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Reconstruction of the Periocular Mucous Membrane by Autologous Conjunctival Transplantation
Reconstruction of the Periocular Mucous Membrane
by Autologous Conjunctival Transplantation
DA VID W. VASTINE, MD, WILLIAM B. STEWART, MD, IVAN R. SCHWAB, MD
Abstract: We have extended the concept of autologous conjunctival transplantation for corneal resurfacing as recommended by Thoft' to reconstruction in 14 patients with unilateral abnormalities of the bulbar and palpebral conjunctiva caused by alkali burns (2), irradiation (2), neoplasms (3), degenerative diseases (5), trauma (1), and developmental anomalies (1). Large, free conjunctival grafts from bulbar and forniceal donor sites were used. No complications have been noted at the recipient or donor sites. Grafts of normal conjunctiva provided intact basement membrane, goblet cells, and epithelium that help restore normal ocular and lid surfaces. The use of free conjunctival grafts provides significant advantage over the use of buccal mucous membrane grafts. The techniques and results of our experience with free conjunctival grafts in 14 patients are discussed. [Key words: alkali burns, anterior segment reconstruction, conjunctiva, cornea, donor, recipient, symblepharon, transplantation.] Ophthalmology 89: 1072-1 081, 1982
Many donor sites have been employed when mucous membrane grafts are necessary for reconstruction of the conjunctival cul-de-sac and associated deformities. Most widely used has been buccal or labial mucous membrane from the mouth. This technique is successful in some cases, but frequently these grafts contract, scarring and shrinking in some situations so vigorously that symblepharon rings may be extruded. The patients may be left with residual lid deformities, foreshortened fornices, and thick, erythematous grafts that are cosmetically unacceptable and functionally less than ideal. The surface cells of these grafts do not
transform into normal conjunctival and corneal epithelial cells. Stimulated by Thoft' s l,2 reports on the use of conjunctiva for corneal re-epithelialization following ocular chemical injury, we have explored application of autologous conjunctival tissue for reconstruction of the associated conjunctival sequelae of chemical burns and other ocular diseases. Large autologous conjunctival grafts have been used by our group to reconstruct the conjunctiva following severe radiation and chemical burns, trauma, resection of tumors, excision of pterygium, and to repair congenital abnormalities.
From the Cornea-External Disease and the OphthalmiC Plastic Reconstructive and Orbital Surgery Services of the Department of Ophthalmology PaCifiC Medical Center, San FrancIsco, California
METHODS
Repnnt request to DaVid W. Vastine, MD, Department of Ophthalmology, PaCifiC Medical Center, 2340 Clay Street, San FrancIsco, CA 94115
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All patients selected for this study had significant ophthalmic disease. The following general procedures were employed in surgical management. 0161-6420/82/0900/1072/$1.30
© American Academy of Ophthalmology
VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
Complete eXCISIOn of the disease process and release of conjunctival restrictions to ocular or lid movement were accomplished initially. Measurements of the mucous membrane defect were then taken. Selection of donor tissue site was based on two major considerations. In cases requiring small fullthickness donor conjunctiva, such as patients with pterygium or small symblepharon, normal conjunctiva could be harvested from the ipsilateral eye. The site preferred was the superotemporal bulbar conjunctiva that is protected by the lid from irritation by light and from exposure to environmental irritants. The superonasal and inferotemporal bulbar and forniceal conjunctiva can also be used for small donor patches. The ipsilateral donor site is useful only if the tissue is normal. In cases requiring extensive reconstruction, as in large recurrent pterygium, unilateral chemical injuries and in tumor resection or reconstruction after surgical excision with resultant cicatricial abnormalities, the opposite eyes are used for donor sites. The superotemporal and superonasal bulbar conjunctiva is preferred, but the inferior bulbar and forniceal conjunctiva can be used if necessary. The donor sites were dissected carefully under high loupe magnification or microscopic control. Care was taken to harvest only the mucosal conjunctival surface. The submucosal connective tissue and Tenon's fascia were dissected carefully from the posterior surface. Large sections of conjunctiva were harvested up to 15 mm by 20 mm as single or multiple patches. Saline or 0.5-1% Xylocaine with 1:200,000 epinephrine can be used to balloon the submucosal tissue to make dissection easier. A 4- to 5-mm rim of normal tissue was always left at the limbus. When taking two patches from the superior bulbar conjunctiva, a 4- to 5mm strip of normal conjunctiva was left over the superior rectus muscle. The posterior dissection into the fornix was stopped at the apex of the cul-de-sac. Because the bulbar conjunctiva is redundant during excision, the donor conjunctiva should be stretched and measured with a calipers or a ruler to approximate the size of patch necessary to cover the defect. Care was taken in transposing the graft not to invert it. Fixation of the donor patches to the conjunctival edges and to the episclera was accomplished with various types of suture materials. We used 10-0 nylon or 8 - 0 chromic collagen most frequently. The chromic collagen causes minimal reaction and is absorbed. The 10-0 nylon frequently needs removal in the postoperative period. On long-term follow-up, the collagen has proved quicker and easier to use with no associated adverse sequelae.
CASE REPORTS Fourteen patients have been operated upon using conjunctival transplantation. Five representative pa-
tients will be described in detail to illustrate the indications, approach, and outcome in our series. The entire series is summarized in Table 1. Case 1. A 45-year-old white man had liquid ammonia thrown in his right eye in December 1979. Four months after injury, foreshortening of the superior cul-de-sac and two granulomas at the superior limbus were present with an associated chronic central corneal epithelial defect. On eversion of the right upper eyelid, the tarsus was found to be distorted markedly. The superior border of the tarsus was adherent to the limbus adjacent to the granulomas (Fig 1). The visual acuity of the eye was light perception. The patient had extensive resection of the conjunctival symblepharon, the granulomas and associated hypertrophied Tenon's capsule superiorly, as well as a 3- to 5-mm strip of abnormal conjunctiva and scar tissue around the entire limbus. The superior dissection was continued over the superior rectus muscle insertion and approximately 4- 5 mm on either side of the muscle. The donor conjunctive was obtained from the left eye. Three donor sites were employed: superotemporal and superonasal bulbar conjunctiva, and inferotemporal bulbar conjunctiva extending into the fornix. One free patch graft was used to cover the superior 100° of the corneal limbus and the insertion of the superior rectus muscle. The second graft was placed over the superior palpebral conjunctival defect. It was sutured to the remaining conjunctiva on the tarsus. The superior edge was sutured deep into the cul-de-sac by everting the lid. These two grafts created a deep superior cul-de-sac. A third smaller patch of conjunctiva was bisected and placed over the inferior nasal and inferior-temporal aspects of the corneal limbus. On the first and second postoperative days, full extraocular muscle motility was possible without restriction, and the upper eyelid could be everted. Over the subsequent year, the vascular hyperemia of the conjunctival grafts regressed, and the cornea cleared with regression of the superficial and deep vessels. The conjunctival transplant resembled normal tissue. The upper lid was of normal configuration with no evidence of shrinkage of the superior fornix, distortion of the tarsus, or recurrence of symblepharon. (Fig 2). The donor sites in the left eye, which were not closed, healed without complication. Case 2. A 14-year-old Mexican-American boy had whitewash alkali splashed into his right eye at approximately 6 years of age. His visual acuity was light perception with color perception in the right eye and 20/20 in the left eye. A large symblepharon was present extending from the mid-tarsal plate to the superior limbus from approximately 11:30 to 1:30 o'clock (Fig 3). This large symblepharon restricted down and medial gaze. There was an opening behind the symblepharon deep in the superior cul-de-sac. Slit-lamp examination revealed a totally opaque cornea. The iris was
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OPHTHALMOLOGY. SEPTEMBER 1982 • VOLUME 89 • NUMBER 9
Table 1. Summary of Patients Undergoing Autologous Conjunctival Transplantation
Diagnosis
Preop Vision
Operative procedure Location of Donor Site Resection of perilimbal tissue and fibrovascular perilimbal corneal tissue. Resection of extensive upper cul-de-sac fibrosis and symblepharon, including hypertrophied Tenon's down to superior rectus muscle. Three donor sites from supero-nasal and temporal and inferior temporal quadrants of left eye used to resurface all bare areas except central cornea. Excision of symblepharon and lamellar keratectomy with two donor sites of conjunctiva from the nasal and temporal aspect of the superior bulbar conjunctiva to place over denuded bulbar conjunctiva. Excision of recurrent tumor from superior bulbar and palpebral conjunctiva. Two large donor sites from nasal and temporal superior bulbar conjunctiva covered entire bare surface. Excision of pterygium with lamellar keratectomy. Recession of remaining normal conjunctiva, full-thickness horizontal mattress suture used to hold part of inferior released symblepharon to palpebral portion of lid. Closure with single large graft from superior temporal aspect of the same eye. Transconjunctival resection of vascular tumor on nasal half of left globe (anterior to equator) with reconstruction by conjunctival graft from superior-temporal quadrant of the opposite eye. The lids were also debulked through transcutaneous approach. Lysis of adhesions and excision of scar with reconstruction of fornix with one patch of conjunctiva from superior temporal quadrant of contralateral eye.
Patient
Age
1.
45
M Liquid ammonia chemical bu rn, rig ht eye
3 mos
LP
2.
14
M Whitewash alkali injury, right eye, with extensive symblepharon to cornea.
8 mos
LP
3.
68
M Recurrent squamous cell Ca of conjunctiva.
3 yrs
20/100
4.
47
M Recurrent pterygium, left eye
6 mos after previous resection
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s.
28
F Extensive vascular tumor of left orbit, conjunctiva and eyelids precluding closure of lids with associated breakdown of corneal epithelium of the left eye.
Progressive enlargement of tumor over years.
20/30
6.
34
F Cicatricial changes, left lateral commisure, inferior fornix and lower eyelid following multiple strabismus procedures, left eye.
2 yrs
20/200
7.
83
18 mos
20/60
8.
3Y2
3Y2 yrs
NLP
9.
45
M Recurrent cicatricial entropion, right upper lid with corneal epithelial breakdown. F Anophthalmic socket. Contraction of lateral fornix precluding external ocular prosthesis. M Superficial irradiation and chronic inflammation. SIP multiple lamellar and one penetrating keratoplasty of the left eye.
30 yrs
HM
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Sex
Time between Injury and Reconstruction
Recession of anterior lid lamella with conjunctival graft to lid margin right upper lid. Donor site from inferior fornix of the same side. Excision of lateral symblepharon, lateral canthotomy with one large patch of conjunctiva from right lower cul-de-sac used to repair defect. Closure of keratoplasty wound dehiscence, overlying of medial, lateral and inferior corneal graft edge with strips of conjunctiva taken from one donor site, bisected and placed over keratoplasty wound. Graft healed without wound dehiscence.
VASTINE, st al • AUTOLOGOUS TRANSPLANTATION
Period of Follow-up
Comments
HM
16 mos
Awaiting corneal transplantation. No shrinkage of reconstructed cul-de-sac.
CF
18 mos
Subsequent keratoplasty failed.
20/200
14 mos
No evidence of recurrence. Normal superior conjunctiva and cul-desac. Gradual development of senile cataract. Appearance normal as compared to buccal mucosa membrane grafts.
Postop Vision
20/30 (with p.h. 20/25)
6 mos
Resolution of inflammation. No recurrence.
20/25
3 mos
Cornea clear. Full closure of the lids. No recurrence of vascular mass on nasal surface of globe.
20/200
16 mos
Good cosmetic appearance. No evidence of shrinkage of reconstructed fornix.
20/60
3 mos
No evidence of recurrence of entropion. Cornea clear. Asymptomatic.
NLP
16 mos
CF
17 mos
Reconstruction allowed stability of prosthesis but subsequent reconstruction required intraconal implant of sclera wrapped sphere. Lateral canthal reconstruction is stable and tolerating progressively larger conformers. Conjunctival graft allowed healing of repeated graft dehiscence and corrected chronic epithelial defect. A subsequent keratoplasty was completed without wound dehiscence; however, the graft failed.
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TABLE 1 continued
Patient
Age
Diagnosis
Sex
Time between Injury and Reconstruction
Preop Vision
Operative procedure Location of Donor Site Lateral canthotomy, biopsy for possible recurrent lesions, separation of symblepharon to recreate normal horizontal lid aperture. Lateral defect closed with two large patches from supero-temporal and nasal bulbar conjunctiva. The defect was closed in three segments, upper and lower palpebral closure and bulbar closure. Excision of 10 by 15 mm rectangular patch of irradiated superior bulbar conjunctiva. Closure of defect with slightly larger patch of nonirradiated conjunctiva from right superior bulbar conjunctiva.
10
62
F Postop resection of squamous Ca in situ of the left eye with post-excision ankyloblepharon and horizontal shortening of the lid aperture and contraction of the lateral fornix.
1Y2 yrs
20/400
11.
44
14 mos
20/400
12.
71
F Keratitis sicca and mild neu roparalytic keratitis of left eye following irradiation for metastatic breast carcinoma to the orbit with one episode of corneal ulceration. Symptoms included persistent pain and irritation. M Recurrent pterygium, left eye.
13.
70
F
14.
52
M Extensive pterygium, left
Extensive pterygium, right eye.
eye.
Gradual progressive growth
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Gradual progressive growth
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5 yrs with gradual progression
barely discernible through the cornea superiorly and nasally. Resection of the symblepharon with excision of the excessive scar tissue and a lamellar keratectomy was performed in December 1979, with repair by a conjunctivoplasty and autologous conjunctival transplantation from the left eye. The base ofthe symblepharon attached to the globe was resected to bare sclera. Six months later, the anterior chamber and iris could be visualized. The eye moved freely in all directions with no evidence of a corneal epithelial defect, contracture of the donor tissue, or inflammation. The tear film appeared normal. There was no indication of xerosis (Fig 4). Case 3. A 68-year-old man had a history of recurrent dysplastic epithelial lesions of the right conjunctiva. The histopathology of the first lesion excised in 1972 showed only epithelial dysplasia. The conjunctival lesion recurred and was excised again in 1974. In October 1977 the patient presented with an extensive re1076
20/40+
Excision of large pterygium and recession of remaining conjunctiva. Defect closed with one large donor graft from superior temporal bulbar conjunctiva from the same eye. Excision of pterygium with recession of remaining normal conjunctiva. Defect closed with one large graft from superior temporal bulbar conjunctiva from the same eye. Excision of pterygium with recession of remaining conjunctiva. Closure of defect with single large patch from superior temporal bulbar conjunctiva.
currence with the histopathologic diagnosis of intraepithelial squamous cell carcinoma involving the temporal aspect of the globe along the inferior cul-desac to the caruncle and superiorly along the limbus to 12 o'clock. An extensive excision of bulbar and palo. pebral conjunctiva with frozen section histopathologic monitoring of the margins was done with repair of the defect with a split thickness labial mucous membrane graft. Postoperatively, adhesions of the palpebral and bulbar mucosal graft developed, which foreshortened the lateral and superior fornices. Six months later, release of the symblepharon and a repeat buccal mucous membrane graft was done. A form-fitting conjunctival conformer was prepared intraoperatively to prevent shrinkage and reformation of the symblepharon. Repeat biopsy showed no evidence of squamous cell carcinoma. Six months later, a localized inferior symblepharon with lower lid ectropion was repaired without repeat grafting. In December 1980, three years after the initial exci-
VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
Postop Vision
Period of FOllow-up
Comments
20/300
10 mos
20170+
3 mos
Marked improvement of tear film; resolution of all symptoms.
20/30
2 mos
No evidence of recurrence. Lost to follow-up after two months; family reports no recurrence.
20/30
3 mos
No evidence of recurrence. Normal appearance of the eye without medications.
20/25-
2 mos
Resolution of inflammation, no recurrence.
sion and 18 months after the last negative biopsy, a new conjunctival lesion was noted on the superior bulbar conjunctiva (Fig 5). Because of the localized area of clinical involvement, a local excision and mucous membrane repair was planned, using a free, fullthickness conjunctival graft. On January 29, 1981, an excision under frozen section control was done. This resulted in removal of the entire superior bulbar conjunctiva and superior fornix up to the tarsal border. Two large free donor grafts were harvested from the superior-temporal and superior-nasal bulbar conjunctiva of the left eye. The grafts were sutured into position with 8-0 chromic collagen and attached to the sclera and the submucosal tissue of the upper fornix. No attempt was made to maintain the fornix or prevent shrinkage with conformers or latex splints. After surgery no problems were encountered with healing in the recipient beds or the donor sites. After ten months of observation, the superior bulbar conjunctiva of the right eye appears normal. The fornix remained deep
Developed cataract causing decrease of vision. Persistent dry eye with superficial keratitis. Showed marked improvement of tear film and wetting. No shrinkage of cul-de-sac or shortening of horizontal aperture as noted after previous reconstruction with latex splints.
and none of the problems encountered with oral mucous membrane grafts have developed. The conjunctival lesion has not recurred (Fig 6). The gradual development of cataract has limited his vision to 201200 in the right eye. Case 4. A 47-year-old Vietnamese refugee noted progressive decrease of vision, redness, and chronic irritation of the left eye. He had had two previous resections of the pterygium in Vietnam. Physical examination demonstrated a pterygium involving the nasal and inferior nasal conjunctiva distorting the plica and extending over the nasal cornea into the visual axis. Preoperative acuity was 20/40 with best correction. Because of encroachment into the visual axis and the marked activity of the pterygium, resection of the pterygium with recession of the conjunctiva was repeated on October 1, 1980. After surgery the eye appeared quiet on topical Pred-Forte 1% drops four times daily. Three months later, evidence of recurrence was noted with marked dragging and distortion of the 1077
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VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
caruncle. Within one month, the entire nasal aspect of the cornea was again covered, and the inferior and nasal cul-de-sac was almost completely obliterated. Shrinkage of the cul-de-sac and growth of the pterygium progressed until the visual axis was again involved, and the best-corrected visual acuity was 20/70 (Fig 7). On April 15, 1981 the pterygium was again resected with a superficial lamellar keratectomy. The abnormal conjunctiva was resected, and the caruncle recessed. The large remaining defect was then repaired by taking a single, large conjunctival graft from the superior temporal quadrant of the same eye. A 5-mm rim of normal conjunctiva was left at the limbus. The postoperative course was uneventful. The best-corrected visual acuity has returned to 20/25, and there has been no evidence of recurrence. The eye is white and quiet, and the appearance is remarkably normal (Fig 8). Case 5. A 28-year-old woman had a long-standing, extensive vascular tumor involving the left orbit, eyelids, and bulbar and palpebral conjunctiva. Visual acuity without correction was 20/20 on the right and 20/30 on the left. Examination demonstrated a prominent vascular abnormality of the left upper and lower eyelids and proptosis. An extensive vascular mass on the nasal aspect of the left eye was accompanied by prolapse of the conjunctiva into the palpebral fissure and inability to close the lids fully with associated corneal punctate staining (Fig 9). Ocular rotations were limited in all fields of gaze on the left, but the patient reported no diplopia. The right eye was normal. A trans conjunctival anterior orbitotomy with excision of the vascular mass on the medial one-half of the globe was done. The dissection was maintained anterior to the equator of the globe. A conjunctival graft from a superotemporal donor site on the right eye was used to cover the conjunctival defect on the nasal aspect of the left globe. Vascular tissue in the nasal aspect of the upper and lower eyelids was also debulked and cauterized. After surgery a significant improvement occurred with a viable graft and no recurrence of the vascular lesion on the eye. The cornea cleared and full lid closure was possible (Fig 10).
RESULTS Table 1 summarizes the diagnoses of 14 cases operated and the overall results. Four patients with recurrent or extensive pterygium, three patients with conjunctival and/or lid tumors, two patients with chemical burns, two patients with irradiation injury, and one each with postsurgical cicatricial changes, cicatricial entropion, and congenital anophthalmos were operated. All patients grafted with autologous conjunctival mucous membrane had an uncomplicated postoperative course. None of the grafts failed. In all cases, the clinical repair was achieved and sufficient donor conjunctiva was available to cover the scleral and/or palpebral defect created. In one patient (case 5) the graft retracted slightly. All patients received topical steroids for two to three months to decrease the inflammatory reaction. Experience in the cases requiring massive resection of the host conjunctiva (case 1, 3, 5~ 6, and 10) showed that the postoperative care was much simpler than would have been the case in repair by labial or buccal mucous membrane grafts. In spite of extensive resection of abnormal conjunctiva, Tenon's fascia or, as in case 10, extensive lateral canthotomy, no observable shrinkage of the grafts was noted even without stents or symblepharon rings. The tendency of these grafts to resist shrinkage and reformation of symblepharon encouraged us to continue this procedure. In alkali burned patients mucous membrane grafts from the mouth are frequently unsuccessful. Scarring and contraction may occur causing extrusion of rigid symblepharon rings. Thus, the structural stability of autologous conjunctival mucous membrane and the absence of progressive shrinkage and scarring, are in marked contrast to buccal mucous membrane grafts (cases 1,2, and 3). An improvement of the tear film with subsequent increased clarity of the cornea was noted after surgery in all patients who had abnormal tear function and ocular surface abnormalities prior to conjunctival grafting. These patients included two with chemical burns (cases 1 and 2), two with a history of periocular
Fig 1. Top left, marked distortion ofthe tarsus with extensive scarring and obliteration of the superior cul-de-sac. The superior tarsal border is attached to the lumbus (case O. Fig 2. Top right, the superior bulbar conjunctival grafts eight months after surgery showing a normal appearance, except at the site of a partially exposed 10-0 nylon suture. The grafts are thin and the surface tear film normal (case I). Fig 3. Second row left, the cornea as it appeared before surgery, with a broad symblepharon, lipoidal degeneration and localized xerosis (case 2). Fig 4. Second row right, the appearance of the cornea six months after the conjunctival graft and reconstruction. The cornea has become more translucent with iris detail noticeable. (case 2). Fig 5. Center left, the extensive recurrence of the squamous cell carcinoma on the remaining superior bulbar conjunctiva. The mucous membrane was rough and the patient had a mucoid discharge and mild irritation (case 3). Fig 6. Center right, the deep superior cul-de-sac and normal conjunctival graft tissue shows no evidence of shrinkage or constriction four months after surgery (case 4), Fig 7. Fourth row left, the recurrent pterygium encroaching on the nasal aspect of the cornea and visual axis eight weeks prior to surgery, The pterygium has advanced into the visual axis with progressive shrinkage of the fornix and dragging of the caruncle (case 4). Fig 8. Fourth row right, six months after surgery, the eye is white and without inflammation or reaction. The corneal haze and scarring are minimal. The visual acuity has returned to 20/25 (case 4). Fig 9, Bottom left, preoperative appearance of the vascular tumor with extensive involvement of the conjunctiva and nasal half of the lids (case 5). Fig 10. Bottom right, post operative appearance with normal conjunctival surface without residual tumor. The upper and lower lid lesions are greatly diminished in size following partial removal (case 5).
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OPHTHALMOLOGY. SEPTEMBER 1982 • VOLUME 89 • NUMBER 9
or ocular irradiation (cases 9 and 11), and one with postoperative keratoconjunctivitis sicca (case 10). In all patients, significant improvement of the tear film was manifested by healing of persistent epithelial defects (cases 1 and 9), marked improvement of chronic extensive superficial punctate keratitis (cases 2, 9, 10 and 11), and resolution of chronic xerosis (case 2). In case 9, the grafts were used to cover a penetrating keratoplasty wound after dehiscence repair. The fornices were partially obliterated secondary to inflammation and irradiation. The patient healed the keratoplasty wound but after repeat keratoplasty, the grafts did not prevent ocular surface abnormalities, as in the alkali burned patient (case 2). Although the patients appear to have a normal postoperative tear film on the basis of break-up time and slit-lamp appearance, no specific tear film components were evaluated before or after surgery. Improvement of the dry eye symptoms and clinical appearance in these cases may be related to the production of a normal lipid and mucin tear layer by the transplanted conjunctival cells and the development of normal microvilli within the transformed epithelial cells of the cornea. The presence of goblet cells, normal basement membrane and vascular network, and the transformation of the transplanted conjunctival epithelium into corneal epithelial cells provide a more normal ocular surface and precorneal tear film, decreasing the stimulus for vascularization and shrinkage. The tear film and ocular surface in the donor eyes were not affected adversely by the transplant procedure. Two patients with recurrent pterygium (cases 4 and 12) and two with active advancing pterygium (cases 13 and 14) were operated with this technique. After surgery these patients received only topical steroids. N one of the patients had beta irradiation or topical thio-tepa. An excellent cosmetic result and improvement of visual acuity by two to four lines on the Snellen chart were achieved in these patients. The patient with a congenital anophthalmic socket (case 8) had a large lateral fornix symblepharon that prevented expansion of the socket and retention of a prosthesis. After excision of the symblepharon and expansion of the socket with conjunctiva, a conformer was retained and progressive expansion of the socket was possible. However, the patient lost her prosthesis and did not return for treatment for several months. During this period, the anterior socket contracted; however, the lateral symblepharon did not recur. The socket was expanded easily on reinsertion of a prosthesis and implantation of a sclera wrapped ball prosthesis in the muscle cone behind posterior Tenon's fascia.
COMMENT While the use of autologous conjunctival grafts from the opposite normal eye has been described for re1080
habilitation of the corneal surface, this is the first report of the use of autologous conjunctiva to repair conjunctival abnormalities. The 14 cases presented here demonstrate the utility of autologous conjunctival grafting for reconstruction of severely compromised eyes and eyelids extensively involved with various disease processes. The use of autologous conjunctiva for reconstruction of palpebral, bulbar, and forniceal portions of the conjunctiva appears to offer significant aid in the management of alkali burns and other abnormalities. The observation that the graft sites did not need to be closed allowed different techniques to be employed from those described by Thoft 1,2 in that larger grafts were used, up to 15 to 20 mm in size, rather than a 5-mm pinch graft. The larger grafts were harvested under microscopic control, taking care to separate the surface membrane from underlying Tenon's and submucosal tissue. These sites reepithelialized without complications, except for the development of a granuloma (which resolved) in one patient. No other significant sequelae were noted at the donor sites in from two to 18 months of follow-up. The grafts were anchored carefully in the recipient beds by suturing with 10-0 nylon or 8-0 chromic collagen. The latter suture proved to be easier to use and was nonreactive. We believe that proper fixation prevents undesirable sliding of the graft, enhances healing, increases the rate of revascularization and decreases edema in the graft. The lack of postoperative reaction and subepithelial scarring and the stability of the graft over long periods were impressive. A major benefit of using conjunctiva for transplantation is the ability of the tissue to heal without contraction and to remain stable without use of symblepharon rings or latex or silicone stents to limit shrinkage. It is our belief that production of normal cells by the transplanted tissue and the presence of normal basement membrane and vascular network for recanalization are critical to minimize scarring. The normal vascular bed may decrease contracture of the grafts and prevent subepithelial fibrosis, which are common with split thickness oral mucous membrane grafts. Care must be taken to assure that the donor tissue is normal. Injury of the donor tissue by the disease process affecting the involved eye may interfere with the anticipated behavior of the transplanted mucous membrane and cells. Therefore, a history of bilateral chemical injury or irradiation, and possibly even of inflammatory disease is a contraindication to the use of this procedure. When corneal and conjunctival surfacing is abnormal because of host disease or injury, autologous conjunctival transplantation offers an effective, rapid, and safe means of restoring a normal ocular mucous membrane with the capacity to provide normal cellular transformation and repair of the ocular surface. 3 In addition, the resulting function and appearance in various conditions where mucous membrane grafting is indicated are far superior, compared to buccal mucous membrane grafts, when autologous conjunctival
VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
grafts are used. In this regard, our observations support the hypothesis of Thoft that nontissue-specific mucous membrane, such as buccal, does not properly transform into normal conjunctival or corneal cells.l.3 Autologous conjunctival transplantation, because of the described advantages, represents the preferred method of periocular mucous membrane replacement in those situations where suitable donor sites are available.
REFERENCES 1. Thoft RA Conjunctival transplantatIOn Arch Ophthalmol 1977,95:1425-7 2 Thoft RA Conjunctival transplantation as an alternative to keratoplasty Ophthalmology 1979, 86 1084-91 3 Thoft RA, Friend J. Biochemical transformation of regenerating ocular surface epithelium Invest Ophthalmol VIS SCI 1977, 1614-20
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by Autologous Conjunctival Transplantation
DA VID W. VASTINE, MD, WILLIAM B. STEWART, MD, IVAN R. SCHWAB, MD
Abstract: We have extended the concept of autologous conjunctival transplantation for corneal resurfacing as recommended by Thoft' to reconstruction in 14 patients with unilateral abnormalities of the bulbar and palpebral conjunctiva caused by alkali burns (2), irradiation (2), neoplasms (3), degenerative diseases (5), trauma (1), and developmental anomalies (1). Large, free conjunctival grafts from bulbar and forniceal donor sites were used. No complications have been noted at the recipient or donor sites. Grafts of normal conjunctiva provided intact basement membrane, goblet cells, and epithelium that help restore normal ocular and lid surfaces. The use of free conjunctival grafts provides significant advantage over the use of buccal mucous membrane grafts. The techniques and results of our experience with free conjunctival grafts in 14 patients are discussed. [Key words: alkali burns, anterior segment reconstruction, conjunctiva, cornea, donor, recipient, symblepharon, transplantation.] Ophthalmology 89: 1072-1 081, 1982
Many donor sites have been employed when mucous membrane grafts are necessary for reconstruction of the conjunctival cul-de-sac and associated deformities. Most widely used has been buccal or labial mucous membrane from the mouth. This technique is successful in some cases, but frequently these grafts contract, scarring and shrinking in some situations so vigorously that symblepharon rings may be extruded. The patients may be left with residual lid deformities, foreshortened fornices, and thick, erythematous grafts that are cosmetically unacceptable and functionally less than ideal. The surface cells of these grafts do not
transform into normal conjunctival and corneal epithelial cells. Stimulated by Thoft' s l,2 reports on the use of conjunctiva for corneal re-epithelialization following ocular chemical injury, we have explored application of autologous conjunctival tissue for reconstruction of the associated conjunctival sequelae of chemical burns and other ocular diseases. Large autologous conjunctival grafts have been used by our group to reconstruct the conjunctiva following severe radiation and chemical burns, trauma, resection of tumors, excision of pterygium, and to repair congenital abnormalities.
From the Cornea-External Disease and the OphthalmiC Plastic Reconstructive and Orbital Surgery Services of the Department of Ophthalmology PaCifiC Medical Center, San FrancIsco, California
METHODS
Repnnt request to DaVid W. Vastine, MD, Department of Ophthalmology, PaCifiC Medical Center, 2340 Clay Street, San FrancIsco, CA 94115
1072
All patients selected for this study had significant ophthalmic disease. The following general procedures were employed in surgical management. 0161-6420/82/0900/1072/$1.30
© American Academy of Ophthalmology
VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
Complete eXCISIOn of the disease process and release of conjunctival restrictions to ocular or lid movement were accomplished initially. Measurements of the mucous membrane defect were then taken. Selection of donor tissue site was based on two major considerations. In cases requiring small fullthickness donor conjunctiva, such as patients with pterygium or small symblepharon, normal conjunctiva could be harvested from the ipsilateral eye. The site preferred was the superotemporal bulbar conjunctiva that is protected by the lid from irritation by light and from exposure to environmental irritants. The superonasal and inferotemporal bulbar and forniceal conjunctiva can also be used for small donor patches. The ipsilateral donor site is useful only if the tissue is normal. In cases requiring extensive reconstruction, as in large recurrent pterygium, unilateral chemical injuries and in tumor resection or reconstruction after surgical excision with resultant cicatricial abnormalities, the opposite eyes are used for donor sites. The superotemporal and superonasal bulbar conjunctiva is preferred, but the inferior bulbar and forniceal conjunctiva can be used if necessary. The donor sites were dissected carefully under high loupe magnification or microscopic control. Care was taken to harvest only the mucosal conjunctival surface. The submucosal connective tissue and Tenon's fascia were dissected carefully from the posterior surface. Large sections of conjunctiva were harvested up to 15 mm by 20 mm as single or multiple patches. Saline or 0.5-1% Xylocaine with 1:200,000 epinephrine can be used to balloon the submucosal tissue to make dissection easier. A 4- to 5-mm rim of normal tissue was always left at the limbus. When taking two patches from the superior bulbar conjunctiva, a 4- to 5mm strip of normal conjunctiva was left over the superior rectus muscle. The posterior dissection into the fornix was stopped at the apex of the cul-de-sac. Because the bulbar conjunctiva is redundant during excision, the donor conjunctiva should be stretched and measured with a calipers or a ruler to approximate the size of patch necessary to cover the defect. Care was taken in transposing the graft not to invert it. Fixation of the donor patches to the conjunctival edges and to the episclera was accomplished with various types of suture materials. We used 10-0 nylon or 8 - 0 chromic collagen most frequently. The chromic collagen causes minimal reaction and is absorbed. The 10-0 nylon frequently needs removal in the postoperative period. On long-term follow-up, the collagen has proved quicker and easier to use with no associated adverse sequelae.
CASE REPORTS Fourteen patients have been operated upon using conjunctival transplantation. Five representative pa-
tients will be described in detail to illustrate the indications, approach, and outcome in our series. The entire series is summarized in Table 1. Case 1. A 45-year-old white man had liquid ammonia thrown in his right eye in December 1979. Four months after injury, foreshortening of the superior cul-de-sac and two granulomas at the superior limbus were present with an associated chronic central corneal epithelial defect. On eversion of the right upper eyelid, the tarsus was found to be distorted markedly. The superior border of the tarsus was adherent to the limbus adjacent to the granulomas (Fig 1). The visual acuity of the eye was light perception. The patient had extensive resection of the conjunctival symblepharon, the granulomas and associated hypertrophied Tenon's capsule superiorly, as well as a 3- to 5-mm strip of abnormal conjunctiva and scar tissue around the entire limbus. The superior dissection was continued over the superior rectus muscle insertion and approximately 4- 5 mm on either side of the muscle. The donor conjunctive was obtained from the left eye. Three donor sites were employed: superotemporal and superonasal bulbar conjunctiva, and inferotemporal bulbar conjunctiva extending into the fornix. One free patch graft was used to cover the superior 100° of the corneal limbus and the insertion of the superior rectus muscle. The second graft was placed over the superior palpebral conjunctival defect. It was sutured to the remaining conjunctiva on the tarsus. The superior edge was sutured deep into the cul-de-sac by everting the lid. These two grafts created a deep superior cul-de-sac. A third smaller patch of conjunctiva was bisected and placed over the inferior nasal and inferior-temporal aspects of the corneal limbus. On the first and second postoperative days, full extraocular muscle motility was possible without restriction, and the upper eyelid could be everted. Over the subsequent year, the vascular hyperemia of the conjunctival grafts regressed, and the cornea cleared with regression of the superficial and deep vessels. The conjunctival transplant resembled normal tissue. The upper lid was of normal configuration with no evidence of shrinkage of the superior fornix, distortion of the tarsus, or recurrence of symblepharon. (Fig 2). The donor sites in the left eye, which were not closed, healed without complication. Case 2. A 14-year-old Mexican-American boy had whitewash alkali splashed into his right eye at approximately 6 years of age. His visual acuity was light perception with color perception in the right eye and 20/20 in the left eye. A large symblepharon was present extending from the mid-tarsal plate to the superior limbus from approximately 11:30 to 1:30 o'clock (Fig 3). This large symblepharon restricted down and medial gaze. There was an opening behind the symblepharon deep in the superior cul-de-sac. Slit-lamp examination revealed a totally opaque cornea. The iris was
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OPHTHALMOLOGY. SEPTEMBER 1982 • VOLUME 89 • NUMBER 9
Table 1. Summary of Patients Undergoing Autologous Conjunctival Transplantation
Diagnosis
Preop Vision
Operative procedure Location of Donor Site Resection of perilimbal tissue and fibrovascular perilimbal corneal tissue. Resection of extensive upper cul-de-sac fibrosis and symblepharon, including hypertrophied Tenon's down to superior rectus muscle. Three donor sites from supero-nasal and temporal and inferior temporal quadrants of left eye used to resurface all bare areas except central cornea. Excision of symblepharon and lamellar keratectomy with two donor sites of conjunctiva from the nasal and temporal aspect of the superior bulbar conjunctiva to place over denuded bulbar conjunctiva. Excision of recurrent tumor from superior bulbar and palpebral conjunctiva. Two large donor sites from nasal and temporal superior bulbar conjunctiva covered entire bare surface. Excision of pterygium with lamellar keratectomy. Recession of remaining normal conjunctiva, full-thickness horizontal mattress suture used to hold part of inferior released symblepharon to palpebral portion of lid. Closure with single large graft from superior temporal aspect of the same eye. Transconjunctival resection of vascular tumor on nasal half of left globe (anterior to equator) with reconstruction by conjunctival graft from superior-temporal quadrant of the opposite eye. The lids were also debulked through transcutaneous approach. Lysis of adhesions and excision of scar with reconstruction of fornix with one patch of conjunctiva from superior temporal quadrant of contralateral eye.
Patient
Age
1.
45
M Liquid ammonia chemical bu rn, rig ht eye
3 mos
LP
2.
14
M Whitewash alkali injury, right eye, with extensive symblepharon to cornea.
8 mos
LP
3.
68
M Recurrent squamous cell Ca of conjunctiva.
3 yrs
20/100
4.
47
M Recurrent pterygium, left eye
6 mos after previous resection
20170
s.
28
F Extensive vascular tumor of left orbit, conjunctiva and eyelids precluding closure of lids with associated breakdown of corneal epithelium of the left eye.
Progressive enlargement of tumor over years.
20/30
6.
34
F Cicatricial changes, left lateral commisure, inferior fornix and lower eyelid following multiple strabismus procedures, left eye.
2 yrs
20/200
7.
83
18 mos
20/60
8.
3Y2
3Y2 yrs
NLP
9.
45
M Recurrent cicatricial entropion, right upper lid with corneal epithelial breakdown. F Anophthalmic socket. Contraction of lateral fornix precluding external ocular prosthesis. M Superficial irradiation and chronic inflammation. SIP multiple lamellar and one penetrating keratoplasty of the left eye.
30 yrs
HM
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Sex
Time between Injury and Reconstruction
Recession of anterior lid lamella with conjunctival graft to lid margin right upper lid. Donor site from inferior fornix of the same side. Excision of lateral symblepharon, lateral canthotomy with one large patch of conjunctiva from right lower cul-de-sac used to repair defect. Closure of keratoplasty wound dehiscence, overlying of medial, lateral and inferior corneal graft edge with strips of conjunctiva taken from one donor site, bisected and placed over keratoplasty wound. Graft healed without wound dehiscence.
VASTINE, st al • AUTOLOGOUS TRANSPLANTATION
Period of Follow-up
Comments
HM
16 mos
Awaiting corneal transplantation. No shrinkage of reconstructed cul-de-sac.
CF
18 mos
Subsequent keratoplasty failed.
20/200
14 mos
No evidence of recurrence. Normal superior conjunctiva and cul-desac. Gradual development of senile cataract. Appearance normal as compared to buccal mucosa membrane grafts.
Postop Vision
20/30 (with p.h. 20/25)
6 mos
Resolution of inflammation. No recurrence.
20/25
3 mos
Cornea clear. Full closure of the lids. No recurrence of vascular mass on nasal surface of globe.
20/200
16 mos
Good cosmetic appearance. No evidence of shrinkage of reconstructed fornix.
20/60
3 mos
No evidence of recurrence of entropion. Cornea clear. Asymptomatic.
NLP
16 mos
CF
17 mos
Reconstruction allowed stability of prosthesis but subsequent reconstruction required intraconal implant of sclera wrapped sphere. Lateral canthal reconstruction is stable and tolerating progressively larger conformers. Conjunctival graft allowed healing of repeated graft dehiscence and corrected chronic epithelial defect. A subsequent keratoplasty was completed without wound dehiscence; however, the graft failed.
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TABLE 1 continued
Patient
Age
Diagnosis
Sex
Time between Injury and Reconstruction
Preop Vision
Operative procedure Location of Donor Site Lateral canthotomy, biopsy for possible recurrent lesions, separation of symblepharon to recreate normal horizontal lid aperture. Lateral defect closed with two large patches from supero-temporal and nasal bulbar conjunctiva. The defect was closed in three segments, upper and lower palpebral closure and bulbar closure. Excision of 10 by 15 mm rectangular patch of irradiated superior bulbar conjunctiva. Closure of defect with slightly larger patch of nonirradiated conjunctiva from right superior bulbar conjunctiva.
10
62
F Postop resection of squamous Ca in situ of the left eye with post-excision ankyloblepharon and horizontal shortening of the lid aperture and contraction of the lateral fornix.
1Y2 yrs
20/400
11.
44
14 mos
20/400
12.
71
F Keratitis sicca and mild neu roparalytic keratitis of left eye following irradiation for metastatic breast carcinoma to the orbit with one episode of corneal ulceration. Symptoms included persistent pain and irritation. M Recurrent pterygium, left eye.
13.
70
F
14.
52
M Extensive pterygium, left
Extensive pterygium, right eye.
eye.
Gradual progressive growth
20170
Gradual progressive growth
20170
5 yrs with gradual progression
barely discernible through the cornea superiorly and nasally. Resection of the symblepharon with excision of the excessive scar tissue and a lamellar keratectomy was performed in December 1979, with repair by a conjunctivoplasty and autologous conjunctival transplantation from the left eye. The base ofthe symblepharon attached to the globe was resected to bare sclera. Six months later, the anterior chamber and iris could be visualized. The eye moved freely in all directions with no evidence of a corneal epithelial defect, contracture of the donor tissue, or inflammation. The tear film appeared normal. There was no indication of xerosis (Fig 4). Case 3. A 68-year-old man had a history of recurrent dysplastic epithelial lesions of the right conjunctiva. The histopathology of the first lesion excised in 1972 showed only epithelial dysplasia. The conjunctival lesion recurred and was excised again in 1974. In October 1977 the patient presented with an extensive re1076
20/40+
Excision of large pterygium and recession of remaining conjunctiva. Defect closed with one large donor graft from superior temporal bulbar conjunctiva from the same eye. Excision of pterygium with recession of remaining normal conjunctiva. Defect closed with one large graft from superior temporal bulbar conjunctiva from the same eye. Excision of pterygium with recession of remaining conjunctiva. Closure of defect with single large patch from superior temporal bulbar conjunctiva.
currence with the histopathologic diagnosis of intraepithelial squamous cell carcinoma involving the temporal aspect of the globe along the inferior cul-desac to the caruncle and superiorly along the limbus to 12 o'clock. An extensive excision of bulbar and palo. pebral conjunctiva with frozen section histopathologic monitoring of the margins was done with repair of the defect with a split thickness labial mucous membrane graft. Postoperatively, adhesions of the palpebral and bulbar mucosal graft developed, which foreshortened the lateral and superior fornices. Six months later, release of the symblepharon and a repeat buccal mucous membrane graft was done. A form-fitting conjunctival conformer was prepared intraoperatively to prevent shrinkage and reformation of the symblepharon. Repeat biopsy showed no evidence of squamous cell carcinoma. Six months later, a localized inferior symblepharon with lower lid ectropion was repaired without repeat grafting. In December 1980, three years after the initial exci-
VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
Postop Vision
Period of FOllow-up
Comments
20/300
10 mos
20170+
3 mos
Marked improvement of tear film; resolution of all symptoms.
20/30
2 mos
No evidence of recurrence. Lost to follow-up after two months; family reports no recurrence.
20/30
3 mos
No evidence of recurrence. Normal appearance of the eye without medications.
20/25-
2 mos
Resolution of inflammation, no recurrence.
sion and 18 months after the last negative biopsy, a new conjunctival lesion was noted on the superior bulbar conjunctiva (Fig 5). Because of the localized area of clinical involvement, a local excision and mucous membrane repair was planned, using a free, fullthickness conjunctival graft. On January 29, 1981, an excision under frozen section control was done. This resulted in removal of the entire superior bulbar conjunctiva and superior fornix up to the tarsal border. Two large free donor grafts were harvested from the superior-temporal and superior-nasal bulbar conjunctiva of the left eye. The grafts were sutured into position with 8-0 chromic collagen and attached to the sclera and the submucosal tissue of the upper fornix. No attempt was made to maintain the fornix or prevent shrinkage with conformers or latex splints. After surgery no problems were encountered with healing in the recipient beds or the donor sites. After ten months of observation, the superior bulbar conjunctiva of the right eye appears normal. The fornix remained deep
Developed cataract causing decrease of vision. Persistent dry eye with superficial keratitis. Showed marked improvement of tear film and wetting. No shrinkage of cul-de-sac or shortening of horizontal aperture as noted after previous reconstruction with latex splints.
and none of the problems encountered with oral mucous membrane grafts have developed. The conjunctival lesion has not recurred (Fig 6). The gradual development of cataract has limited his vision to 201200 in the right eye. Case 4. A 47-year-old Vietnamese refugee noted progressive decrease of vision, redness, and chronic irritation of the left eye. He had had two previous resections of the pterygium in Vietnam. Physical examination demonstrated a pterygium involving the nasal and inferior nasal conjunctiva distorting the plica and extending over the nasal cornea into the visual axis. Preoperative acuity was 20/40 with best correction. Because of encroachment into the visual axis and the marked activity of the pterygium, resection of the pterygium with recession of the conjunctiva was repeated on October 1, 1980. After surgery the eye appeared quiet on topical Pred-Forte 1% drops four times daily. Three months later, evidence of recurrence was noted with marked dragging and distortion of the 1077
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VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
caruncle. Within one month, the entire nasal aspect of the cornea was again covered, and the inferior and nasal cul-de-sac was almost completely obliterated. Shrinkage of the cul-de-sac and growth of the pterygium progressed until the visual axis was again involved, and the best-corrected visual acuity was 20/70 (Fig 7). On April 15, 1981 the pterygium was again resected with a superficial lamellar keratectomy. The abnormal conjunctiva was resected, and the caruncle recessed. The large remaining defect was then repaired by taking a single, large conjunctival graft from the superior temporal quadrant of the same eye. A 5-mm rim of normal conjunctiva was left at the limbus. The postoperative course was uneventful. The best-corrected visual acuity has returned to 20/25, and there has been no evidence of recurrence. The eye is white and quiet, and the appearance is remarkably normal (Fig 8). Case 5. A 28-year-old woman had a long-standing, extensive vascular tumor involving the left orbit, eyelids, and bulbar and palpebral conjunctiva. Visual acuity without correction was 20/20 on the right and 20/30 on the left. Examination demonstrated a prominent vascular abnormality of the left upper and lower eyelids and proptosis. An extensive vascular mass on the nasal aspect of the left eye was accompanied by prolapse of the conjunctiva into the palpebral fissure and inability to close the lids fully with associated corneal punctate staining (Fig 9). Ocular rotations were limited in all fields of gaze on the left, but the patient reported no diplopia. The right eye was normal. A trans conjunctival anterior orbitotomy with excision of the vascular mass on the medial one-half of the globe was done. The dissection was maintained anterior to the equator of the globe. A conjunctival graft from a superotemporal donor site on the right eye was used to cover the conjunctival defect on the nasal aspect of the left globe. Vascular tissue in the nasal aspect of the upper and lower eyelids was also debulked and cauterized. After surgery a significant improvement occurred with a viable graft and no recurrence of the vascular lesion on the eye. The cornea cleared and full lid closure was possible (Fig 10).
RESULTS Table 1 summarizes the diagnoses of 14 cases operated and the overall results. Four patients with recurrent or extensive pterygium, three patients with conjunctival and/or lid tumors, two patients with chemical burns, two patients with irradiation injury, and one each with postsurgical cicatricial changes, cicatricial entropion, and congenital anophthalmos were operated. All patients grafted with autologous conjunctival mucous membrane had an uncomplicated postoperative course. None of the grafts failed. In all cases, the clinical repair was achieved and sufficient donor conjunctiva was available to cover the scleral and/or palpebral defect created. In one patient (case 5) the graft retracted slightly. All patients received topical steroids for two to three months to decrease the inflammatory reaction. Experience in the cases requiring massive resection of the host conjunctiva (case 1, 3, 5~ 6, and 10) showed that the postoperative care was much simpler than would have been the case in repair by labial or buccal mucous membrane grafts. In spite of extensive resection of abnormal conjunctiva, Tenon's fascia or, as in case 10, extensive lateral canthotomy, no observable shrinkage of the grafts was noted even without stents or symblepharon rings. The tendency of these grafts to resist shrinkage and reformation of symblepharon encouraged us to continue this procedure. In alkali burned patients mucous membrane grafts from the mouth are frequently unsuccessful. Scarring and contraction may occur causing extrusion of rigid symblepharon rings. Thus, the structural stability of autologous conjunctival mucous membrane and the absence of progressive shrinkage and scarring, are in marked contrast to buccal mucous membrane grafts (cases 1,2, and 3). An improvement of the tear film with subsequent increased clarity of the cornea was noted after surgery in all patients who had abnormal tear function and ocular surface abnormalities prior to conjunctival grafting. These patients included two with chemical burns (cases 1 and 2), two with a history of periocular
Fig 1. Top left, marked distortion ofthe tarsus with extensive scarring and obliteration of the superior cul-de-sac. The superior tarsal border is attached to the lumbus (case O. Fig 2. Top right, the superior bulbar conjunctival grafts eight months after surgery showing a normal appearance, except at the site of a partially exposed 10-0 nylon suture. The grafts are thin and the surface tear film normal (case I). Fig 3. Second row left, the cornea as it appeared before surgery, with a broad symblepharon, lipoidal degeneration and localized xerosis (case 2). Fig 4. Second row right, the appearance of the cornea six months after the conjunctival graft and reconstruction. The cornea has become more translucent with iris detail noticeable. (case 2). Fig 5. Center left, the extensive recurrence of the squamous cell carcinoma on the remaining superior bulbar conjunctiva. The mucous membrane was rough and the patient had a mucoid discharge and mild irritation (case 3). Fig 6. Center right, the deep superior cul-de-sac and normal conjunctival graft tissue shows no evidence of shrinkage or constriction four months after surgery (case 4), Fig 7. Fourth row left, the recurrent pterygium encroaching on the nasal aspect of the cornea and visual axis eight weeks prior to surgery, The pterygium has advanced into the visual axis with progressive shrinkage of the fornix and dragging of the caruncle (case 4). Fig 8. Fourth row right, six months after surgery, the eye is white and without inflammation or reaction. The corneal haze and scarring are minimal. The visual acuity has returned to 20/25 (case 4). Fig 9, Bottom left, preoperative appearance of the vascular tumor with extensive involvement of the conjunctiva and nasal half of the lids (case 5). Fig 10. Bottom right, post operative appearance with normal conjunctival surface without residual tumor. The upper and lower lid lesions are greatly diminished in size following partial removal (case 5).
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OPHTHALMOLOGY. SEPTEMBER 1982 • VOLUME 89 • NUMBER 9
or ocular irradiation (cases 9 and 11), and one with postoperative keratoconjunctivitis sicca (case 10). In all patients, significant improvement of the tear film was manifested by healing of persistent epithelial defects (cases 1 and 9), marked improvement of chronic extensive superficial punctate keratitis (cases 2, 9, 10 and 11), and resolution of chronic xerosis (case 2). In case 9, the grafts were used to cover a penetrating keratoplasty wound after dehiscence repair. The fornices were partially obliterated secondary to inflammation and irradiation. The patient healed the keratoplasty wound but after repeat keratoplasty, the grafts did not prevent ocular surface abnormalities, as in the alkali burned patient (case 2). Although the patients appear to have a normal postoperative tear film on the basis of break-up time and slit-lamp appearance, no specific tear film components were evaluated before or after surgery. Improvement of the dry eye symptoms and clinical appearance in these cases may be related to the production of a normal lipid and mucin tear layer by the transplanted conjunctival cells and the development of normal microvilli within the transformed epithelial cells of the cornea. The presence of goblet cells, normal basement membrane and vascular network, and the transformation of the transplanted conjunctival epithelium into corneal epithelial cells provide a more normal ocular surface and precorneal tear film, decreasing the stimulus for vascularization and shrinkage. The tear film and ocular surface in the donor eyes were not affected adversely by the transplant procedure. Two patients with recurrent pterygium (cases 4 and 12) and two with active advancing pterygium (cases 13 and 14) were operated with this technique. After surgery these patients received only topical steroids. N one of the patients had beta irradiation or topical thio-tepa. An excellent cosmetic result and improvement of visual acuity by two to four lines on the Snellen chart were achieved in these patients. The patient with a congenital anophthalmic socket (case 8) had a large lateral fornix symblepharon that prevented expansion of the socket and retention of a prosthesis. After excision of the symblepharon and expansion of the socket with conjunctiva, a conformer was retained and progressive expansion of the socket was possible. However, the patient lost her prosthesis and did not return for treatment for several months. During this period, the anterior socket contracted; however, the lateral symblepharon did not recur. The socket was expanded easily on reinsertion of a prosthesis and implantation of a sclera wrapped ball prosthesis in the muscle cone behind posterior Tenon's fascia.
COMMENT While the use of autologous conjunctival grafts from the opposite normal eye has been described for re1080
habilitation of the corneal surface, this is the first report of the use of autologous conjunctiva to repair conjunctival abnormalities. The 14 cases presented here demonstrate the utility of autologous conjunctival grafting for reconstruction of severely compromised eyes and eyelids extensively involved with various disease processes. The use of autologous conjunctiva for reconstruction of palpebral, bulbar, and forniceal portions of the conjunctiva appears to offer significant aid in the management of alkali burns and other abnormalities. The observation that the graft sites did not need to be closed allowed different techniques to be employed from those described by Thoft 1,2 in that larger grafts were used, up to 15 to 20 mm in size, rather than a 5-mm pinch graft. The larger grafts were harvested under microscopic control, taking care to separate the surface membrane from underlying Tenon's and submucosal tissue. These sites reepithelialized without complications, except for the development of a granuloma (which resolved) in one patient. No other significant sequelae were noted at the donor sites in from two to 18 months of follow-up. The grafts were anchored carefully in the recipient beds by suturing with 10-0 nylon or 8-0 chromic collagen. The latter suture proved to be easier to use and was nonreactive. We believe that proper fixation prevents undesirable sliding of the graft, enhances healing, increases the rate of revascularization and decreases edema in the graft. The lack of postoperative reaction and subepithelial scarring and the stability of the graft over long periods were impressive. A major benefit of using conjunctiva for transplantation is the ability of the tissue to heal without contraction and to remain stable without use of symblepharon rings or latex or silicone stents to limit shrinkage. It is our belief that production of normal cells by the transplanted tissue and the presence of normal basement membrane and vascular network for recanalization are critical to minimize scarring. The normal vascular bed may decrease contracture of the grafts and prevent subepithelial fibrosis, which are common with split thickness oral mucous membrane grafts. Care must be taken to assure that the donor tissue is normal. Injury of the donor tissue by the disease process affecting the involved eye may interfere with the anticipated behavior of the transplanted mucous membrane and cells. Therefore, a history of bilateral chemical injury or irradiation, and possibly even of inflammatory disease is a contraindication to the use of this procedure. When corneal and conjunctival surfacing is abnormal because of host disease or injury, autologous conjunctival transplantation offers an effective, rapid, and safe means of restoring a normal ocular mucous membrane with the capacity to provide normal cellular transformation and repair of the ocular surface. 3 In addition, the resulting function and appearance in various conditions where mucous membrane grafting is indicated are far superior, compared to buccal mucous membrane grafts, when autologous conjunctival
VASTINE, et al • AUTOLOGOUS TRANSPLANTATION
grafts are used. In this regard, our observations support the hypothesis of Thoft that nontissue-specific mucous membrane, such as buccal, does not properly transform into normal conjunctival or corneal cells.l.3 Autologous conjunctival transplantation, because of the described advantages, represents the preferred method of periocular mucous membrane replacement in those situations where suitable donor sites are available.
REFERENCES 1. Thoft RA Conjunctival transplantatIOn Arch Ophthalmol 1977,95:1425-7 2 Thoft RA Conjunctival transplantation as an alternative to keratoplasty Ophthalmology 1979, 86 1084-91 3 Thoft RA, Friend J. Biochemical transformation of regenerating ocular surface epithelium Invest Ophthalmol VIS SCI 1977, 1614-20
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