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Sealing of the Gap between the Conjunctiva andTenon Capsule to Improve Symblepharon

Surgery

DANDAN ZHAO, HAN Y. YIN, ANNY CHENG, RENDIAN CHEN, HOSAM SHEHA, AND SCHEFFER C.G. TSENG

PURPOSE: To report the surgical outcome of ‘‘sealing

the gap’’ in treating symblepharon caused by various eti-ologies other than recurrent pterygium. DESIGN: Retrospective, interventional case series. METHODS: Sixteen eyes of 14 patients with pathogenicsymblepharon were consecutively operated by conjunc-

tival recession, sealing the gap between recessed conjunc-

tiva and Tenon capsule with a running 9-0 nylon suture,and covering of the bare sclera with amniotic membrane.

For severe symblepharon where there was conjunctivalshortening, oral mucosa graft was added. Outcome mea-

sures include ocular surface inflammation, fornix refor-

mation, and restoration of ocular motility. RESULTS: The underlying causes of symblepharon

included Stevens-Johnson syndrome (n [ 6), chemical

burn (n [ 5), ocular cicatricial pemphigoid (n [ 1), ther-mal burn (n [ 1), following excision of conjunctival squa-mous cell carcinoma (n [ 1), conjunctival scarring

following exposed buckle (n [ 1), and immune dysregula-

tion (n [ 1). Twelve eyes (75%) had an average of 1.6 ±0.9 previous surgeries. Before surgery, ocular motility re-

striction was significantly correlated with the severity of

symblepharon. During the follow-up period of 17.1 ±13.6 months, 13 eyes (81.3%) achieved complete success,

2 eyes (12.5%) achieved partial success, and 1 eye withimmune dysregulation had failure (6.3%). There was no

correlation between the success rate and the severity of

symblepharon. After surgery, the ocular motility andinflammation were significantly improved. Visual acuity

had improved in 2 of 15 eyes. CONCLUSIONS: Sealing the gap between the conjunc-tiva and Tenon capsule is an important step in the surgical

management of pathogenic symblepharon. This methodnot only avoids the use of mitomycin C, but also creates

a strong barrier to prevent recurrence, restore ocular

surface integrity, reform a deep fornix, and regain fullocular motility. (Am J Ophthalmol 2015;160(3):

438–446. 2015 by Elsevier Inc. All rights reserved.)

SYMBLEPHARON REFERS TO ANY ADHESION BETWEEN

the palpebral and bulbar conjunctiva that developsfollowing diverse etiologies such as trauma, chemical

injuries, infections, and immune dysregulation. The patho-

genic effects of symblepharon depend on its location andseverity. In general, mild symblepharon located near the

lacrimal gland orifices may cause blockage and lead to dry

eye, while that located at the inferior fornix may obliteratethe tear reservoir and interfere with effective replenish-

ment of tears in the meniscus and the ocular surface. Insevere cases, symblepharon may cause inadequate blinking,

lagophthalmos, and ocular motility restriction.

No treatment is necessary if symblepharon does not carrythe aforementioned pathogenic elements. However, patients

with pathogenic symblepharon, as defined above, should be

treated to avoid sight-threatening corneal complications asa result of cumulative insults and chronic inflammation. Avariety of surgical approaches have been reported for the

treatment of symblepharon. Tissue substitutes such as con-

junctiva,1,2 oral mucosa graft,3–5 or amniotic membrane6–10

were used for ocular surface reconstruction after

symblepharon lysis. Anchoring sutures were also useful to

secure the released conjunctiva deep into the fornix.10

Various materials have been evaluated to keep the poten-

tially adhesive surfaces apart after surgery and to reduce re-currences such as symblepharon ring,11 silicone sheet

implant,12,13 nylon foil–anchored polytetrafluoroetyhlene

(Gore-Tex),14 mitomycin C (MMC),15,16 bevacizumab,17

or postoperative application of b-irradiation.18 Despite all

these efforts, the recurrence rates remained highly variable

from 6.2% to 40%6–10,16,19,20 (Table 1).For managing symblepharon caused by multi-recurrent

pterygia, we have recently reported a significant improve-ment of the surgical outcome in restoring caruncle

morphology and full ocular motility by adding an extra

step termed ‘‘sealing the gap,’’ with or without conjunc-tival autograft or oral mucosa graft, which is added for

eyes with a severe shortage of remaining conjunctival tis-

sue, measured from the tip of the symblepharon to theremaining caruncle.21 This technique can be achievedby anchoring sutures as mentioned above10 o r b y a

running 9-O nylon suture. Herein, we reported our clin-

ical experience in adding this extra step, ‘‘sealing thegap,’’ using such a running suture (Figure 1) to manage

symblepharon caused by various etiologies other than

recurrent pterygia.

Accepted for publication Jun 9, 2015.From theDepartment of Ophthalmology, Yan’ An Hospital of Kunming

City, Kunming, Yunnan, China (D.Z.); Ocular Surface Center and OcularSurface Research & Education Foundation, Miami, Florida (D.Z., H.Y.Y.,A.C., R.C., H.S., S.C.G.T.); and Department of Ophthalmology,Shenzhen Children’s Hospital, Shenzhen, Guangzhou, China (R.C.).

Inquiries to Scheffer C.G. Tseng, Ocular Surface Center and Ocular

Surface Research & Education Foundation, 7000 SW 97th Avenue,Suite 213, Miami, FL 33173; e-mail: [email protected]

438 0002-9394/$36.00http://dx.doi.org/10.1016/j.ajo.2015.06.003

2015 BY ELSEVIER INC. ALL RIGHTS RESERVED.

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METHODS

THIS RETROSPECTIVE INTERVENTIONAL CASE SERIES STUDY

was approved by the Institutional Review Board of BaptistHospital of Miami/South Miami Hospital Inc, Miami, Flor-

ida. A total of 16 eyes of 14 patients who underwent surgicalcorrection of symblepharon with the technique of ‘‘sealingthe gap’’ from July 19th, 2010 through February 27th, 2015

were included in this study. Before surgery, possible advan-

tages and disadvantages of the procedures were explainedfully to the patients and their written informed consentswere obtained. The advantages and disadvantages of the

off-label use of fibrin glue in ophthalmology were also

discussed. Demographic information, clinical presentation,prior surgeries, and outcomes are summarized in Table 2.

The severity of symblepharon was graded according to its

length, width, and inflammation, as previously reported.19

The length of the symblepharon was defined as the distance

between the lid margin and the limbus. It was graded as I if it

was equal to or greater than the length of the palpebral con-

junctiva (Figure 2, Top left), II if it was shorter than thelength of the palpebral conjunctiva but equal to or greaterthan that of the tarsus (Figure 2, Top middle), III if it was

shorter than the tarsus (Figure 2, Top right), or IV if it wasclose to zero; ankyloblepharon was added to this categoryas well (Figure 2, Bottom left). The width of symblepharon

was defined as the horizontal width in relation to the width

of the eyelid. It was graded as a if the width was one-thirdor less of the eyelid width (Figure 2, Top left), b if it was

more than one-third but equal to or less than two-thirds of the eyelid width (Figure 2, Top middle), or c if it was more

than two-thirds of the eyelid width (Figure 2, Top right).

Inflammation was judged by conjunctival hyperemia andgraded as 0 if absent (Figure 2, Top left), 1þ if mild

(Figure 2, Top right), 2þ if moderate (Figure 2, Bottom mid-

dle), or 3þ if severe (Figure 2, Bottom right).

TABLE 1. Literature Summary of Symblepharon Surgery Techniques Studies

Source Technique

Eyes

(N) Underlying Cause Symblepharon Severity

Mean (SD)

Follow-up

(mo)

Minimal

Follow-up

(mo)

Recurrence

Rate

Tseng 19978 AMT 5 OCP ( n ¼ 2), TB (n ¼ 1), RP

(n¼

1), TEN (n¼

1)

14.54 5.5 40%

Patel 20127 AMT 10 6 20%

Katircioglu 20039 AMT þ AS 6 Alkali burn Severe ( n ¼ 3), moderate

(n ¼ 2), mild (n ¼ 1)

10 4 16.67%

Solomon 200310 AMT þ AS 17 Autoimmune disorders

(n ¼ 9), after ocular surgery

(n ¼ 4), after ocular trauma

(n ¼ 4)

One location (n ¼ 11), 2

locations (n ¼ 5), 3

locations (n ¼ 1)

37 9 17.65%

Jain 20046 AMT þ AS 20 RP (n ¼ 5), acid burns (n ¼ 1),

alkali burns (n ¼ 5), SJS

(n ¼ 4), TB (n ¼ 3), and

congenital symblepharon

(n ¼ 2)

Stage II or III 12 12 40%

Tseng 200516 MMC þ AMT þ AS 18 CB/TB (n ¼ 7), RP (n ¼ 5),

SJS (4 eyes), OCP (n ¼ 2)

One location (n ¼ 6), 2

locations (n ¼ 12)

14.16 6 18.75%

Kheirkhah 200819 MMC þ CAU/OMG þ

AMT þ AS

61 SJS (n ¼ 26), CB (n ¼ 19),

chronic cicatricial

conjunctivitis of unknown

cause (n ¼ 9), RP (n ¼ 3),

MMP (n ¼ 2),

pseudopemphigoid

(n ¼ 1), lid sebaceous

carcinoma (n ¼ 1)

Grade I (n ¼ 17), grade II

(n ¼ 26), grade III (n ¼ 9),

grade IV (n ¼ 9)

25 12 14.8%

Kheirkhah 201320 MMC þ OMG þ

AMT þ AS

32 CB (n ¼16), TB (n ¼ 7), SJS

(n ¼ 5), OCP (n ¼ 2),

xeroderma pigmentosum

(n ¼ 1), graft-vs-host

disease (n ¼ 1)

Grade III (n ¼ 19), grade IV

(n ¼ 13)

16.4 6 6.2%

AMT ¼ amniotic membrane transplant; AS ¼ anchoring suture; CAU ¼ conjunctival autograft; CB ¼ chemical burn; MMC ¼ mitomycin;

MMP ¼ mucous membrane pemphigoid; OCP ¼ ocular cicatricial pemphigoid; OMG ¼ oral mocusa graft; RP ¼ recurrent pterygium;

SJS ¼ Stevens-Johnson syndrome; TB ¼ thermal burn; TEN ¼ toxic epidermal necrolysis.

VOL. 160, NO. 3 439SEALING THE GAP IN SYMBLEPHARON SURGERY



The surgery was carried out by a single surgeon(S.C.G.T.) under general anesthesia or topical anesthesia

with 2% lidocaine gel, depending on the severity of symble-

pharon. Epinephrine (1:1000) drops were instilled for he-

mostasis in all patients. The eyelids were separated using

a speculum or 4-0 silk sutures (Ethicon Inc, Somerville, New Jersey, USA), then a 7-0 traction suture (Vicryl;

Ethicon Inc) was placed at limbal episclera to achieve

adequate exposure. All eyes received symblepharon lysis,

which involved circumlunar incision of the conjunctiva

FIGURE 1. Schematic illustration showing the surgical procedure of sealing the gap in symblepharon surgery. After symblepharon

lysis and removal of subconjunctival fibrovascular tissue (Left, pink), the healthy Tenon (Middle, yellow) was identified and an

anatomic gap was created between the excised conjunctiva (Middle, red) and the Tenon capsule (Middle, green). The gap was sealed

by running sutures and then a deep fornix was reconstructed by pulling the Tenon capsule when it naturally retracts posteriorly

(Right, arrow).

TABLE 2. Clinical Characteristics, Surgical Procedures, and Outcomes in Eyes With Various Grades of Symblepharon

Eye

No. Sex

Age

( y) Un de rl yi ng C au se P ri or S urg er y, N o. Gr ad in g OM G a Outcome

Postoperative

Inflammation

Visual Acuity

Ocular Motility

RestrictionFollow-up

(mo)Pre Post Pre Post

1 F 57 Chronic

cicatricial

conjunctivitis

SL þ MMC þ AS, 1 I a1þ CS 0 20/20 20/20 0 0 6

2 M 41 C on ju nctival

scar

AMT, 3 I a2þ CS 0 20/25 20/25 0 0 19

3 F 21 SJS LR, 1 II a1þ CS 1þ CF CF 0 0 8

4 F 44 SJS AMT,1 AMT þ OMG,

1 LR, 1

II a1þ CS 0 HM HM 0 0 33

5 F 23 SJS AMT, 1 IIc0 CS 1þ HM HM 0 0 45

6 M 75 CB KLAL,1 IIc0 CS 0 HM HM 0 0 7

7 M 72 CB CAU þ AMT, 1 III a0 þ CS 0 CF CF 0 0 7

8 F 15 CB LR, 1 III a3þ CS 0 CF 20/400 0 0 9

9 F 23 SJS AMT, 1 IIIc1þ F 1þ 20/30 20/30 0 0 45

10 F 2 TB AMT, 1 SL þ

AMT þ AS,1

IIIc0 þ CS 0 Not

checked

Not

checked

2 0 18

11 F 83 OCP LR, 1 IIIc1þ CS 0 HM HM 2 0 4

12 M 55 SJS IIIc1þ CS 0 HM HM 1 0 11

13 M 55 SJS IIIc1þ PS 0 HM HM 2 0 9

14 F 74 Conjunctival

tumor

Excision of tumor þ SL,

2 CAU þ AMT, 1

IIIc1þ CS 1þ 20/30 20/30 2 0 6

15 M 49 CB IV b0 þ CS 0 20/30 20/20 3 0 24

16 F 51 CB IVc2þ þ PS 1þ CF CF 3 0 22

AMT ¼ amniotic membrane transplant; AS ¼ anchoring suture; CAU ¼ conjunctival autograft; CB ¼ chemical burn; CF ¼ count fingers;

CS ¼ complete success; F ¼ failure; HM ¼ hand motion; KLAL ¼ keratolimbal allograft; LR ¼ lid reconstruction; MMC ¼ mitomycin C;

OCP ¼ ocular cicatricial pemphigoid; OMG ¼ oralmocusagraft; PS ¼ partial success; SJS ¼ Stevens-Johnson syndrome; SL ¼ symblepharon

lysis; TB ¼ thermal burn. a

þ, yes; , no.

440 SEPTEMBER 2015AMERICAN JOURNAL OF OPHTHALMOLOGY

http://-/?-

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at the perilimbal region of the symblepharon, followed byrelaxing incisions toward the fornix along the borders of

symblepharon. Healthy Tenon capsule was distinguishedfrom the subconjunctival abnormal fibrovascular tissue(Figure 3, Top left) by its appearance and by using dryWeck-cel (Beaver-Visitec International, Inc, Waltham,

Massachusetts, USA), which tended to catch the abnormal

tissue (Figure 3, Top middle). The healthy Tenon was iden-tified as nonsticky, relatively nonstretchable, dense, white,

and fascia-like tissue (Figure 3, Top right), while the

abnormal fibrovascular tissue was sticky, slimy, stretchable,and vascular. The fibrovascular tissue was then carefully

dissected off without excising the overlying conjunctivaor the underlying healthy Tenon.

Removal of the abnormal fibrovascular tissue invariablyresulted in further recession of the incised conjunctiva intothe fornix. The gap created between the recessed conjunctiva

and thecut edge of the Tenon capsule was identified and sealed

using a 9-O nylon running suture (Ethicon Inc) along theentire fornix (Figure 3, Middle left and Center). In eyes withsevere symblepharon or ankyloblepharon where there was a

shortage of theremaining conjunctivaltissue, oralmucosagraft

was attached tothelid margin with a running 8-OVicryl suture(Ethicon Inc) before being used to seal the gap, as mentioned

above (Figure 3, Middle right and Bottom left). One layer of

amniotic membrane (AmnioGraft; Bio-Tissue, Miami, Flor-

ida,USA) wasthenusedtocover the exposed extraocularmus-

cle(Figure 3, Bottom middle) and thesecond layer to cover theentire bare sclera (Figure 3, Bottom right), both by fibrin glue

(Tisseel; Baxter Inc, Westlake Village, California, USA).Postoperatively, topical 0.3% ofloxacin drops (Ocuflox;

Allergan Inc, Irvine, California, USA) were applied 3times per day together with 1% prednisolone acetate

(Pred Forte; Allergan Inc) 4 times per day. The former

was discontinued when epithelialization was complete,while the latter was tapered off according to the extent of

conjunctival inflammation. Subconjunctival injection of

Kenalog (Bristol-Myers Squibb Company, Princeton, New Jersey, USA) was given in selective cases.

The surgical outcome was determined based on review-ing documented photographs by a masked reader (A.C).

Complete success was defined as restoration of a smoothocular surface without scarring, reformation of a deepfornix, and regaining of full ocular motility. Partial success

was defined as focal scarring, incomplete formation of the

fornix, or residual ocular motility restriction. Failure wasdefined as recurrence of the symblepharon.

All data were reported as mean 6 standard deviation and

were analyzed using SPSS statistical software, version 19.0

(SPSS Inc, Chicago, Illinois, USA). The correlation indifferent grades of symblepharon with motility restriction and

inflammation was analyzed by Fisher x2 analysis. Correlation

among the variable preoperative factors and complete success

was analyzed by multivariate regression analysis. Differences

FIGURE 2. Photographs demonstrating symblepharon grading. According to the length, symblepharon was graded as I if it was equal

to or greater than the length of palpebral conjunctiva (Top left), II if it was shorter than the length of the palpebral conjunctiva but

equal to or more than that of the tarsus (Top middle), III if it was shorter than the tarsus (Top right), or IV if it was close to zero;

ankyloblepharon was added to this category as well (Bottom left). According to the width, symblepharon was graded as a if the width

was one-third or less of the eyelid width (Top left), b if it was more than one-third but equal to or less than two-thirds of the eyelid

width (Top middle), or c if it was more than two-thirds of the eyelid width (Top right). Inflammation was also graded as 0 if absent

(Top left), 1D if mild (Top right), 2D if moderate (Bottom middle), or 3D if severe (Bottom right).




between preoperative and postoperative factors were analyzedby paired t test. P< .05 was considered statistically significant.

RESULTS

THIS STUDY INCLUDED 16 EYES OF 14 PATIENTS (5 MALE AND 9

female) with a mean age of 47.3 6 24.7 years (range, 2–83years). The underlying cause of symblepharon includedStevens-Johnson syndrome (SJS) (n ¼ 6), chemical burn

(n ¼ 5), ocular cicatricial pemphigoid (OCP) (n ¼ 1), ther-

mal burn (n ¼ 1), following excision of conjunctival squa-mous cell carcinoma (n ¼ 1), conjunctival scarring

following exposed buckle (n ¼ 1), and immune dysregulation

(n ¼ 1). Twelve eyes (75%) had an average of 1.66 0.9 pre-

vious surgeries (range, 1–3). Topical or systemic steroids and

immune modulation were used to control preoperative ocularinflammation in 5 of 6 SJS eyes (83.3%), 1 of 1 OCP eye

(100%), 1 of5 chemicalburn eyes (20%), and 1 of 1 conjunc-tival scarring eye following exposed buckle (100%). More

specifically, in the 7 cases of OCP and SJS, oral steroidsand immune modulation were used in 3 eyes and topical ste-roid eye drops were used in the other 3 eyes.

Before surgery, the severity of symblepharon based on

the length was I in 2 eyes (12.5%), II in 4 eyes (25%), IIIin 8 eyes (50%), and IV in 2 eyes (12.5%). The gradingof the symblepharon width was a in 6 eyes (37.5%), b in

1 eye (6.3%) and c in 9 eyes (56.3%). Inflammation was

found in 2 of 2 grade I eyes, 2 of 4 grade II eyes, 6 of 8 gradeIII eyes, and 1 of 2 grade IV eyes (Table 2). Ocular motility

restriction was significantly correlated with the severity of

symblepharon (P ¼ .02 for both length and width). There

was no ocular motility restriction in grade I and II, mild

FIGURE 3. Photographs showing the key surgical steps in symblepharon surgery. After symblepharon lysis, healthy Tenon capsule

was distinguished from the subconjunctival fibrovascular tissue by its appearance (Top left; the border is marked by arrows) and by

contacting with a dry Weck-cel to catch the abnormal tissue (Top middle, marked by arrows). After excision of abnormal fibrovas-

cular tissue, the healthy Tenon was identified (Top right) and sealed with the recessed conjunctiva by a 9-O nylon running suture

along the entire fornix (Middle left and Center). In eyes with severe symblepharon, oral mucosa graft is attached to the lid margin

by a running 8-O Vicryl suture to one edge while the other is used for the sealing of the gap (Middle right and Bottom left). Amniotic

membrane then was used to cover the exposed muscle (Bottom middle) and the entire bare sclera (Bottom right) by fibrin glue.




(1) in 1 of 8 grade III eyes, moderate (2) in 3 of 8 grade

III eyes, and severe (3) in 2 of 2 grade IV eyes.

Surgery was uneventfully performed in all cases, with seal-ing the gap by 9-0 nylon running sutures in all cases. Amni-

otic membrane was used to cover the bare sclera in all eyes

and to cover the muscle in 11 eyes with or without motilityrestriction. Four eyes with severe symblepharon had extreme

conjunctival shortage and required oral mucosa graft to allowadequate sealing of the gap. Amniotic membrane and oral

mucosa graft were completely secured on the eye surface aftersurgery with either suture or fibrin glue.

After surgery, the mean follow-up time was 17.1 6

13.6 months. Thirteen eyes (81.3%) achieved completesuccess, 2 eyes (12.5%) achieved partial success, and 1

eye with immune dysregulation (6.3%) had failure(Figure 4). There was no correlation between the success

rate and the severity of symblepharon (P ¼ .57 and P ¼

.37 for length and width, respectively). Based on thesymblepharon length, complete success was achieved in

all grade I and II eyes, 75% of grade III eyes, and 50% of grade IV eyes. Based on the symblepharon width, completesuccess was noted in all grade a and b eyes and 66.7% of grade c eyes. Cases with partial success or failure developed

scarring or recurrence within 4 months after surgery. Multi-

variate regression analysis showed that the total success(Complete success þ Partial success) had no significant

correlation with age (P ¼ .29), underlying cause of symble-

pharon (P ¼ .24), preoperative ocular motility restriction(P ¼ .09), or preoperative inflammation (P ¼ .29).

Besides the anatomic success in eliminating symblepharonand regaining a deeper fornix, conjunctival inflammation

was markedly reduced in 8 of 11 eyes with preoperativeinflammation (72.7%) (P ¼ .02). However, all partial successand failure eyes showed a mild inflammatory activity (1þ)

that persisted through follow-up after surgery. The average

length of time for topical steroid eye drops in 12 eyes was6.0 6 1.9 weeks. For the 4 remaining eyes (2 with SJS, 1

with OCP, 1 with chemical burn), topical steroid dropswere continued during the entire follow-up period. Subcon-

junctival injection of Kenalog was given 2 months after sur-gery in 1 eye with SJS but the eye failed to improve. Both oral

steroids and systemic medications were used in 1 patient with

SJS and 1 patient with OCP before and after surgery.

Other additional benefits of the surgery included signif-icantly improved ocular motility in all 7 eyes with prior

ocular motility restriction (P ¼ .006) and improved visualacuity in 2 eyes (13.3%); conditions in the other 13 eyes

(86.7%) remained unchanged without any additional sur-gery to restore the vision.

DISCUSSION

THE SURGICAL GOALS OF TREATING SYMBLEPHARON ARE

to remove the cicatrix; restore ocular surface integrity;

reconstruct the fornix; improve the ocular motility, if

restricted; and prevent recurrence. A variety of surgical ap-

proaches have been attempted to achieve these goals, withvariable results6–10,16,19,20 (Table 1). Previously we have re-

ported a high success rate of 85.2% by selectively deploying

cicatrix lysis, amniotic membrane transplantation, intrao-perative MMC, oral mucosa graft, conjunctival autograft,

and anchoring sutures.19 We have also reported a signifi-cant improvement in the surgical outcome of symble-

pharon following multiple pterygium surgeries by sealingthe gap, which was created between the excised edges of

the conjunctiva and the Tenon capsule following bare

sclera excision of the pterygium.21 Specifically, in thatstudy, we used 3 different methods of sealing the gap (ie,

anchoring sutures, fibrin glue, and a running suture).Because we have reported that the ensuing fibrinolysis of

fibrin glue did not keep the gap sealed as long as 9-0 nylon

did to withstand emanation of fibrovascular tissue in treat-ing multi-recurrent pterygium,21 we chose the latter in this

study to seal the gap. Herein, we deployed the surgical tech-nique of sealing the gap by a continuous 9-O nylon runningsuture in treating pathogenic symblepharon induced bycauses other than recurrent pterygium. Our results showed

that this surgical technique not only creates a strong barrier

to prevent recurrences, but also helps restore ocular surfaceintegrity, reform a deep fornix, and regain full ocular

motility.

The surgical technique of sealing the gap can furtherimprove the surgical outcome by addressing the following

2 major features that might have been overlooked in thesymblepharon surgery. Firstly, it is important to recognize

that the residual abnormal fibrovascular tissue, if not thor-oughly removed, might impede the surgical outcome.6

Previously, this abnormality has been addressed by the

use of MMC.15,16 However, we noted that intraoperative

‘‘thorough’’ and ‘‘meticulous’’ removal of subconjunctivalfibrovascular tissue without removing the upper

conjunctival epithelium or the remaining healthy Tenoncapsule was important. The way of distinguishing

abnormal fibrovascular tissue and the healthy Tenoncapsule is by paying attention to the color, texture,

stretchability/stickiness, and vascularity, of which the

stretchability/stickiness can be further distinguished with

the help of a Weck-cel (Figure 3, Top middle and Topright). In brief, upon contact, abnormal fibrovascular tissue

tended to adhere to Weck-cel and was stretchable andvascular. Secondly, after ‘‘thorough’’ and ‘‘meticulous’’

removal of the subconjunctival fibrovascular tissue, thegap (space) is created between the recessed conjunctiva

and the underlying healthy Tenon capsule. If this gap

was not sealed with a running 9-O nylon suture, it canslowly invite recurrences. Because sealing the gap is suffi-

cient in achieving satisfactory outcome, we recommend

abandoning the use of MMC in symblepharon repair.Future studies are needed to determine if the above mea-

sures are sufficient to mitigate the use of MMC. Taking




FIGURE 4. Representative surgical outcome in eyes with various grades of symblepharon. Preoperative (Left column) and postop-

erative photographs (Right column) of Case 2 with Grade Ia2D symblepharon (Top row, left and right), Case 6 with grade IIc0

symblepharon (Second row, left and right), Case 11 with grade IIIc1D symblepharon (Third row, left and right), and Case 15

with grade IVb0 symblepharon (Bottom row, left and right).




advantage of the natural tendency of the Tenon capsule to

retract posteriorly, the described technique of sealing the

gap appeared to be as effective as the anchoring suturesin restoring a deep fornix. Consequently, it also eliminates

the postoperative need for the patient to come back for the

removal of anchoring sutures.In this study, the recurrence rate of symblepharon was

6.3%, which was comparable to 3.1% when similar sealingthe gap was used for treating recurrent pterygium,21 but

overall less than 14.8% in our previous report, where seal-ing the gap was not performed19 (Table 1). Complete suc-

cess was also noted to increase from 63.9% to 81.3%

compared with our previous study. Our results were similarto Kheirkhah’s combined approach of MMC þ oral mucosa

graft þ amniotic membrane transplantation þ anchoringsuture for fornix reconstruction in severe symblepharon,

which also achieved a low recurrence rate of 6.2%20

(Table 1). However, we did not use an anchoring sutureor MMC and should also help avoid its potential serious

toxic effects of MMC such as scleral necrosis.22,23, Owingto the limited number of cases in this study, the severityof the symbleparon did not influence the outcome.

Controlling inflammation both preoperatively and post-

operatively has substantial impact on the outcome of the

surgery. In our study, topical steroids were used to controlpreoperative ocular inflammation in 5 of 6 SJS eyes, 1 of

1 OCP eye, 1 of 5 chemical burn eyes, and 1 of 1 conjunc-

tival scarring eye following exposed buckle, while oral ste-roids or immune modulation were used in 3 eyes with SJS/

OCP. All eyes underwent operation with stabilized preop-

erative inflammation. Postoperative inflammation control

was used in patients with SJS and OCP. As in other

studies,24,25 the time period with oral or topical anti-inflammatory medication was extended appropriately to

control postoperative inflammation. In our study, 5 of 7

eyes with SJS/OCP continued the use of topical and/or sys-temic steroids during the follow-up period. Subconjuncti-

val injection of Kenalog was used 2 months after thesurgery in 1 eye with SJS but the eye failed to improve.

The 2 cases with partial success had suffered from severesymblepharon due to either chemical burn or SJS, in which

postoperative inflammation continued. The failed case had

immune dysregulation, which persisted after surgery, lead-ing to the recurrence.26 Therefore further studies are neces-

sary to improve the management of preoperative andpostoperative inflammation in patients with autoimmune

disease.

In summary, our findings highlight the importance of the fibrovascular tissue emanating from the fornix in

contributing to symblepharon growth and demonstratethe effectiveness of sealing the gap in combating symble-pharon recurrences. We believed that sealing of the gapbetween the conjunctiva and Tenon capsule is an effec-

tive surgical technique to create a strong barrier for

preventing recurrence, reconstructing a deep fornix,improving visual acuity, regaining full ocular motility,

and reducing conjunctival inflammation in symble-

pharon. We speculate that failure in sealing such a gapexplains the highly variable recurrence rates by different

surgical approaches.

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTERESTand none were reported. Financial Disclosures: Scheffer C.G. Tseng has obtained a patent for the method of preparation and clinical uses of amnioticmembrane and has licensed the rights to TissueTech, Inc, which procures and processes, and to Bio-Tissue, Inc, which is a subsidiary of TissueTech,Inc, to distribute cryopreserved amniotic membrane for clinical and research uses. Funding/Support: This study was supported in part by an unrestrictedgrant from Ocular Surface Research Education Foundation, Miami, Florida. All authors attest that they meet the current ICMJE requirements to qualify asauthors.

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Biosketch

Dandan Zhao, MD, is an attending Ophthalmologist working at Yan’An Hospital of Kunming City, Kunming, Yunnan,

China. She received her master degree from Sichuan University and majored in Ophthalmology. Dr. Zhao received a

government founded training program where she completed a fellowship at Ocular Surface Research & Education

Foundation, Miami, FL, in March 2015. Her primary research interests include ocular surface disease and clinical use of

amniotic membrane.

VOL. 160, NO. 3 446.e1SEALING THE GAP IN SYMBLEPHARON SURGERY

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