Tarsal polishing and mucous membrane grafting for cicatricial entropion, trichiasis and epidermalization

SURVEY OF OPHTHALMOLOGY

CURRENT

VOLUME 30 * NUMBER 2 * SEPTEMBER-OCTOBER

1985

OPHTHALMOLOGY

CREIG HOYT, EDITOR

Tarsal Polishing and Mucous Membrane Grafting for Cicatricial Entropion, Trichiasis and Epidermalization, by C. D. McCord, Jr. and W. P. Chen. Ophthalmic Surg 14: 1021-1025, 1983 cicatricial entropian with trichiasis is a difftcult clinical problem. The treatment of epidermalization, Various authors have described techniques using superficial cautery, sutures, tarsal resection, tarsal rotation, grafting with buccal mucous membrane, nasochondral mucosal grafts, and donor eye bank sclera. In Stevens-Johnson syndrome and ocular pemphigoid, cicatrization of the mucous membrane, metaplasia of the meibomian glands, keratinization, and a progressive decrease in the cell density of goblet cells are seen in the chronic phase. This results in cornea1 irritation due to epidermalization, cicatricial entropion, and trichiasis. The authors describe the simple and effective treatment mode combining tarsal polishing with grafting of full-thickness buccal mucous membrane. (Author address: William P. Chen, M.D., 2699 Atlantic Ave., Long

Beach,

CA 90806.)

Comment Whether or not mucosal grafting alone (either bucccal or chondromucosal) helps people with StevensJohnson syndrome is unknown because the keratitis caused by this disease is due to ( 1) an irregular, 1hickened 1 acrimal hyposecretion. Since the case palpebral and bulbar conjunctiva, (2) trichiasis or entropion, or (3) reports presented in this paper are not detailed, it is not possible to determine which of the above components was at fault and how severe the problem was. Moreover, objective details are not given about pre- and postoperative conditions, e.g., cornea1 conditions, Shirmer test results, tear lysozyme levels, visual acuities, descriptions (or pictures) of the lid margins, histological evaluations, etc. From my experience, I would raise a number of questions about the authors’ approach and conclusions. 1) Fig. 3 shows exposed loops of a nylon suture, which I am afraid could abrade the cornea. If I were using this approach I would use a bandage soft contact lens to lessen the chance of cornea1 abrasion. However, I would prefer to thread a nylon suture through the submucosal tissue or, if a submucosal running suture is not used, I would use the 6-O Luken suture (as described by Beard). 2) The authors state that the dermabrading tip removed the “abnormal tarsoconjunctiva,” but the extent to which it is “abnormal” is uncertain. Does it contain keratinized epithelium? The authors’ statement that goblet cells survive with the free graft is unsubstantiated; whether a graft of buccal mucosa creates a higher ambient oxygen tension is questionable, since the vascularity of a free graft is decreased compared to its vascularity at the donor site. 3) Caution would be appropriate concerning the surgical treatment of ocular pemphigoid, because the slightest surgical insult can sometimes precipitate a sudden exacerbation of the shrinkage process. In my own experience, I can honestly say that cryodestruction of lashes, and transverse blepharotomy with tarsal rotation (Weis or Ballen procedure), in addition to frequent use of topical lubricant, is more effective in reversing cornea1 changes than the chondromucosal grafting. I expect the same to be true of full thickness huccal mucosal grafting. MICHAEI. CAIJAHAN, M.D. BIRXlINGHAht,

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