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L. Rubinate, M. N. Welch, A. J. Johnson, S. L. DeMartelaere; New Technique for Manufacture and Placement of Enlarged Symblepharon Ring With Amniotic Membrane Transplantation for Ocular Surface Protection in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Invest. Ophthalmol. Vis. Sci. 2010;51(13):1135.
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Describe a surgical technique for reduced surgical time and the manufacture and placement of an enlarged symblepharon ring during amniotic membrane placement in patients with ocular surface disease from Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis.
Noncomparative, consecutive interventional case series in which ten eyes in five patients being treated for Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis underwent symblepharon release and placement of amniotic membrane over the entire surface of the eyelid margins, palpebral conjunctiva, deep fornices, bulbar conjunctiva, and cornea. Eyelashes were trimmed in all patients, and three 3.5cm amniotic membrane grafts were thawed and arranged in a 3.5x10.5cm rectangle and the edges sutured together with 10-0 nylon on a spatulated needle under an operating microscope. The height and width of the palpebral fissure and the distance from the eyelid margins to the superior and inferior fornices were measured to determine dimensions necessary for a custom-sized conformer. The ring was formed using to the custom dimension of each eye using IV tubing. The amniotic membrane sheet was then placed stromal side down over the eye, draped over the eyelid with redundancy present at the fornices of both eyes. The custom conformer was then slipped under the patients’ lids and over the amniotic membrane, such that the amniotic membrane was folded onto the custom conformer, thus covering the entire conjunctival surface with amniotic membrane using the custom conformer to push the amniotic membrane into the fornices. At this point a running 8-0 Vicryl suture was used at the lid margins to secure the amniotic membrane, and the excess membrane was trimmed. This is a modification of a technique decribed by Gregory in The Ocular Surface in 2008.
All eyes achieved reepithelialization within 1 week and resolved inflammation of mucosal surfaces within 2 weeks. All eyes maintained visual acuity, ocular surface wetting, and were without symblepharon and pain-free 6 months after surgery.
This application technique allows a 25-30% reduction in surgical time and provides improved coverage of the deep fornices which may better prevent future symblepharon.
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