Fornix Reconstruction Surgical Technique for Mild Symblepharon
Figure 11A Figure 11B
Transplantation of Cryopreserved Amnion Graft Alone:
For mild cases (judged by the vertical length measured from the limbus to the lid margin of the foreshortened fornix), the recessed symblepharon conjunctiva is large enough to be used to cover the entire palpebral conjunctiva (Fig. 11, after removing the cicatrix in gray, the original host conjunctiva in green in the preoperative scheme (Fig. 11A) is recessed in the postoperative scheme (Fig. 11B) and contiguous with cryopreserved amnion graft denoted in black). First, attach the recessed conjunctiva to the palpebral area using fibrin glue with the two components applied separately. The remaining bare bulbar sclera is covered with cryopreserved amnion graft also using fibrin glue as follows.
Peel the amnion graft from the nitrocellulose filter paper and lay it down on the defect with the sticky, stromal surface down to cover the entire bare sclera. Use 0.12 forceps to flip half of amnion graft onto the other half to allow half of the stromal surface to face upwards (Fig. 12A). Apply the thrombin (watery, colorless) solution to the bare sclera adjacent to the folded graft (Fig. 12B). Then apply the fibrinogen (viscous, tawny) solution on the stromal surface of folded graft (Fig. 12C). Flip the graft back on the sclera and a muscle hook is used to spread the fibrin glue into an even and thin layer under the amnion graft (Fig. 12D). These steps are repeated for the other half of the amnion graft to cover the entire sclera. Check the graft edges using 0.12 forceps to make sure they are secure. If not, apply small drops of both components to secure any loose areas. Trim off any excess membrane graft and fibrin gel to make the graft flush with the conjunctival edge.
If sutures are used instead, 10-O nylon sutures are placed interruptedly to secure the amnion graft to the limbal and bulbar sclera, while 8-O Vicryl sutures are placed interruptedly to secure the recessed conjunctival tissue over the amnion graft with episcleral bites parallel to (but not perpendicular to) the forniceal line.
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