Anterior Lamellar Recession With Buccal Mucous Membrane Grafting for Cicatricial Entropion

Surgical management of patients with corneal lesions due to lid pathologies

BACKGROUND

The surgical management of corneal lesions resulting from eyelid pathologies requires a comprehensive approach to ensure optimal patient outcomes. Eyelid lesions, ranging from benign to malignant, can lead to corneal damage through mechanisms such as mechanical abrasion, secondary infection, or inflammatory responses.

AIM

To assess the surgical methodologies utilized in the treatment of corneal lesions resulting from eyelid disorders and evaluate their effects on patient outcomes, recurrence rates, and postoperative complications. The incorporation of advanced imaging techniques, including optical coherence tomography and ultrasound biomicroscopy, in conjunction with histopathological analysis, is addressed to improve surgical accuracy and patient outcomes.

METHODS

The authors searched online databases (PubMed and Cochrane) for publications on the surgical management of lid lesions. Records received from the two databases were checked for duplicates and relevance. Only records with full texts and in English language were included.

RESULTS

A total of 28 records were obtained following the screening for relevancy and duplication. The review underscores essential surgical approaches employed in the treatment of corneal lesions resulting from common eyelid diseases, focusing on operative efficacy, complication rates, and long-term results.

CONCLUSION

This systematic review emphasizes the significance of choosing suitable surgical techniques tailored to individual patient characteristics and stresses the need for interdisciplinary collaboration in ophthalmic care. The results indicate that sophisticated imaging techniques and careful preoperative preparation markedly improve surgical accuracy and long-term results.

A Novel Percutaneous Surgical Approach Using Silicone Sheets for Lower Eyelid Lengthening: A Descriptive Case Series

Background

Lower eyelid lengthening is essential to correct eyelid retraction and preserve ocular surface integrity. We evaluated the efficacy of a novel percutaneous surgical technique that utilizes a silicone sheet to elongate the lower eyelids to minimize ocular surface inflammation and corneal damage.

Methods

This case series included 15 patients (22 eyelids) with lower eyelid retraction who underwent a novel silicone-sheet-based lower eyelid elongation surgery by the same surgeon and completed at least 3 months of follow-up that involved consistent methods (ie, slit-lamp examination) between November 2014 and November 2023. Corneal epithelial damage and changes in the margin reflex distance-2 were measured preoperatively and postoperatively. Ocular surface discharge and foreign body sensation were assessed in patient interviews within the first postoperative week.

Results

During a mean postoperative follow-up of 31.9 months, the mean margin reflex distance-2 decreased from 7.17 to 5.89 mm. No recurrence or complications were observed. In all cases, superficial punctate keratopathy diminished within the first postoperative week and resolved within 1 month. Ocular discharge and foreign body sensation significantly decreased within a few days after surgery.

Conclusions

A novel surgical technique using silicone-sheet spacers for lower eyelid elongation showed promising results in reducing ocular surface damage and improving patient outcomes. Despite its potential benefits over traditional methods, further large-scale, multicenter studies, including clinical trials, with diverse study populations are needed to generate robust data to validate and expand the applicability of this technique for managing lower eyelid retraction, particularly when involving eyelash contact with the ocular surface.

Management of Eyelid Pathologies That Cause Corneal Lesions

Corneal injuries, which make up 3% of emergency room visits, can vary from small scratches to exposure or trauma-related damage that might be fatal to vision. Mechanical trauma, diseases of the eyelids, neurotrophic abnormalities, and chemical burns are common causes. A thorough examination is necessary for an accurate diagnosis and treatment plan. The goal of this study is to review corneal damage from both functional and traumatic causes associated with eyelid problems and surgical therapy. Based on a comprehensive analysis of the literature, it focuses on identifying important eyelid diseases that can compromise the integrity of the corneal epithelium, including entropion, ectropion, trichiasis, distichiasis, epiblepharon, and lagophthalmos. To find research on surgical care of eyelid disorders resulting in corneal injury, the MEDLINE and Reference Citation Analysis databases were searched (from 2008 to the present). At least two impartial reviewers examined every article to guarantee that all pertinent articles were found. Relevant publications were found using a literature search. Each pertinent paper's reference list was manually checked to include relevant documents the original search missed. There were 28 papers about surgical management of eyelid abnormalities that could jeopardize the integrity of the corneal epithelium: entropion, ectropion, trichiasis, distichiasis, epiblepharon, and lagophthalmos. Entropion treatment was the subject of the majority of these studies. The review strongly emphasizes determining the precise anatomical source of corneal injury in disorders of the eyelids and customizing surgical techniques accordingly. Cooperation between plastic surgeons and ophthalmologists is crucial to manage complicated situations and guarantee stable, long-term results.

Mucous membrane grafting for cicatricial entropion repair: review of surgical techniques and outcomes

Mucous membrane graft (MMG) is used for moderate-to-severe cicatricial entropion repair either in primary or recurrent cases. We conducted a review to comprehensively summarize the various surgical techniques, outcomes, and complications of using MMG for cicatricial entropion. Though the comparison between different techniques is limited by multiple factors like small numbers of cicatricial entgropion patients, variable severity and success criteria across studies, and different underlying cicatricial entropion etiologies, the author has brought forth the nuances of the use of MMG for cicatricial entropion repair along with its outcomes and complications. MMG use in moderate-to-severe cicatricial entropion gives favourable outcomes. The shortened tarsoconjunctiva is lengthened using MMG, which is used either with terminal tarsal rotation or anterior lamellar recession (ALR) or tarsotomy alone. Non-trachomatous entropion has poor outcomes compared to trachomatous entropion. The most common source of MMG is labial or buccal mucosa and the exact size of MMG harvested is variable according to the defect, and very few prefer oversizing the graft by 10-30%. The outcomes of ALR+MMG appear similar to tarsal rotation and MMG for severe cicatricial entropion. The recurrences of trichiasis or entropion can occur for up to one year after surgery, irrespective of the technique used. Factors affecting the outcomes of cicatricial entropion repair are not well known. There is a non-uniformity in data reporting across literature; hence, future studies with details on severity of entropion, ocular surface changes, forniceal depth and ocular surface inflammation, and the degree of dry eye disease would be informative.

The current alternative for ocular surface and anophthalmic socket reconstruction, cryopreserved umbilical amniotic membrane (cUAM)

PURPOSE

This report presents the results of using cryopreserved umbilical amniotic membrane (cUAM) as an alternative mucosal graft for ocular surface reconstruction in cases of anophthalmic socket contracture (ASC), cicatricial entropion (CE), and conjunctival-scleral defects.

METHODS

The study included patients who underwent non-commercial implantation of cUAM grafts (prepared by corneal banking methods) for ASC, CE, conjunctival defect, and scleral melting. The main success criteria for this study were the comfortable fitting of the ocular prosthesis in ASC patients, the natural eyelid position in CE patients, and the degree of conjunctivalisation in melting patients.

RESULTS

cUAM transplantation was performed in 2 patients who could not use a prosthetic eye due to conjunctival contracture, 2 patients with CE, and 1 patient with conjunctival defect and 1 patient with conjunctival-scleral melting. The primary outcome was achieved in 83.3% (5/6) of patients. In one patient with CE, partial healing was achieved due to the persistence of CE in the medial upper eyelid.

CONCLUSIONS

cUAM is a viable alternative to mucosal grafting for reconstructing the bulbar and palpebral conjunctival surface, fornix, and orbit, with reduced donor morbidity and shorter surgical time. Its regenerative ability allows for tissue defect healing and improves cosmetic appearance through epithelialization within weeks.

Cicatricial Entropion in Chronic Cicatrizing Conjunctivitis: Potential Pathophysiologic Mechanisms and Long-Term Outcomes of a Modified Technique

PURPOSE

The purpose of this study was to assess the long-term outcomes of severe cicatricial entropion repair with mucous membrane grafting in patients with chronic cicatrizing conjunctivitis and report histopathological changes in the eyelid margin area.

METHODS

Prospective interventional study included 19 patients with severe cicatricial entropion with trichiasis (N = 20 eyelids; 19 upper and 1 lower eyelid) who underwent anterior lamellar recession (with back cuts) and mucous membrane grafting cover for bare anterior tarsus, lid margin, and 2 mm of marginal tarsus, and had a minimum 6 months of follow-up. The anterior lamella and metaplastic eyelid margins were sent for routine Haematoxylin and Eosin and special staining with Masson trichrome stain.

RESULTS

The etiologies were chronic Stevens-Johnson syndrome (N = 6), chemical injury (N = 11), and drug-induced pseudopemphigoid (N = 2). Five eyes had undergone entropion correction in the past, and 9 had electroepilation for trichiasis. Entropion was well corrected (without residual trichiasis) in 85% of eyelids with primary surgery. The etiology-wise success rates were 100% for Stevens-Johnson syndrome, 72.7% for chemical injury, and 100% for drug-induced pseudopemphigoid. Three eyelids with failure belonged to chemical injury, and trichiasis in these eyes could be managed with subsequent interventions except in 1 case. All eyelids had no entropion at a mean follow-up of 10.8 months (range, 6-18). Histopathological evaluation of anterior lamella (N = 10) and eyelid margins revealed significant fibrosis in subepithelial, perimysium (muscle of Riolan), and perifollicular areas.

CONCLUSION

Anterior lamellar recession combined with mucous membrane grafting achieves good cicatricial entropion correction except in eyes with chemical injury. The eyelid margins in these eyes have persistent inflammation, and fibrosis involving lash follicles.

Single-Staged Surgical Correction of Eyelid Sequelae Along With Lid Margin Mucous Membrane Grafting in Stevens-Johnson Syndrome and Other Cicatricial Ocular Surface Diseases

PURPOSE

The purpose of this study was to study the outcome of single-staged entropion surgery along with lid margin mucous membrane grafting for cicatrizing ocular surface disease.

METHODS

Retrospective review of medical records of patients who underwent single-staged surgical correction of cicatricial entropion along with lid margin mucous membrane grafting for lid margin keratinization.

RESULTS

Twenty-six eyes of 19 patients were studied. The mean age of patients was 42.5 years (standard deviation, SD-17.67), of which 7 patients were male and 12 were female. The most common disorder was Stevens-Johnson syndrome (SJS) sequelae (83.33%, n = 20), followed by mucous membrane pemphigoid (n = 4, 16.67%). The most common eyelid changes observed were cicatricial entropion in all 26 eyes (100%, n = 26), followed by trichiasis in 13 eyes (50%, n = 13). Lid margin keratinization was noted in all eyes. Postoperative improvement in corneal surface staining was noted in 70% of the patients (n = 13), no change in 20% of the patients (n = 4), and worsening of corneal surface staining in 10% of the patients (n = 2). Postoperative visual acuity improvement was noted in 50% of the eyes (n = 13), no improvement in 39% of the eyes (n = 10), and vision worsened in 12% of the eyes (n = 3). An entropion recurrence rate of 25% (n = 6) was observed over an average 10-month follow-up, whereas 75% (n = 20) reported no recurrence.

CONCLUSIONS

Single-staged correction of eyelid cicatricial entropion with a lid margin mucous membrane graft (MMG) has promising outcomes in ocular surface diseases. It can decrease the need for multiple surgeries and provide symptomatic relief in patients with chronic cicatricial surface changes.

Treatment of Oculoplastic and Ocular Surface Disease in Eyes Implanted with a Type I Boston Keratoprosthesis in Southern China: A Retrospective Study

INTRODUCTION

This study aimed to describe the clinical features, surgical management of the eyelid and ocular surface, and outcomes of 16 patients implanted with a Boston type I keratoprosthesis (KPro).

METHODS

A retrospective, single-center, consecutive case series of 16 patients with Stevens-Johnson syndrome (1), ocular chemical burns (12), and ocular thermal burns (3) implanted with KPro was studied. All subjects were men aged 27-51 years. Surgical treatment and outcomes for eyelid malposition, symblepharon, and glaucoma were assessed.

RESULTS

From September 2010 to February 2019, 29 patients were admitted to Zhongshan Ophthalmic Center for KPro implantation, of whom 16 (55%) required eyelid or ocular surface surgeries to maintain hydration and protect the corneal tissue, which is vulnerable to epithelial defects. Forty-one adnexal surgical procedures were performed. The most common indication for surgery was symblepharon, and the most frequent procedures were symblepharon lysis with ocular mucous membrane grafts and amniotic membranes (7) and full-thickness skin grafts to the eyelids (7). Preoperative conjunctival injection and corneal staining were documented in 9 (56%) and 8 (50%) eyes, respectively, and at up to 4 months postoperative follow-up (the last adnexal surgery before KPro) were recorded in 3 (19%, p = 0.03) and 2 (12%, p = 0.02) eyes, respectively. Glaucoma drainage devices were inserted in six patients. One patient with Stevens-Johnson syndrome underwent FP7 Ahmed glaucoma valve (AGV) implantation inferotemporally and developed plate exposure 2 months postoperatively. Five patients underwent FP8 AGV implantation with tube insertion into the vitreous cavity due to the scarred conjunctiva and limited subconjunctival space. In the study period, intraocular pressure (IOP) was in the normal range, and no tube or plate exposure was observed.

CONCLUSION

The ocular environment is critical for successful KPro surgery. A multidisciplinary approach for any lid and ocular surface abnormality in ocular burns or Stevens-Johnson syndrome is important to improve the quality of the ocular surface and accommodate KPro and AGV, which is vital for maintaining vision after KPro surgery. FP8 AGV may be feasible for IOP control in adult KPro cases with restricted subconjunctival space.

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.

Levator-Muller's recession using labial mucosa as a spacer in severe eyelid retraction

OBJECTIVE

To evaluate the use of labial mucosa as a spacer for levator-Muller's recession in correction of severe eyelid retraction.

DESIGN

Retrospective interventional study.

PARTICIPANTS

We retrospectively reviewed records of 4 patients with severe upper eyelid retraction not associated with cicatricial diseases of the conjunctiva.

METHOD

Surgical correction of eyelid retraction was performed by Levator-Muller's recession using autologous mucosal graft (from lip) as a spacer through transconjunctival approach. Eyelid height and contour were the main outcome measures evaluated after surgery.

RESULTS

There was resolution of dry eye symptoms in all 4 cases. In 2 cases the corrected eyelid height was within 1 mm of the desired lid position. The lid contour was good in 2 cases and satisfactory in 2 cases because of mild lateral flare. The eyelid height remained stationary till the last follow-up, which ranged from Eyelid height and contour were the main outcome measures evaluated after surgery. 6-30 months (mean: 18 months).

CONCLUSIONS

Labial mucosal graft as a spacer for levator-Muller's recession is a good option for correction of severe upper eyelid retraction. It provides stable eyelid position within 3 months of surgery with no corneal complications.

The Use of Umbilical Amnion for Conjunctival Socket, Fornix, and Eyelid Margin Reconstruction

PURPOSE

To describe outcomes using umbilical amnion for conjunctival fornix, socket, and eyelid margin reconstruction.

METHODS

A medical record review was performed to identify patients who had received umbilical amnion over a 2-year period in their department. Patient demographics, disease etiology, and data regarding surgical outcomes were collected. The primary outcome was the success rate of the surgical intervention.

RESULTS

Twenty-one patients received umbilical amnion for anophthalmic socket contracture (n = 16), orbital implant exposure (n = 3), ocular surface burn (n = 1), and cicatricial entropion repair (n = 1). The primary outcome was met in 76% of patients overall. In anophthalmic socket contracture, the primary outcome was met in 86% and 0% of patients with acquired and congenital anophthalmia, respectively. The primary outcome was met in all cases of orbital implant exposure and cicatricial entropion. The primary outcome was not met in a Roper-Hall grade IV ocular surface burn.

CONCLUSIONS

Umbilical amnion is an ideal substrate graft for reconstruction of the conjunctival fornix, socket, and eyelid margin. Umbilical amnion appears to be efficacious for the management of socket contracture in acquired anophthalmia, orbital implant exposure, and cicatricial entropion. Further experience is needed to determine the efficacy of umbilical amnion in ocular surface burns.

A conjunctival-sparing surgical technique for lower eyelid cicatricial entropion repair in ocular cicatricial pemphigoid

Purpose: To present five cases of lower eyelid cicatricial entropion secondary to ocular cicatricial pemphigoid (OCP) successfully repaired with a conjunctival-sparing surgical technique.Methods: The records of one surgeon (SKF) were reviewed to identify patients with lower eyelid cicatricial entropion secondary to OCP who underwent repair with a conjunctival-sparing technique between September 1, 2016 and October 18, 2017. The medical records were reviewed and extracted data included: age, gender, past medical history, current medical and OCP status, clinical examination, details of entropion repair surgery, and outcome.Results: Five patients (three female, two male) were included with ages ranging from 44 to 93 years. All had biopsy proven OCP, which was in remission at the time of surgery, and all were currently receiving immunomodulatory medications. All patients were symptomatic from cicatricial entropion secondary to OCP and underwent successful lower eyelid entropion repair with a conjunctival-sparing technique described herein, involving infraciliary rotation with suture fixation of the orbicularis muscle to the tarsus. Other contributing mechanisms of eyelid malposition including horizontal eyelid laxity and orbicularis oculi override were addressed simultaneously with lateral tarsal plication or orbicularis muscle debulking, resulting in 100% anatomic success and relief of symptoms with no cases of OCP reactivation, and with good durability with an average 13.9 months follow up (range 6.5-22 months).Conclusions: Successful repair of lower eyelid cicatricial entropion in immunomodulated patients with OCP can be achieved without disease reactivation using a surgical technique that spares the conjunctiva and lower eyelid retractors.

Oral mucosa grafting in periorbital reconstruction

To provide an extensive literature review on the clinical indications of oral mucosa grafts (OMG) and minor salivary gland grafts (MSGG) in periorbital reconstruction together with safe practice graft harvesting techniques to minimize donor-site morbidity. A literature review was performed by searching the databases of PUBMED, EMBASE, and COCHRANE library using the keywords: minor salivary glands; oral mucosal graft; orbit; and eye. The bibliographies of the pertinent articles were examined for additional papers. Indications for OMG include treatment of recurrent pterygia; socket contracture in anophthalmic patients; repair of eyelid deformities; ocular surface and fornix reconstruction following tumour resection, cicatricial ocular surface disorders, or chemical burns. More novel uses include repair of glaucoma aqueous drainage device erosions or leaking trabeculectomy blebs; scleral buckle exposure; and keratoprosthesis-related corneal melts as well as lining the dacryocystorhinostomy tract to prevent closure. Simultaneous MSGG transplantation may be used in the treatment of severe dry eyes or dry anophthalmic cavities. Harvesting from the inner cheek is preferred to lower lip as it causes less post-operative discomfort and neurosensory deficits. Suturing is recommended for smaller ovoid grafts as it allows less painful closure without tension, while larger rectangular defects are best left to heal by secondary intention. OMG and MSGG transplantation is a viable alternative to replace conjunctiva and restore the ocular surface. The donor site is readily accessible and widely available in most patients, grafting is fast and cheap, and the same site may undergo repeated harvesting with few donor site complications.

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.

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.

Acute and Chronic Ophthalmic Involvement in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis - A Comprehensive Review and Guide to Therapy. II. Ophthalmic Disease

Our purpose is to comprehensively review the state of the art with regard to Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), with particular attention to improving the management of associated ocular surface complications. SJS and TEN are two ends of a spectrum of immune-mediated disease, characterized in the acute phase by a febrile illness followed by skin and mucous membrane necrosis and detachment. Part I of this review focused on the systemic aspects of SJS/TEN and was published in the January 2016 issue of this journal. The purpose of Part II is to summarize the ocular manifestations and their management through all phases of SJS/TEN, from acute to chronic. We hope this effort will assist ophthalmologists in their management of SJS/TEN, so that patients with this complex and debilitating disease receive the best possible care and experience the most optimal outcomes in their vision and quality of life.

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.

Shared buccal mucosal graft for simultaneous repair of severe upper and lower eyelid cicatricial entropion

PURPOSE

Cicatricial entropion is typically an acquired condition that can affect the upper and lower eyelids. The purpose of this prospective study is to examine the effect of shared buccal mucosal grafts for simultaneous repair of severe upper and lower eyelid cicatricial entropion on eyelid position.

METHODS

Patients at the University of Texas-Southwestern Medical Center Aston Ophthalmology clinic were identified who were diagnosed with cicatricial entropion. Patients found to have severe upper and lower eyelid cicatricial entropion were included in the study if they had undergone or were scheduled to undergo simultaneous upper and lower eyelid repair through the use of a shared mucosal graft. Pre-operative exams which included pre-operative photos and description of eyelid position were performed. Shared mucosal graft surgery was performed. At post-operative week 1, the patients had splitting of their shared mucosal grafts. Post-operative photos as well as post-operative description of eyelid position were made at 6 weeks, 3 months, and 6 months.

RESULTS

At 6 months after surgical repair of severe upper and lower eyelid cicatricial entropion by shared mucosal grafts, patients were found to have resolution of entropic eyelid position as well improvement in ocular surface irritation. No adverse events were found and no graft failures occurred.

CONCLUSIONS

The use of a shared mucosal graft for the repair of severe upper and lower eyelid entropion, when sufficient tarsal structural support is present, is effective for the correction of eyelid malpositions and ocular surface irritation.

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.

Outcomes of lower eyelid cicatricial entropion with grey-line split, retractor recession, lateral-horn lysis, and anterior lamella repositioning

PURPOSE

To report indications and outcomes of a technique for the correction of lower eyelid cicatricial entropion using a lower eyelid gray-line split, inferior retractor recession, lateral-horn lysis, and anterior lamella repositioning.

PATIENTS AND METHODS

Retrospective, 5-year, single-center, consecutive case series of patients with lower eyelid cicatricial margin entropion undergoing the above procedure. Patients with significant inferior fornix contraction or symblepharon undergoing concurrent fornix reconstruction with buccal mucosal grafts at the same time as lamella repositioning were excluded. Outcomes were assessed based on the review of medical case notes and clinical photographs assessed independently. Success was defined by: 1) improvement in eyelid position and 2) improvement in lower eyelid retraction.

RESULTS

Twenty-one eyelids of 19 patients (mean age 57.7 ± 22.6 years, range 5-95 years, 8 men and 11 women) were included. The mean follow up was 27.4 ± 16.8 (range 3.2-59.6) months. The causes of cicatricial entropion were as follows: ocular cicatricial pemphigoid (6), Stevens-Johnson syndrome (3), previous eyelid reconstruction (2), socket scarring (2), thermal burn (1), chemical burn (3), postradiotherapy (1), and meibomian gland dysfunction (1). A second procedure was carried out in 38% (8/21) of eyelids within 1 year. Within 3 years, 10% (2/21) and 5% (1/21) of eyelids required a third and fourth procedure, respectively. The most common lower eyelid revision procedures included anterior lamellar repositioning. Other procedures required included buccal mucous membrane grafts, everting sutures, and lateral tarsorrhaphy. Three patients with loss of >50% inferior fornix depth were included. Two had previously undergone mucosal grafts and 2 required subsequent mucosal grafts. Overall, 90% (19/21) of eyelids eventually achieved improvement in lower eyelid position following repeat surgery, including mucosal grafts in 3 eyelids. Mid-pupil lower eyelid elevation was 1 mm in 6 of 19 (32%) patients and lower eyelid lateral retraction significantly improved in 9 of 19 (47%) patients.

CONCLUSION

Based on the principles of lamella repositioning and posterior middle lamella release with formal retractor recession through a gray-line incision, this technique is of value as a lash-preserving procedure in moderate-to-severe cicatricial lower eyelid entropion, particularly where tarsoconjuctival contraction or eyelid margin distortion exists.

Oral mucosal graft to correct lid margin pathologic features in cicatricial ocular surface diseases

PURPOSE

To evaluate the efficacy of oral mucosal graft to correct not only lid margin keratinization and trichiasis or distichiasis, but also incomplete closure in severe cicatricial ocular surface diseases.

DESIGN

Retrospective, noncomparative, interventional case series.

METHODS

Twenty-two eyes (39 eyelids) of 19 patients received an oral mucosal graft during lid margin reconstruction from September 2007 through February 2010. Relief of symptoms, conjunctival inflammation, corneal epithelial abnormalities, and visual acuity were compared before and after surgeries as outcome measures.

RESULTS

Among 22 eyes, 10 eyes (45.5%) had lid margin keratinization, trichiasis or distichiasis, or both, resulting in blink-related microtrauma. The oral mucosal graft resulted in successful correction in 6 eyes; in the remaining eyes, trichiasis in 3 eyes and distichiasis in 1 eye were away from the corneal surface. Incomplete closure present in 12 (54.5%) eyes was completely corrected in 9 eyes and was much improved in the remaining 3 eyes. During a mean follow-up of 16.2 months, reports of foreign body sensation, photophobia, pain, burning, tearing, and discharge were relieved significantly in 17 (77.3%) of 22 eyes. The visual acuity was improved in 13 eyes (59.1%) and was maintained in 8 eyes. Conjunctival inflammation was reduced markedly in 19 eyes (86.4%). Corneal epithelial defect and superficial punctate keratopathy were healed rapidly or improved in 14 eyes, and regression of superficial vascularization was noted in 1 eye.

CONCLUSIONS

Oral mucosal graft can reduce not only blink-related microtrauma caused by lid margin keratinization and trichiasis or distichiasis, but also exposure caused by cicatricially induced incomplete closure, thus preventing further deterioration of the ocular surface.