Fornix Reconstruction

Overview:

The conjunctival tissue starts from the limbus and ends in the lid margin. According to the anatomic location, the conjunctiva can be subdivided into the bulbar and palpebral portions; palpebral conjunctiva can further be subdivided into tarsal and forniceal portions. Under normal circumstances, the fornix is deep creating a tear reservoir for the formation of a tear meniscus. A normal, deep fornix also helps provide a full range of ocular motility when there is a natural, smooth contact between the lid and globe during the blink. Collectively, it helps maintain a stable tear film and a healthy ocular surface.

Obliteration or foreshortening of the fornix by a symblepharon due to scar tissue (cicatrix) may result in ocular surface failure. The pathogenic elements include: sicca due to the depletion of the tear flow and spread; blink-related microtrauma due to cicatricial entropion, lid margin/tarsal keratinization/scarring or misdirected lashes; exposure due to inadequate blinking and closure; entropion and ptosis; and restriction of ocular motility.

When symblepharon develops in the superotemporal fornix, severe sicca can develop by the blockage of the lacrimal gland. When symblepharon develops in the inferior fornix, nocturnal corneal exposure may further develop due to the loss of the Bell’s phenomenon during sleep. Although there are diverse causes for developing symblephara, inflammation is invariably the common denominator. If uncontrolled, inflammation can progressively cause additional scarring worsening the symblepharon and fornix obliteration.

Depending on the location and severity of symblepharon, fornix obliteration can be pathogenic and even give rise to severe visual loss. In moderate to extreme situations, fornix obliteration may cause difficulties for contact/scleral lens insertion and wear; result in ankyloblepharon and socket contraction. All potential pathogenic elements of symblepharon are summarized below.

Pathogenic Elements of Symblepharon
1. Causing Dry Eye                                 Obliteration of lacrimal excretory ductules

2. Contributing to Dry Eye                       Obliteration of tear meniscus, interference 
                                                                   with lid blinking and closure

3. Causing Blink-related Microtrauma       Cicatricial entropion together with
                                                                  abnormal lid margins, tarsi and lashes

4. Causing Diplopia                                 Restriction of ocular motility

5. Causing Decreased Vision                    Cicatricial ptosis and symblepharon 
                                                                  extending to the cornea
6. Partaking in Ocular Surface Failure       Carrying uncontrolled inflammation

7. Interfering with Contact (Scleral)          Ankyloblepharon or socket contraction
        Lens Wear

Written Surgical Information:

Stages of Symblepharon
Symblepharon Management
Surgical Supplies
Surgical Technique
    For Mild Symblepharon
    For Moderate Symblepharon
    For Severe Symblepharon
Post-Operative Points
Literature Summary
Frequently Asked Questions

Click here to download the illustrated written surgical guide on Fornix Reconstruction.

Instructional Videos:

Video: Surgical Step Overview: Step-by-Step video reviewing the surgical procedure of treating symblepharon lysis with fornix reconstruction using fibrin glue OSREF Fornix Reconstruction Surgical Overview

Video: Technique for Moderate Symblepharon:Video of sealing the Space Between the Conjunctiva and Tenon's Capsule with Fibrin Glue

Video: Technique for Moderate Symblepharon including covering the muscle: Video of fornix reconstruction and covering the muscle using amniotic membrane an fibrin glue for symblepharon lysis with motility restriction.

Video: Fornix Reconstruction for Late Stage Chemical Burn Surgical 1: Video of a fornix reconstruction procedure for late stage treatment for a chemical burn using amniotic membrane without sutures OSREF Fornix Reconstruction Surgery Sample 1

Video: Fornix Reconstruction for Late Stage Chemical Burn Surgical 2: Video of a fornix reconstruction procedure for a patient with severe ankyloblepharon, cicatricial entropion, and trichiasis; an oral mucosa graft is harvested and affixed with sutures and amniotic membrane is affixed with fibrin glue to reconstruct the fornix and ocular surface OSREF Fornix Reconstruction Surgery Sample 2

Video: Late Stage Chemical Burn Treatment: Review of late stage treatment for a chemical burn using patient photos OSREF Late Stage Chemical Burn Case Discussion

Videos edited by:
Scheffer C.G. Tseng, MD, PhD
Hosam Sheha, MD, PhD
Ahmad Kheirkhah, MD
Antonio Elizondo, MD
Victoria Casas, MD

If you have additional surgical questions after viewing this information, contact OSREF’s Research Director, Scheffer C.G. Tseng, MD, PhD, by e-mail at stseng@ocularsurface.comor by phone at 305-274-1299.