Anterior lamellar repositioning and grey line split for upper lid entropion in ocular cicatricial pemphigoid

Evaluation of outcomes of lower eyelid entropion and ectropion surgical repair

<b><br>Introduction:</b> The imbalance of external and internal forces acting on the lower eyelid can result in entropion and ectropion, both of which cause ocular irritation and loss of proper eye protection. Potential complications of untreated cases include recurrent inflammation of the conjunctiva and cornea, conjunctival neovascularization, corneal abrasion or perforation, and ultimately even loss of vision. Although various surgical techniques are used to address this problem, their long-term outcome and effectiveness are still under discussion. </br> <b><br>Aim:</b> To evaluate outcomes of surgery for entropion and ectropion, including a modified Wheeler's method for entropion correction.</br> <b><br>Methods:</b> A non-comparative study (prospective and retrospective groups) included 100 patients operated on in two university hospitals' plastic surgery departments for lower eyelid entropion or ectropion, following formal ethics approval. The prospective group included 50 patients assessed preoperatively and at 3 and 12 months postoperatively. The retrospective group was comprised of 50 patients (2012-2018), whose preoperative documentation and clinical examinations were analyzed. The main outcome measures were change between pre- and postoperative patient-reported symptoms (VAS scale), ectropion/entropion grading scale (EGS/EnGS), quality of life (WHOQOL-BREF), and occurrence of complications.</br> <b><br>Results:</b> The differences in the severity of all symptoms before and after surgery evaluated with the VAS scale were statistically significant in both groups (p <0.05). We observed 6 recurrences (12%) in the prospective group and 9 (18%) in the retrospective group, with minor complications. Very good functional and esthetic postoperative results were confirmed in 70% (79) of the whole group and in 13 patients (81.3%) treated with the modified Wheeler's method. In the prospective group, the Mann- Whitney U test for dependent variables revealed significant improvement in the somatic, psychological, and environmental domains, with no significant change in the social relationships domain.</br> <b><br>Conclusions:</b> The results following entropion/ectropion surgery prove the effectiveness of the methods used. Complementing them with the modified Wheeler's method brought an increase in the number of very good outcomes. Surgery of lower eyelid malposition contributed to reduced symptoms and improved quality of life. The rates of postoperative sequelae were low.</br>.

Recurrent upper eyelid trachomatous entropion repair: long-term efficacy of a five-step approach

PURPOSE

To describe the lid characteristics of recurrent upper eyelid trachomatous entropion and to report the long-term outcomes of a five-step surgical approach based on the principles of upper eyelid crease lamellar splitting and retractor release with redirection.

SUBJECTS AND METHODS

Retrospective case review of adult patients with recurrent upper eyelid trachomatous entropion who had undergone surgical correction using the five-step surgical technique between March 2014 and March 2018. Cases with primary entropion and/or <2 years of follow-up were excluded from this series.

MAIN OUTCOME MEASURES

Eyelid deformities (type of trichiasis, anterior lamellar laxity, lid margin abnormality, lid retraction and lagophthalmos), recurrence of entropion and trichiasis, cosmetic satisfaction, and surgical complications.

RESULTS

Forty-two upper eyelids in 33 patients met inclusion criteria. Preoperative anterior lamellar laxity was present in 36 eyelids (85.7%), lid retraction in 31 eyelids (73.8%) with a mean preoperative MRD1 of 6.48 ± 1.1 mm, atrophic tarsus in 28 eyelids (66.7%), lid margin notching in 22 eyelids (52.4%), and lagophthalmos in 15 eyelids (35.7%). The surgical success rate was 92.9% (95% CI 0.805-0.985). There was no documented recurrence of entropion over a mean follow-up period of 31.79 months. Postoperative trichiasis without entropion occurred in three eyelids, which required repeat epilation.

CONCLUSIONS

The five step-approach based on the principles of lamellar splitting is effective in correction of recurrent trachomatous entropion with long-term stability. The procedure addresses the fundamental changes frequently seen in recurrent cases, in particular anterior lamellar laxity, scarred shortened posterior lamella, and trichiasis.

Labial mucosa grafting for lid margin, anterior lamellar, and posterior lamellar correction in recurrent cicatricial entropion

PURPOSE

To report a novel modified technique for severe recurrent cicatricial entropion correction based on anterior lamellar recession (ALR) and grafting.

METHODS

Six eyelids of five patients (9-48 years; three females) with severe cicatricial entropion (three upper and three lower eyelids) had surgical correction using ALR and labial mucosal grafting for spacing the ciliary margin away from the lid margin and reconstruction of the lid margin and posterior lamella. The modified technique included using mucous membrane as a single unit for anterior lamella, lid margin, and posterior lamella reconstruction employing a different suturing technique.

RESULTS

The indications for surgery included Stevens-Johnson syndrome (3), chemical injury (2), and post-surgical scarring in congenital distichiasis with lymphedema (1). Entropion resolved in all patients with restoration of eyelid margin and reduction in ocular discomfort. Trichiasis was present in all six eyelids (100%) preoperatively and resolved completely in all but one case (83% success rate) with three residual focal trichiatic lashes in the temporal area, which was successfully managed with radiofrequency ablation. There were no recurrences of trichiatic or distichiatic lashes at a median follow-up duration of 16 months (range, 12-18 months).

CONCLUSION

Successful resolution of the recurrent cicatricial entropion can be achieved with the use of labial mucosa as one solution for spacing the anterior lamella and reconstruction of the lid margin and posterior lamella with minimal recurrence rate.

Ocular Mucous Membrane Pemphigoid: Current State of Pathophysiology, Diagnostics and Treatment

Mucous membrane pemphigoid (MMP) is a systemic cicatrizing autoimmune disease that primarily affects orificial mucous membranes, such as the conjunctiva, the nasal cavity, the oropharynx, and the genitalia. Ocular involvement occurs in about 70% of all MMP cases. Ocular MMP (OcMMP) also encompasses the conditions linear immunoglobulin A disease, mucosal dominated epidermolysis bullosa acquisita, and anti-laminin 332/anti-epiligrin/anti-laminin 5 pemphigoid. It is a complex clinical entity that may lead to ocular surface failure and result in inflammatory and infectious complications, as well as potentially devastating visual loss. Early diagnosis and appropriate treatment are of paramount importance and require a high level of expertise as this condition can be extremely challenging to diagnose and treat even for experienced clinicians. In this review we provide an up-to-date insight on the pathophysiology of OcMMP, with an emphasis on the current state of its diagnostics and therapeutics. Our the aim is to increase our understanding of OcMMP and highlight modern diagnostic and therapeutic options.

Upper eyelid levator-recession and anterior lamella repositioning through the grey-line: Avoiding a skin-crease incision

Purpose:

This study aims to report a case series of upper eyelid cicatricial margin entropion with retraction, corrected through a grey-line approach only. We remind readers of the grey-line approach to levator recession (LR) and lamellar repositioning surgery.

Methods:

A retrospective review of clinic notes and photographs of patients who underwent grey-line split (GLS), LR, release of orbital septum, recession of levator, advancement of posterior lamella and anterior lamellar repositioning without a skin crease incision, from December 2015 to December 2016. Indications for surgery included mild-to-moderate cicatricial margin upper eyelid entropion, tarsal curling, and meibomian gland inversion. Patients requiring spacer interposition to lengthen the posterior lamella were excluded from the study. Parameters of the study included lid margin position, lid height, ocular surface health and symptom improvement.

Results:

Eleven eyelids of eight patients were included in the study, and underwent the procedure described. Lid margin position measured as the marginal reflex distance lowered (improved) in 72.7% of patients. Lid margin eversion was achieved in all eyes (100%). Corneal punctate epithelial erosions markedly improved, being present in 72.7% of patients preoperatively, and only 9.1% of patients postoperatively. Eight of eleven eyes showed symptomatic improvement, with six (54.5%) being completely asymptomatic and two achieving partial relief. An added observation was a pretarsal show asymmetry in some patients which improved in 36.4% of surgeries postoperatively.

Conclusion:

Upper eyelid LR with GLS and anterior lamella repositioning can all be performed through the plane of the split, avoiding a skin incision. Normal lid margin apposition was achieved in all eyes with 91% demonstrating a clear cornea and 72% having symptomatic improvement.

Anterior lamellar recession for management of upper eyelid cicatricial entropion and associated eyelid abnormalities

AIM

To evaluate the functional and aesthetic outcomes of upper eyelid cicatricial entropion (UCE) correction using anterior lamellar recession (ALR) with addressing the associated conditions including dermatochalasis, brow ptosis, blepharoptosis, and lid retraction.

METHODS

Chart review of patients with upper lid cicatricial entropion who had undergone ALR from 2013 to 2016 was reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, and acceptable cosmesis at the final follow up.

RESULTS

Sixty eight patients (97 eyelids) were operated by ALR with simultaneous correction of associated lid problems in each case when necessary. The mean follow-up time was 17.8mo (range, 6.0-24.0mo). Concomitantly, levator tucking was performed in 19 eyelids (19.6%), upper lid retractor recession in 18 eyelids (18.6%), and internal browpexy in 31 eyelids (32.0%). In 95.8% of patients (95%CI: 0.85-0.96), satisfactory functional and cosmetic outcome was achieved with a single surgical procedure.

CONCLUSION

Based on the principles of lamellar recession and concurrently addressing the associated lid problems, this approach is an effective and safe treatment of UCE.

[Anterior lamellar resection with lid margin split of the upper eyelid in the treatment of trachomatous entropion]

INTRODUCTION

The goal of this study is to assess functional and aesthetic results of anterior lamellar resection with lid margin splitting of the upper lid in the treatment of cicatricial trachomatous entropion.

PATIENTS AND METHODS

Descriptive cross-sectional study of a series of 26 consecutive patients treated between January 2014 and December 2015. All patients were operated for cicatricial trachomatous entropion in our tertiary center using the technique of the anterior lamellar resection with lid margin splitting of the upper eyelid. All patients were followed for 6 to 12 months after surgery. The anatomical, functional and aesthetic results were evaluated six months after surgery. They were considered good if there was no recurrence of the entropion, no lashes in contact with the cornea and no associated eyelid complications.

RESULTS

The mean age of the patients was 68.5±10 years with a male predominance (sex ratio=1.8). The average initial corrected visual acuity was 0.65±0.35 LogMAR, ranging from counting fingers at 1m to 6/10. Involvement was bilateral in 34.6% of cases. Correction of the cicatricial entropion was achieved in 24 patients (92.3% of cases) and full correction of misdirected lashes without any contact with the ocular surface was obtained in 23 patients (88.4% of cases). The lid margin was regular in 88.4% of cases. A significant improvement of the tear film and corneal surface was observed in 84.6% of patients. During the follow-up period, no cases of recurrent entropion were reported.

DISCUSSION

Among the various surgical techniques, anterior lamellar resection with lid margin splitting is one that most respects the anatomy of the upper eyelid and allows precise intraoperative control of eyelid rotation and eversion of the misdirected lashes. Therefore, it reduces significantly the risk of recurrence and significantly enhances the aesthetic results of surgery.

CONCLUSION

Anterior lamellar resection with lid margin splitting of the upper eyelid is a simple and effective technique that significantly improves the aesthetic result of cicatricial trachomatous entropion.

Long-Term Results for Entropion Repair by Tarsal Margin Rotation With Posterior Lamella Superadvancement

PURPOSE

To report the long-term stability of tarsal margin rotation and posterior lamellar superadvancement (TMR PLS) for the repair of upper eyelid cicatricial entropion.

METHODS

A retrospective chart review was performed from January 2000 through December 2014 to identify all patients who had TMR PLS at the authors' institution. Charts were reviewed for demographic information, recurrence of entropion or trichiasis, and surgical complications. Failure was defined as return of entropion. Patients with greater than 24 months of follow up were included.

RESULTS

A total of 30 TMR PLS procedures were performed during the review period. Nineteen cases from 14 patients were included in the final analysis. None of the 19 cases demonstrated recurrence of entropion over an average follow-up period of 78.3 months. Eight cases demonstrated trichiasis after TMR PLS, 5 of which required treatment.

CONCLUSION

This case series suggests that TMR PLS for the treatment of upper eyelid cicatricial entropion has excellent long-term stability.

Anterior lamellar recession, blepharoplasty, and supratarsal fixation for cicatricial upper eyelid entropion without lagophthalmos

PURPOSE

To assess the results of anterior lamellar recession, blepharoplasty, and supratarsal fixation procedure in patients with upper eyelid cicatricial entropion without lagophthalmos.

METHODS

In a prospective interventional case series, 52 eyelids (32 patients) were included (April 2009-December 2010). Excluded were patients with previous eyelid surgeries, lagophthalmos, and <12 months of follow-up. Using a microscope, after recessing anterior lamella 3-4 mm above the eyelid margin, it was fixed with 4-5 interrupted 6-0 vicryl sutures. Excess anterior lamella was then excised (blepharoplasty), supratarsal fixation sutures (6-0 vicryl) were put and the skin was closed with 6-0 nylon sutures. Success and failure defined based upon eyelash-globe touch on the last follow-up visit (at least 12 months), respectively.

RESULTS

There were 21 females (65.6%) and 11 males (34.4%) with a mean age of 69.7 years (SD=6.9) and mean follow-up of 21.06 months (SD=8.26). Success was observed in 39 (75%) and failure in 13 (25%). Mean time of failure was 4.5 months (SD=3). Although re-treatment with radio-frequency electrolysis (eight eyelids) and re-anterior lamellar recession (two eyelids) resulted in success in 12 eyelids with failure, two patients (three eyelids) declined further procedure. Except for thickened eyelid margin, no complications were observed.

CONCLUSION

Anterior lamellar recession, blepharoplasty, and supratarsal fixation procedure is an effective and safe technique for the treatment of the upper eyelid cicatricial entropion without lagophthalmos.

Short term outcome of anterior lamellar reposition in treating trachomatous trichiasis

Purpose. To evaluate the outcome of anterior lamellar reposition (ALR) in treating trachomatous trichiasis. Methods. Patients with trachomatous trichiasis or entropion with short tarsus were treated by ALR between February 2009 and November 2013. This included splitting of the lid margin behind the aberrant lash line to separate the lid lamellae. The anterior lamella was recessed and fixated using 4/0 silk sutures. The extra lashes and their routes were excised. Sutures were removed by the 3rd week and patients completed 6 months of follow-up. Recurrence of ≤5 lashes was treated by electrolysis. Results. The study included 752 eyelids (445 patients; 58.4% females, 41.6% males), mean age 53.2 ± 6.9 y. 179 (25.1%) lids had entropion while 287 (64.5%) patients had corneal affection. By the third week, 2.66% lid had trichiasis while 30.8% had no rubbing lashes. By the 6th month, 14.9% of lids showed recurrence while 66.1% were completely cured (CI = 0.63–0.69) and 19% had partial success (CI = 0.16–0.21). Abnormal lid appearance persisted in 2.66% and 12.9% required another surgery. Conclusion. ALR is a good option for treating trachomatous trichiasis especially without cicatricial entropion. Excision of dysplastic lashes is thought to augment the surgical outcome.

Correction of lower eyelid marginal entropion by eyelid margin splitting and anterior lamellar repositioning

PURPOSE

There is a paucity of data in the literature on the surgical management of lower eyelid marginal entropion. In this study, the authors report outcomes of a surgical technique of eyelid margin splitting and anterior lamellar reposition in patients with lower eyelid marginal entropion.

METHODS

The medical records for 30 eyelids from 22 patients with lower eyelid marginal entropion who had undergone eyelid margin splitting and anterior lamellar repositioning at Seoul National University Hospital from January 2004 to December 2012 were retrospectively reviewed. Success was defined as the lack of any lash in contact with the globe, no need for a second procedure, the complete resolution of symptoms, and acceptable cosmesis at the final follow up.

RESULTS

The mean follow-up duration was 16.7 months. The split eyelid margin exhibited good wound healing in each case, but trichiasis recurred postoperatively in 3 of 30 eyelids, even though the eyelid margin was ultimately well positioned. That is, the overall success rate was 90%. Of the 3 eyelids with recurrent trichiasis, 2 required additional electrolysis to remove irritated cilia, but the other did not require to be treated. In the latter case, the trichiasis observed was fine, focal, and unaccompanied by symptoms or corneal lesions. There was no significant complication such as secondary ectropion or eyelid retraction.

CONCLUSIONS

Eyelid margin splitting and anterior lamellar repositioning achieve success with a low rate of complications among patients with lower eyelid marginal entropion.

Treatment strategies in mucous membrane pemphigoid

Mucous membrane pemphigoid (MMP) is an autoimmune blistering disorder that is characterized by subepithelial bullae. Various basement membrane zone components have been identified as targets of autoantibodies in MMP. Considerable variability exists in the clinical presentation of MMP. Mucous membranes that may be involved include the oral cavity, conjunctiva, nasopharynx, larynx, esophagus, genitourinary tract, and anus. A multidisciplinary approach is essential in the management of MMP. Early recognition of this disorder and treatment may decrease disease-related complications. The choice of agents for treatment of MMP is based upon the sites of involvement, clinical severity, and disease progression. For more severe disease, or with rapid progression, systemic corticosteroids are the agents of choice for initial treatment, combined with steroid-sparing agents for long-term maintenance. Due to the rarity of this disease, large controlled studies comparing the efficacy of various agents are lacking.

Anterior lamellar excision and laissez-faire healing for aberrant lashes in ocular cicatricial pemphigoid

PURPOSE

To describe the outcomes of a simple technique of anterior lamellar excision (ALE) with laissez-faire healing for management of aberrant lashes in ocular cicatricial pemphigoid (OCP).

METHODS

Prospective interventional case series.

RESULTS

Seven OCP patients underwent grey line split and ALE with laissez-faire healing over a 24-month period in a tertiary referral centre. All patients had undergone previous interventions for the misdirected lashes. Nine procedures were undertaken (three upper and six lower lids). Mean follow-up was for 25.66+/-12.3 months (range: 9-43 months). Residual lashes were noted in three patients. In two cases, the lashes were isolated and managed successfully by a single electrolysis treatment. One patient needed further ALE for residual remnant of trichiatic cilia at the lateral edge of the lid. All patients were satisfied with their post-operative appearance. None of the patients showed exacerbation of disease or needed additional immunosuppression as a consequence of the lid surgery.

CONCLUSIONS

Anterior lamellar excision with spontaneous granulation is a simple and effective procedure for management of aberrant lashes. Risk of disease exacerbation was reduced in OCP with minimal conjunctival manipulation and reduced post-operative lash-globe touch.

Lid margin split in the surgical correction of epiblepharon

PURPOSE

To describe the technique of splitting the lid margin combined with the excision of redundant skin and muscle during the surgical correction of epiblepharon and to report its clinical outcome.

METHODS

A combined procedure that included splitting the lid margin to repair lower eyelid epiblepharon was performed on 31 eyes of 19 consecutive patients. Lid margin splitting was performed along the grey line on the medial third or half of the lower eyelid by making a 1 mm-deep incision. Having made a transverse subciliary skin incision and a dissection between the tarsus and the orbicularis oculi muscle, the subcutaneous tissue of the superior edge of the incision was secured to the tarsus with interrupted sutures to evert the cilia. An excision of the redundant skin and orbicularis tissue was made and the skin was closed. The patients were followed for direct inspection of the wound, the split lid margin, the direction of the lashes and the status of the cornea.

RESULTS

The mean postoperative follow-up period was 29.4 weeks. Symptoms disappeared in all patients. In 30 eyelids of 19 patients the cilia did not touch the cornea, even in the down-gaze. In one eyelid the cilium touched the medial conjunctiva, but not the cornea. The cosmetic outcome of the lower lid was satisfactory in all cases and the wounds of the split lid margin healed without scarring. To date, there have been no complications such as wound dehiscence, ectropion or eyelid retraction.

CONCLUSIONS

The lamellar splitting of the lid margin is a beneficial addition to the repair of prominent lower lid epiblepharon, especially on the medial aspect of the eyelid. This simple technique ensures easier eversion of the cilia in epiblepharon repair, without disturbing the posterior lamella or causing unfavourable results.

Efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique

OBJECTIVE

To determine the efficacy of lamellar division for correcting cicatricial lid entropion and its associated features unrectified by the tarsal fracture technique.

METHODS

Fifty patients (92 lids) diagnosed as having cicatricial lid entropion were operated by the tarsal fracture technique. There was defective lid closure in 34/92 lids, irregular lid margin in 48/92 lids, distichiatic or metaplastic cilia in 28/92 lids and a history of previous entropion surgery in 34/92 lids. All patients were followed up for one year and the surgical failures at the end of this period were subjected to lamellar division. These subjects were further followed up for one more year.

RESULTS

An overall success rate of 28.26% (26/92 lids) was obtained with the tarsal fracture technique. A correction was achieved in all the 20 lids having cicatricial entropion without any associated features. However, this technique succeeded in only six of the remaining 72 lids (8.33%) with a history of previous surgery or the associated features stated above. Furthermore, it was not effective in correcting associated anomalies such as defective lid closure, irregular lid margin and distichiatic or metaplastic cilia. Reoperation using lamellar division gave good correction in 97% of the lids (64/66).

CONCLUSIONS

Lamellar division is a better procedure for treating cicatricial lid entropion, especially in patients with associated complications or with a previous history of entropion surgery.

Interventions for involutional lower lid entropion

BACKGROUND

Entropion is a condition in which the eyelid margin turns in against the eyeball. The involutional or senile type of entropion is one of the most common lower lid malpositions in the elderly. The interventions described and currently used for the treatment of this condition are surgical in nature, although non-surgical temporary medical treatment for the early stages of entropion has also been reported. The relative effectiveness of these interventions has not yet been resolved.

OBJECTIVES

The purpose of this review is to examine the effect of interventions for involutional entropion and to assess whether any method is superior to the others.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register - CENTRAL/CCTR, which contains the Cochrane Eyes and Vision Group specialised register (Cochrane Library Issue 3, 2000), MEDLINE (1966 to October 2000), EMBASE (1980 to September 2000), the metaRegister of Controlled Trials (mRCT), oculoplastic textbooks, conference proceedings and bibliographies of relevant reports. We contacted investigators and experts in the field for details of other published and unpublished studies.

SELECTION CRITERIA

The criteria for including studies in this review were randomised controlled trials where one intervention for involutional lower lid entropion has been compared to another method of treatment in people older than 60 years of age with involutional lower lid entropion.

DATA COLLECTION AND ANALYSIS

Both reviewers assessed the search results according to the criteria for including studies in the review. No studies were found that met these criteria, and therefore no data were collected and no meta-analysis was performed.

MAIN RESULTS

Since no studies met our selection criteria no results were produced.

REVIEWER'S CONCLUSIONS

No conclusions could be reached about the effectiveness of interventions for involutional lower lid entropion, although retrospective case series studies suggest that some forms of treatment may be associated with higher recurrence rates than others. Lack of suitable data highlights the need for randomised controlled trials in the fields of entropion management.

Amniotic membrane transplantation in entropion surgery

PURPOSE

To evaluate the role of amniotic membrane transplantation in the management of cicatricial eyelid entropion.

DESIGN

Prospective, noncomparative interventional case series.

PARTICIPANTS

Eighteen consecutive patients with cicatricial entropion.

METHODS

A gray line lid split procedure with vertical anterior lamella repositioning was performed on 25 eyelids (upper or lower) of 18 patients with moderate to severe cicatricial entropion. Preserved human amniotic membrane (AM) was used to cover the bare tarsus up to the lid margin and secured with running 7-0 Vicryl. Impression cytology of the AM was performed at various stages postoperatively to study the epithelialization process.

MAIN OUTCOME MEASURES

(1) Reepithelialization of bare tarsus, (2) extent of tarsal shrinkage, (3) recurrence of entropion.

RESULTS

All the AM grafts took well. The most common complication was hemorrhage below the graft, which occurred in six cases. Complete success with no lashes touching the globe was achieved in 22 of 25 (88%) lids after a minimum follow-up of 12.0 months. The mean follow-up was 17.8 months. Two cases (qualified success) had recurrent trichiasis treated successfully with electrolysis. One case with severe trachomatous upper lid entropion recurred 14 months after surgery. The AM accelerated the epithelialization of bare tarsus; this was demonstrated by lack of fluorescein staining and reversion to skin color within 2 to 3 weeks. However, AM could not prevent tarsal shrinkage. Impression cytology demonstrated that features of conjunctival epithelium were present for the first postoperative month, but this was gradually replaced by squamous metaplasia, with keratinization appearing as early as 3 weeks postoperatively.

CONCLUSIONS

The use of AM in a lid split procedure for correction of cicatricial entropion helps the bare tarsus epithelialize rapidly and improves the initial cosmetic result of surgery.

Management of conjunctival cicatrizing diseases and severe ocular surface dysfunction

Physical or chemical injuries, infections, immunologic oculocutaneous disorders, drugs, and various systemic disorders may cause scarring of the conjunctiva and disturbances of the ocular surface. Trichiasis, lid margin malposition, and dry eye may result in persistent ocular irritation. The cornea may be primarily or secondarily involved. If severe, disturbances of the ocular surface may lead to significant visual impairment. Thorough evaluation of patients and of the underlying disease process is required for optimal management. Treatment may be challenging and should be comprehensive, combining medical measures and surgical correction of structural changes. Suppression of exogenous irritants, treatment of dry eye, antiinflammatory therapy, and immunosuppressants are paramount to control the underlying disease and allow optimal surgical results. Surgical correction of trichiasis and lid margin malposition, conjunctival grafting, mucous membrane transplantation, limbal stem cell transplantation, amniotic membrane transplantation, and penetrating keratoplasty help reestablish a physiologic ocular surface. Severe cases may require keratoprosthetics for visual rehabilitation. Corneal ulceration or perforation requires prompt attention to maintain ocular integrity. Special measures should be considered for patients who require cataract or glaucoma surgery.