The article by Fu and associates evaluating the oral mucosal graft in cicatricial ocular surface reconstruction is very interesting. The lamellar division of the eyelid at the grey line with repositioning is used for corrections of entropion and lid margin keratinization. We also have found the technique very useful for such cases. In addition to the correction of lid margin deformity, the procedure also corrects lid retraction and lagophthalmos. However, the technique at our center differs from that of Fu and associates in the following respects. We carry out the splitting of anterior and posterior lamella just short of superior fornix along with the passage of 3 mattress sutures from the conjunctiva toward the skin. These sutures prevent retraction of the posterior lamella in the postoperative period and are removed at the third week. Second, in the presence of lid retraction, we perform the recession of the Müller muscle by freeing it from the superior tarsus border and conjunctiva. This produces slight ptosis and corrects retraction as well as lagophthalmos. In the present series, for eyes with incomplete closure, the oral mucosal graft was obtained intentionally with more stromal fat so that the tarsal height could be lengthened. In 3 of 12 cases, the residual incomplete closure could be attributed to fat resorption that required oral mucosal graft to both the upper and lower lid. For such cases with severe scarring, our technique may be used.

The cicatricial diseases usually cause contraction and shortening of posterior lamella with severe entropion. Therefore, some may advocate the use of posterior lamella as a substitute in such situations, rather than tarso-conjunctiva advancement. A stiff replacement such as hard palate mucosal graft, nasal septal cartilage with mucoperichondrium, and ear cartilage can cause significant morbidity at the donor site. However, if the surface of the tarsal conjunctiva is severely keratinized and rough, it may be better to replace it with healthier mucosa. Therefore, we prefer posterior lamella graft in such patients.

We routinely use topical antibiotics and copious lubrication for healing of the epithelial defects. Ten eyes (45.4%) in present study had persistent epithelial defect diagnosed before surgery. Their postoperative treatment included topical 0.1% dexamethasone drops. By decreasing inflammation, corticosteroids may facilitate epithelial migration and may suppress sterile ulceration by reducing proteolytic enzymes. Hence, their use by the authors may have altered the course of the corneal findings. Nevertheless, the correction of blink-related microtrauma and lagophthalmos by buccal mucosal graft would aid in healing of corneal lesions.