J Korean Ophthalmol Soc.  2011 Dec;52(12):1405-1413. 10.3341/jkos.2011.52.12.1405.

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

• Choi WS
• Lee GJ
• Park YJ
• Lee KW

• KMID: 2215142
• DOI: http://doi.org/10.3341/jkos.2011.52.12.1405

Abstract

PURPOSE
To evaluate the surgical results and complications arising from scleral graft and free conjunctival autograft using tissue adhesive and temporary amniotic membrane transplantation as the surgical treatment for scleromalacia.
METHODS
Scleral graft and free conjunctival autograft using tissue adhesive and temporary amniotic membrane transplantation was performed in 20 eyes of 20 patients with scleromalacia caused by pterygium excision. The surgical results and complications arising from the procedure were monitored and analyzed through follow-up.
RESULTS
During the follow-up period of 17.6 +/- 5.9 months, the wound injection and edema at the free conjunctival autograft and operation site healed in all the cases except 1 at postoperative 1 month. The stability of the ocular surface for graft transplantation was maintained at postoperative 3 months. Although a partial absorption of the conjunctival autograft induced by careless treatment occurred 2 weeks postoperative in 1 case, the ocular surface stabilized due to suitable treatment after 6 months. Although the edges of the scleral graft in 3 patients were partially absorbed 6 months postoperatively, the ocular surface stability was maintained by covering the conjunctival autografts.
CONCLUSIONS
For scleromalacia patients, scleral graft and free conjunctival autograft using tissue adhesive and temporary amniotic membrane transplantation rapidly stabilized the ocular surface and presented excellent aesthetic results.

Keyword

Fibrin glue; Free conjunctival autograft; Scleral graft; Scleromalacia

MeSH Terms

Absorption
Amnion
Edema
Eye
Fibrin Tissue Adhesive
Follow-Up Studies
Humans
Pterygium
Tissue Adhesives
Transplants
Fibrin Tissue Adhesive
Tissue Adhesives

Figure

• 

  Figure 1. Surgical procedures of scleral graft, free conjunctival autograft using tissue adhesive (Tissucol Duo Quick®, Baxter AG, Vienna, Austria) and temporary amniotic membrane patching in scleromalacia. (A-D) After debridement of the necrotic and surrounding sclera tissue, a scleral graft of appropriate size was prepared. Fibrin tissue adhesive, Tissucol Duo Quick® was used to at-tach the precisely cut-to-fit scleral graft to the recipient site. (E-G) A free conjunctival autograft from the superior palpebral conjunctiva was prepared making sure it was a little larger than the scleral defect size. The conjunctival autograft and the recipient site were attached in the following manner: Tissucol Duo Quick® was applied to the recipient site and the conjunctival autograft was pressed firmly on to it making sure all the edges were matched with no conjunctival surfaces exposed. Then, the recipient site and conjunctival autograft were sutured with 10-0 nylon at 4 points. (H-I) A temporary amniotic membrane was sutured on top of the conjunctival autograft to protect and facilitate the healing of the implanted scleral graft and conjunctival autograft. It was removed 5 to 7 days after the operation.

• 

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

• 

  Figure 3. A case photograph of scleromalacia in a 55 years old female after free conjunctival autograft with sclera graft. (A) Preoperative photograph showed sclera thinning with exposed uveal tissue and a severe avascular sclera bed at the site of previous pterygium excision. (B) Postoperative photograph at 2 weeks showed partial melting of the free conjunctival autograft due to steroid eye drop use following the operation (C) Postoperative photograph at 6 months showed partial absorption of the sclera graft and conjunctival autograft. (D-1, 2) Last followup photographs (18 months postop) showed relatively stable ocular surface with vascularized scleral bed and reepithelialization of the conjunctival autograft despite the additional absorption of the sclera graft.

• 

  Figure 4. Photographs of scleral graft edge partial absorption after free conjuntival autograft with scleral graft. (A, B-1) Preoperative photographs show scleral thinning with exposed uveal tissue at the sites of previous pterygium excision. (A, B-2) Scleral grafts were completely covered by free conjunctival autografts and edemas of conjunctival autografts decreased in postoperative photographs at 3 months. (A, B-3) Stable ocular surfaces, with complete coverage of conjunctival autograft were shown despite the partial absorptions of the scleral grafts edges (black arrow) in postoperative 6 to 12 months photographs.

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  Figure 5. Excessive vascularization (black arrow) at donor site in free conjunctival autograft with scleral graft for restoration of scleromalacia.

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