Fornix Reconstruction for Severe Symblepharon:

 
                  Figure 16A                                    Figure 16B

Transplantation of Cryopreserved Amnion Graft, Anchoring Sutures, and Oral Mucosal Graft/Conjunctival Graft:

For severe cases (judged by the vertical length measured from the limbus to the lid margin of the foreshortened fornix), the recessed symblepharon conjunctiva is not enough to cover the tarsal area (Fig. 16, after removing the cicatrix in gray, the original host conjunctiva is sealed to the Tenon and contiguous with an oral mucosal graft in brown and with cryopreserved amnion graft denoted in black, and secured by an anchoring suture in red as shown in the postoperative scheme (Fig.16B). Therefore, it is necessary to obtain a free cell-containing graft to substitute the tarsal conjunctiva. A conjunctival autograft is the natural choice if it is available from the same eye or the fellow eye. However, if it is not available, an oral mucosal graft from the mouth is the alternative. The size of conjunctival autograft or oral mucosal graft depends on the width of symblepharon.

To obtain an oral mucosal graft, the oral cavity is opened with two towel clamps and the oral mucosa is prepared with beta-iodine. Submucosal injections of 2% lidocaine with epinephrine are given using a 30 gauge needle. An incision is made into the oral mucosa with a superblade (Fig. 17A) and the free graft is dissected off with scissors (Fig. 17B), and soaked in gentamicin solution. After trimming off the stromal fat, the oral mucosal graft is sutured to the recessed conjunctiva with interrupted 8-O Vicryl sutures at each corner. The graft is attached to the tarsal plate with fibrin glue (Fig. 18A) and then further secured to the palpebral area by anchoring a double armed 4-O black silk suture to the edge of the mucosal graft and secured to the skin with a bolster made of 25 gauge butterfly tubing (Fig. 18B). One anchoring suture is needed per quadrant. The remaining bare sclera and bare palpebral area is covered with cryopreserved amnion graft in the same manner as described for moderate cases.

To minimize the eye exposure for severe cases where a large bulbar sclera is covered by cryopreserved amnion graft, it is advised that the eye is closed with 4-O black silk suture passing through the bolster (Fig. 19).

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