Fornix Reconstruction Surgical Technique

In general, the surgical approach is formulated based on the severity of symblepharon according to the grading system described. In principle, the grading of the vertical length affects the necessity of using anchoring sutures to the lid skin and/or additional transplantation of oral mucosal graft; the grading of the horizontal width affects the size of conjunctival autograft (if possible), oral mucosal graft or cryopreserved amnion graft; and the grading of location and severity of the inflammatory activity affects the site and the duration of intraoperative application of MMC.

Key Surgical Steps

Anesthesia:

Topical anesthesia with 2% lidocaine gel under intravenous sedation is preferred for mild cases. General anesthesia is preferred for moderate to severe cases in which traction sutures to open the eyelids without a speculum, more extensive excision, an oral mucosal graft, or anchoring sutures are required.

Preparation of the Eye:

After standard prep and drape of the eye, a speculum is inserted for mild cases. In moderate to severe cases, one 4-O black silk suture is placed at each lid margin as a traction suture to open the eye if the speculum cannot be inserted (Fig. 5). Several drops of non-preserved 1:1000 epinephrine (Hospira, Inc., Lakes Forest, IL) are applied on the entire ocular surface to achieve vasoconstriction for subsequent hemostasis.

Incision, Traction Suture and Excision of Cicatrix:

Circumlunar incision (like peritomy) starts from the perilimbal region between the normal conjunctiva and the beginning of the symblepharon (Fig. 6). Relaxing incisions are made extending toward the fornix along the border of symblepharon (Fig. 7). A traction suture made of double-armed 7-O polyglactin (Vicryl, Ethicon Inc., Johnson & Johnson, Somerville, NJ) is placed near the exposed bulbar sclera, and the eye is rotated opposite to the vertical axis of symblepharon, allowing better exposure of symblepharon and subsequent excision of cicatrix (Fig. 8).

With the assistant grabbing the tip of the symblepharon, the cicatrix, which consists of scar and thickened fibrovascular tissue included in the Tenons capsule, is dissected away from the epithelial tissue of the symblepharon and amputated at the base using scissors near either the fornix or the tarsus (Fig. 9A-9C). This step invariably results in further recession of the symblepharon epithelial tissue to the fornix, leaving a larger bare bulbar sclera. The epithelial lining tissue is intentionally saved for reconstructing the palpebral conjunctiva. The thoroughness of cicatrix removal can be judged by the free motility of the globe under the traction suture.

Intraoperative Application of Mitomycin C:

With the exception of cases without inflammation, nearly all symblephara need intraoperative application of 0.04% MMC delivered via soaked sponges. The MMC sponges are inserted at the base where cicatrix is amputated (Fig. 10, arrow marks the inserted sponge). The duration of MMC application depends on the severity of inflammatory activity. For those graded as 3+, MMC is applied for 5 min; for those graded as 2+, MMC is applied for 4 min; and for those graded as 1+, MMC is applied for 3 min. During incubation, the inserted sponge is covered by the recessed symblepharon tissue. The traction suture helps pull the bulbar sclera away from being exposed to the MMC sponges. Periodically dry the bulbar sclera with a dry Weckcell sponge. After incubation, the sponges are removed and counted, and the contact area is thoroughly rinsed with BSS (half a bottle).

 
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              Mild Symblepharon                          Moderate Symblepharon                    Severe Symblepharon

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