Scleral Graft, Free Conjunctival Autograft Using Tissue Adhesive and Temporary Amniotic Membrane Transplantation in Scleromalacia

Won Suk Choi; Gwang Ja Lee; Young Jeung Park; Kyoo Won Lee

doi:10.3341/jkos.2011.52.12.1405

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Choi, Lee, Park, and Lee: Scleral Graft, Free Conjunctival Autograft Using Tissue Adhesive and Temporary Amniotic Membrane Transplantation in Scleromalacia

Original Article

J Korean Ophthalmol Soc 2011;52(12):1405-1413.

Published online: 7 September 2011

DOI: https://doi.org/10.3341/jkos.2011.52.12.1405

Scleral Graft, Free Conjunctival Autograft Using Tissue Adhesive and Temporary Amniotic Membrane Transplantation in Scleromalacia

Won Suk Choi, MD, Gwang Ja Lee, MD, PhD, Young Jeung Park, MD, PhD, Kyoo Won Lee, MD, PhD

Cheil Eye Hospital, Daegu, Korea

Address reprint requests to Young Jeung Park, MD, PhD Cheil Eye Hospital #803-2 Sinam-dong, Dong-gu, Daegu 701-011, Korea Tel: 82-53-959-1751, Fax: 82-53-959-1758, E-mail: eyepark9@dreamwiz.com

Received 7 February 201118 June 2011 Accepted 18 October 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the surgical results and complications arising from scleral graft and free conjunctival autograft using tissue adhesive and temporary amniotic membrane transplantation as the surgical treatment for scleromalacia.

Methods

Scleral graft and free conjunctival autograft using tissue adhesive and temporary amniotic membrane transplantation was performed in 20 eyes of 20 patients with scleromalacia caused by pterygium excision. The surgical results and complications arising from the procedure were monitored and analyzed through followup.

Results

During the followup period of 17.6 ± 5.9 months, the wound injection and edema at the free conjunctival autograft and operation site healed in all the cases except 1 at postoperative 1 month. The stability of the ocular surface for graft transplantation was maintained at postoperative 3 months. Although a partial absorption of the conjunctival autograft induced by careless treatment occurred 2 weeks postoperative in 1 case, the ocular surface stabilized due to suitable treatment after 6 months. Although the edges of the scleral graft in 3 patients were partially absorbed 6 months postoperatively, the ocular surface stability was maintained by covering the conjunctival autografts.

Conclusions

For scleromalacia patients, scleral graft and free conjunctival autograft using tissue adhesive and temporary amniotic membrane transplantation rapidly stabilized the ocular surface and presented excellent aesthetic results.

Keywords: Fibrin glue, Free conjunctival autograft, Scleral graft, Scleromalacia

References

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Figure 1.

Surgical procedures of scleral graft, free conjunctival autograft using tissue adhesive (Tissucol Duo Quick®, Baxter AG, Vienna, Austria) and temporary amniotic membrane patching in scleromalacia. (A-D) After debridement of the necrotic and surrounding sclera tissue, a scleral graft of appropriate size was prepared. Fibrin tissue adhesive, Tissucol Duo Quick® was used to at-tach the precisely cut-to-fit scleral graft to the recipient site. (E-G) A free conjunctival autograft from the superior palpebral conjunctiva was prepared making sure it was a little larger than the scleral defect size. The conjunctival autograft and the recipient site were attached in the following manner: Tissucol Duo Quick® was applied to the recipient site and the conjunctival autograft was pressed firmly on to it making sure all the edges were matched with no conjunctival surfaces exposed. Then, the recipient site and conjunctival autograft were sutured with 10-0 nylon at 4 points. (H-I) A temporary amniotic membrane was sutured on top of the conjunctival autograft to protect and facilitate the healing of the implanted scleral graft and conjunctival autograft. It was removed 5 to 7 days after the operation.

Figure 2.

Photographs of patients undergoing free conjunctival autograft with scleral graft for restoration of scleromalacia. (A, B, C-1) Preoperative photographs show scleral thinning with exposed uveal tissue at the previous pterygium excision site. (A, B, C-2) In all cases, scleral grafts were completely covered by conjunctival autograft and injections and edemas of free conjunctival autografts decreased in the 3 month postoperative photographs. (A, B, C-3) Last followup photographs showed stable ocular surface and absence of irregular fibrovascular proliferations.

Figure 3.

A case photograph of scleromalacia in a 55 years old female after free conjunctival autograft with sclera graft. (A) Preoperative photograph showed sclera thinning with exposed uveal tissue and a severe avascular sclera bed at the site of previous pterygium excision. (B) Postoperative photograph at 2 weeks showed partial melting of the free conjunctival autograft due to steroid eye drop use following the operation (C) Postoperative photograph at 6 months showed partial absorption of the sclera graft and conjunctival autograft. (D-1, 2) Last followup photographs (18 months postop) showed relatively stable ocular surface with vascularized scleral bed and reepithelialization of the conjunctival autograft despite the additional absorption of the sclera graft.

Figure 4.

Photographs of scleral graft edge partial absorption after free conjuntival autograft with scleral graft. (A, B-1) Preoperative photographs show scleral thinning with exposed uveal tissue at the sites of previous pterygium excision. (A, B-2) Scleral grafts were completely covered by free conjunctival autografts and edemas of conjunctival autografts decreased in postoperative photographs at 3 months. (A, B-3) Stable ocular surfaces, with complete coverage of conjunctival autograft were shown despite the partial absorptions of the scleral grafts edges (black arrow) in postoperative 6 to 12 months photographs.

Figure 5.

Excessive vascularization (black arrow) at donor site in free conjunctival autograft with scleral graft for restoration of scleromalacia.

Table 1.

Clinical characteristics, outcomes and complications of patients undergoing free conjunctival autograft with scleral graft for repair of scleromalacia

Case number	Sex/age	Pterygium exision (years ago)	MMC treatment	Followup (mon)	Preoperative visual acuity (log MAR)	Postoperative visual acuity (log MAR)	Surgical success	Complication
1	M/73	Unknown	Unknown	20	0.5	0.2	Stable	None
2	F/65	Unknown	+	12	0.4	0.5	Stable	PS
3	M/62	3	Unknown	24	0.1	0.2	Stable	EV
4	F/55	2	Unknown	18	0.2	0.3	Relatively Stable	PSFCA
5	F/51	4	+	19	0.2	0.1	Stable	PS
6	F/75	19	Unknown	12	0.5	0.4	Stable	None
7	F/73	5	Unknown	12	0.7	0.5	Stable	None
8	F/69	2	+	29	0.4	0.4	Stable	None
9	F/74	8	Unknown	20	0.3	0.1	Stable	None
10	M/70	Unknown	+	18	0.3	0.2	Stable	None
11	F/77	9	Unknown	10	0.5	0.4	Stable	None
12	F/61	9	+	12	0.2	0.2	Stable	None
13	F/60	8	Unknown	25	0.2	0.1	Stable	None
14	F/70	Unknown	Unknown	27	0.3	0.3	Stable	None
15	F/78	Unknown	Unknown	18	0.3	0.2	Stable	PS
16	F/63	10	Unknown	25	0.2	0	Stable	None
17	F/73	10	Unknown	12	0.4	0.3	Stable	None
18	M/67	1	Unknown	12	0.2	0.3	Stable	None
19	F/59	Unknown	Unknown	12	0.2	0.4	Stable	None
20	F/61	7	Unknown	12	0.3	0.2	Stable	None

MMC = mitomycin C; PS = partial absorption of scleral graft; EV = excessive vascularization on donor site; PSFCA = partial absorption of scleral graft and free conjunctival autograft.

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