Fornix Reconstruction for Moderate Symblepharon
Transplantation of Cryopreserved Amnion Graft and Anchoring Sutures:
Figure 13 A Figure 13 B
For moderate cases (judged by the vertical length measured from the limbus to the lid margin of the foreshortened fornix), there is enough recessed symblepharon conjunctiva to cover the tarsal area but not large enough to cover the entire palpebral area. (Fig. 13, after removing the cicatrix in gray, the original host conjunctiva in green in the preoperative scheme (Fig. 13A) is recessed in the postoperative scheme (Fig. 13B) and contiguous with cryopreserved amnion graft denoted in black, and is secured to the tarsus by an anchoring suture in red). The space between the recessed conjunctiva and the Tenon is sealed by fibrin glue and then secured by an anchoring suture (double armed 4-0 black silk) toward the palpebral lid skin with a bolster made of 25 gauge butterfly tubing (Fig. 14A-C). One such anchoring suture is needed per quadrant. The remaining bare sclera and bare palpebral area is covered by cryopreserved amnion graft using the following steps.
After it is removed from the filter paper, the amnion graft is laid down to cover the entire bare area with reflection made at the fornix. The portion of the membrane laid on the bulbar sclera is first attached with fibrin glue using the steps described in the mild symblepharon section. The portion of the graft supposed to be attached to the palpebral area is first flipped on the graft attached onto the bulbar sclera with the stromal surface facing up (Fig. 15A). After the two components of fibrin glue are applied on the flipped surface, a muscle hook is used to glide this flipped membrane toward the fornix and continuously upward to reach the recessed symblepharon conjunctiva which is now anchored by 4-O black silk (Fig. 15B). Use 0.12 forceps to check the edges to make sure the graft is not detachable. If it is, an additional touch up by applying drops of both components of the fibrin glue is needed. The excessive graft and fibrin gel are trimmed off to make the membrane flush with the conjunctival edge.
Video:
Technique for Moderate Symblepharon:Video of sealing the Space Between the Conjunctiva and Tenon's Capsule with Fibrin Glue
Technique for Moderate Symblepharon including a Muscle Wrap: Video of fornix reconstruction and muscle wrap using amniotic membrane an fibrin glue for symblepharon lysis with motility restriction.
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