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A. Kheirkhah, V.-K. Raju, S. C. G. Tseng; Surgical Strategies for Fornix Reconstruction Based on Symblepharon Severity. Invest. Ophthalmol. Vis. Sci. 2008;49(13):2366. doi: https://doi.org/.
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Pathogenic symblepharon threatens ocular surface health and vision. We sought to identify key surgical strategies that are useful for correcting symblepharon with different severities.
We retrospectively reviewed 61 eyes with symblepharon from 47 patients (30 males and 17 females with a mean age of 44.6 ± 19.3 years) caused by Stevens-Johnson syndrome (n=26), chemical burn (n=19), chronic cicatricial conjunctivitis (n=9), recurrent pterygium (n=3), mucous membrane pemphigoid (n=2), pesudopemphigoid (n=1), and multiple previous surgeries (n=1). The severity of symblepharon was graded according to the length from the lid margin to the limbus, the horizontal width, and the underlying inflammatory activity. They all had undergone cicatrix lysis and amniotic membrane transplantation (AMT) using sutures (n=34) or fibrin glue (n=27) together with (n=46) or without (n=15) intraoperative application of MMC, plus the following additional modalities: fornix reconstruction using anchoring sutures (n=31) or oral mucosal graft (n=7), and a follow up of at least 12 months. Complete success was defined if an anatomically deep fornix without scar or motility restriction was restored, partial success if there was focal occurrence of scar tissue, whereas failure if symblepharon returned.
For a mean follow-up of 24.9 ± 10.8 months, the overall complete and partial success rate was 85.2%. For Grade I (n=17), complete and partial successes were obtained in 16 eyes (94.1%) by AMT alone (n=13, 76.5%) or with additional anchoring sutures (n=3, 17.6%). For Grade II (n=26), complete and partial successes were noted in 20 eyes (76.9%) by AMT alone (n=6, 23.1%) or with additional anchoring sutures (n=14, 53.8%). For Grade III (n=9), complete and partial successes were achieved in 7 eyes (77.8%) by AMT alone (n=3, 33.3%), with additional anchoring sutures alone (n=2, 22.2%) or with additional oral mucosa graft (n=2, 22.2%). For Grade IV (ankyloblepharon, n=9), complete and partial successes were found in 9 eyes (100%) by fornix reconstruction using anchoring sutures alone (n=4, 44%) or with additional oral mucosa graft (n=5, 55.6%).
Successful outcome can be achieved by deploying surgical strategies based on the severity of pathogenic symblepharon. These include cicatrix lysis and AMT with additional anchoring sutures and/or oral mucosal graft. Such reconstructive measures are prerequisite for restoring ocular surface health and ensure the success for subsequent limbal stem cell transplantation.
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