Fornix Reconstruction Literature Summary
Traditionally, fornix reconstruction involves symblepharon lysis and cicatrix removal followed by measures taken to prevent readhesion (reformation of symblepharon). The efforts toward latter include insertion of conformers, (1) silicone rubber sheets, (2) or plastic.(3) It is also believed that these measures can postpone but not prevent regrowth of symblepharon. To augment the success, transplantation of such tissues as a pedicle graft from skin, (4) and full-thickness mucous membrane graft (5) have been attempted to prevent symblepharon reformation.
A conjunctival autograft is the best free graft option for reconstruction when there is enough healthy conjunctival tissue available. Tseng et al (6) first showed that cryopreserved amnion grafts can be considered as an alternative substrate for conjunctival surface reconstruction during the removal of large conjunctival lesions, scars or symblepharon. Using sutures to anchor cryopreserved amnion graft, 5 of 16 eyes (31%) showed partial success or failure due to persistent host conjunctival inflammation.
Prabhasawat and Tesavibul (7) noted a success rate of 54% in 13 eyes with symblepharon. Katircioglu et al (8) reported that 1 of 6 eyes (17%) with chemical burns failed because there was no healthy host conjunctiva before surgery. Oberhansli and Spahn (9) reported that 8 of 48 eyes (17%) failed to achieve a deep fornix due to progressive retraction.
Solomon et al (10) introduced anchoring sutures to achieve 12 of 17 eyes (71%) success in fornix reconstruction. The remaining failed cases had underlying causes such as autoimmune disorders or recurrent pterygium.
Barabino et al (11) used the same approach together with systemic immunosuppression and reported 100% success rate in 9 eyes with mucous membrane pemphigoid for the first 16 weeks of follow up. A small area of symblepharon returned in 4 eyes (44%) in 28 weeks.
Recently, Tseng et al (12) added the intraoperative application of MMC to the subconjunctival space in the fornix to the above procedure and reported that all 18 eyes (100%) regained a deep fornix and continuous tear meniscus, but 3 of 12 eyes (25%) with motility restriction showed recurrence of partial motility restriction. Most notable was a combination of transplantation of cryopreserved amnion graft, anchoring sutures and intraoperative application of MMC which achieved a deep fornix in all 6 eyes with prior mucous membrane graft. Nava-Castaneda et al (13) also confirmed that additional use of intraoperative MMC significantly enhanced the success of transplantation of cryopreserved amnion graft.
References:
1. Lubkin V, Hughes WL. The fornix conformer; a new device in reconstruction of the fornices. Arch Ophthalmol. 1959;61:248.
2. Ralph RA. Reconstruction of conjunctival fornices using silicone rubber sheets. Ophthalmic Surg. 1975;6:55-57.
3. Piffaretti JM. Problems of conjunctival closure after fornixplasty. Klin Monatsbl Augenheilkd. 1978;172:530-533.
4. Shukla KN. Reconstruction of the lower fornix by a pedicle graft from skin of the upper lid. Am J Ophthalmol. 1953;36:694-697.
5. Karesh JW, Putterman AM. Reconstruction of the partially contracted ocular socket or fornix. Arch Ophthalmol. 1988;106:552-556.
6. Tseng SCG, Prabhasawat P, Lee S-H. Amniotic membrane transplantation for conjunctival surface reconstruction. Am J Ophthalmol. 1997;124:765-774.
7. Prabhasawat P, Tesavibul N. Preserved amniotic membrane transplantation for conjunctival surface reconstruction. Cell Tissue Bank. 2001;2:31-39.
8. Katircioglu YA, Budak K, Salvarli S, Dumn S. Amniotic membrane transplantation to reconstruct the conjunctival surface in cases of chemical burn. Jap J Ophthalmol. 2003;47:519-22.
9. Oberhansli C, Spahn B. Amniotic membrane transplantation for oculopalpebral and reconstructive surgery. J Fr Ophtalmol. 2005;28:759-764.
10. Solomon A, Espana EM, Tseng SCG. Amniotic membrane transplantation for reconstruction of the conjunctival fornices. Ophthalmology. 2003;110:93-100.
11. Barabino S, Rolando M, Bentivoglio G, Mingari C, Zanardi S, Bellomo R, Calabria G. Role of amniotic membrane transplantation for conjunctival reconstruction in ocularcicatricial pemphigoid. Ophthalmology. 2003;110:474-480.
12. Tseng SCG, Di Pascuale MA, Liu D-Z, GAO Y-Y, Baradaran-Rafii A. Intraoperative mitomycin C and amniotic membrane transplantation for fornix reconstruction in severe cicatricial ocular surface diseases. Ophthalmology. 2005;112:896-903.
13. Nava-Castaneda A, Tovila-Canales JL, Monroy-Serrano MH,et al Comparative study of amniotic membrane transplantation, with and without simultaneous application of mitomycin C in conjunctival fornix reconstruction. Arch Soc Esp Oftalmol. 2005;80:345-352.
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