC), amniotic membrane transplantation (AMT), and placement of another symblepharon ring.

MMC has been found to decrease recurrence in pterygium surgery [2, 3], and Tseng et al. have reported success when using MMC in conjunction with AMT in fornix reconstruction for severe cicatrizing ocular surface disease [4].

The placement of a temporary suture tarsorrhaphy is often required to achieve a stable ocular surface, after which it may be removed. This may be performed either in the clinic, procedure room, or operating room, depending on the situation. The eyelids should be prepped using dilute povidone-iodine solution. The eyelids are anesthetized temporally using a solution consisting of 1% lidocaine and 1:100,000 epinephrine and may be injected using a 27 or 30 gauge needle. Care should be taken to achieve adequate anesthesia, while avoiding significant distortion of the eyelid anatomy.

For a temporal, temporary tarsorrhaphy, a 5-0 double-armed nylon suture is used. A foam or silicone bolster is used for the upper and lower eyelid, and the sutures are passed through the bolster to prevent skin necrosis and irritation. After placement through a bolster, each needle is passed mattress style through the gray line of the upper eyelid (just temporal to the temporal aspect of the limbus). The suture then placed mattress style through the gray line of the lower eyelid and then tied in a 3-1-1 fashion cutting to allow a 2–3 mm tail of the suture to remain, taking care to bring the lid margins together with adequate tension but again without significant distortion of the eyelid anatomy. If for some reason a temporal tarsorrhaphy is only required for a limited period of time, an absorbable suture such a 4-0 chromic gut may be used with the same method described above, without the need for bolsters. An alternative approach that has been described is to use cyanoacrylate glue at the eyelid margin temporally. However, the duration of effect is relatively unpredictable, and exposure of the ocular surface to cyanoacrylate glue can lead to undesired irritation. Alternatively, silk suture can be used and is more tolerable to the ocular surface if the tarsorrhaphy loosens but is more irritating to the skin.

A permanent tarsorrhaphy is performed in the operating room or procedure room, with prepping and anesthetic delivery as described above. The anterior and posterior lamella of the eyelid along the length of desired tarsorrhaphy are separated using a #11 blade. The superficial 1 mm of the posterior aspect of the upper and lower eyelid margins are removed from the lateral aspect of the limbus toward the lateral canthus. A 6-0 vicryl suture is passed partial thickness, avoiding passage through the conjunctival tissue, in the posterior lamellar flap and used to affix the upper and lower eyelid. Interrupted passes are used until the posterior lamella is closed. Similarly, the anterior lamella is sutured together using an absorbable suture. Eyelashes can be removed prior to tarsorrhaphy if desired.

Symblepharon rings are translucent, non-sterile devices produced by multiple manufacturers and are usually made of polymethylmethacrylate (PMMA). They may be used alone or together with AMT although it has been reported that their use alone in the setting of acute Stevens-Johnson syndrome leads to more severe ocular sequelae [5]. They are used in the acute setting as well as at the time of fornix reconstruction to prevent symblepharon formation and maintain the fornices (i.e., prevent forniceal foreshortening). Other potential uses include severe chemical and thermal burns and during acute exacerbations of conditions that cause a cicatrizing conjunctivitis (e.g., rosacea keratoconjunctivitis, ocular cicatricial pemphigoid). At the time of fornix reconstruction, a symblepharon ring is often placed if there is a concern regarding reformation of symblepharon and forniceal foreshortening due to conjunctival inflammation. Even though the conjunctival surface may be quiet at the time of surgery, the lysis of symblepharon itself may lead to a significant inflammatory response. Postoperatively, we prefer to keep the ring in the eye for a minimum of 3 months (preferably longer if the patient can tolerate).

Over the course of the next year, our patient had the symblepharon ring removed, followed by a repeat fornix reconstruction procedure with symblepharon ring placement with MMC and AMT and with subsequent removal of the symblepharon ring after a few months. Unfortunately, he was found to once again develop symblepharon, as well as progressive ectropion of the left lower eyelid (Fig. 17.2 ). Although this patient has slowly improved with each subsequent intervention, his clinical course exemplifies the potentially difficult nature of ocular surface injuries.

We placed a 4-0 silk suture through the eyelid margin for traction and exposure. Dissection into the fornix was then performed to release the symblepharon. The buccal mucous membrane graft was debulked. A double-armed 4-0 Prolene suture was passed through the inferior section of the graft, through a number 42 retinal silicone band and then passed toward the infraorbital rim, affixing a piece of periosteum and coming out percutaneously to rotate the lid slightly toward the globe. This allowed for good draping of the palpebral portion of the buccal mucous membrane graft over the palpebral conjunctiva, reconstructing this portion of the fornix. The two arms of the suture were pulled percutaneously and tied over another section of the number 42 silicone band. After 5 months, he required another fornix reconstruction procedure using free conjunctival autograft from the superior bulbar area and this time also underwent repair of mild cicatricial entropion. The symblepharon ring was left in place for about 6 months. Following removal of the ring, the patient has done well with mild recurrence of the symblepharon. Patient does have inferior limbal stem cell deficiency which will need to be addressed in the future.

Discussion: There are several aspects of this patient’s care which are worth discussing. First, starting with the initial treatment (symblepharon repair with amniotic membrane which was done prior to presentation), the timing of the surgery may have been too early. In general, it is best to wait for the inflammation from the chemical injury to subside (at least 1 year or longer if possible). In the most severe cases (e.g., Stevens-Johnson syndrome), it may be necessary to treat the patient with systemic immunosuppression for several months prior to starting surface/eyelid reconstruction. Second, when harvesting a mucous membrane graft, one may consider using a mucotome that allows for harvesting very thin tissue. Also, leaving a symblepharon ring in the eye as long as possible would also help reduce the likelihood of recurrence. We aim for a minimum of 3 months but in recurrent cases keep for up to 6 months. Finally, another adjunctive measure which was not used in this case is steroid or 5-FU injection into early recurrent lesions. Many surgeons have reported positive experiences particularly with 5-FU for stopping recurrent symblepharon. It is very well tolerated (unlike mitomycin C which has to be used with more caution).

A 54-year-old female with advanced ocular cicatricial pemphigoid was referred for oculoplastics service evaluation in advance of a planned Boston keratoprosthesis (K-Pro) type II. She was noted to have a prior history of AMT and failed PKP OS. On examination, her visual acuities were hand motion (HM) OD and light perception (LP) OS. There was lid margin keratinization, as well as extensive symblepharon formation, limiting extraocular movements OU. There was also a neovascular pannus over both corneas. Anterior chambers were formed and the iris was grossly within normal limits. The view to the lens was hazy in both eyes.