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Sutureless surgical technique can treat conjunctivochalasis
Surgeons explain their technique for conjunctivochalasis using fibrin tissue adhesive.
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Introduction
Conjunctivochalasis is an under-recognized and under-treated ocular condition. Symptomatic patients who fail to respond to medical treatment to control associated inflammation can benefit from surgical intervention and correction of conjunctivochalasis, or CCh. This month’s guest columnists present a surgical approach to managing this condition using fibrin glue.
Thomas John, MD
OSN Corneal Dissection Editor
Topical anesthesia is preferred for the correction of CCh. After the usual surgical preparation, a few drops of non-preserved epinephrine 1:1000 (Hospira) are instilled on the ocular surface to achieve vasoconstriction for hemostasis, and 2% lidocaine gel (AstraZeneca) is applied for anesthesia.
Surgical technique
Thomas John |
The location and severity of CCh are confirmed during surgery by grabbing the conjunctiva with 0.12 forceps to reveal conjunctival “tenting.”
The globe is rotated superiorly by placing a traction suture made of 7-0 Vicryl 1 mm posterior to the limbus at the 6 o’clock position.
An arc-like conjunctival peritomy is created about 1 mm to 2 mm posterior to the limbus in the area of CCh, eg, from 3- to 9-o’clock positions for inferior CCh (Figure 1a). This incision is extended to remove pinguecula, if present. In the latter condition, peritomy should be extended to the entire interpalpebral zone to avoid a postoperative disfiguring scar in the exposed area. Because of poor adhesion of the conjunctiva to the sclera and the dissolution of Tenon’s capsule in eyes with CCh (Figure 1b), the bulbar conjunctiva posterior to the peritomy readily retracts, exposing the bare sclera.
The remaining movable Tenon’s capsule including prolapsed subconjunctival fat, if present, is excised. Conjunctiva is then recessed to the fornix. In cases of severe conjunctival thinning, the conjunctival edge is trimmed (Figure 1c). If significant subconjunctival fat prolapse is noted, it might be necessary to suture the recessed edge of conjunctiva to the sclera about 10 mm to 12 mm posterior to the limbus. This is done by interrupted 8-0 Vicryl sutures that are placed parallel to the fornix line, and this prevents future herniation of the orbital fat into the fornix.
Cryopreserved amniotic membrane (Bio-Tissue) is peeled off the nitrocellulose filter paper and placed on the sclera with the stromal surface facing down. Half of the membrane is folded over onto the other half to expose the stromal surface.
The fibrinogen solution (Tisseel, Baxter) is first applied onto the scleral surface (Figure 1d); then the thrombin solution is applied onto the same location (Figure 1e) or onto the stromal surface of amniotic membrane that has been exposed via folding. Then the membrane is flipped back on the sclera, and after 5 seconds a muscle hook is used to spread the fibrin glue under the amniotic membrane (Figure 1f). The above steps are repeated for the other half of the membrane. The excessive membrane and fibrin glue are trimmed. The traction suture is removed. Fibrin glue is also used to attach the surrounding loose conjunctiva to the sclera.
| Figure 1. Surgical steps of amniotic membrane transplantation using fibrin glue for conjunctivochalasis | ||
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Images: John T |
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Surgical instruments and supplies
One AmnioGraft AG-2520 Size A (Bio-Tissue) will be needed for each eye if CCh involves the entire inferior bulbar conjunctiva. The “F” version is preferred, as it is slightly thicker and therefore favorable for this indication.
Tisseel (1 mL) should be prepared in the operating room as per the manufacturer’s instructions and be ready for use.
The traction suture is made with 7-0 Vicryl.
Treatment
In cases associated with pinguecula, at the end of the operation triamcinolone acetonide can be injected subconjunctivally adjacent to the site where pinguecula is removed.
After surgery, a steroid-antibiotic ointment (0.3% tobramycin and 0.1% dexamethasone) should be used before sleep for 1 week. An antibiotic eye drop (eg, ofloxacin) and a steroid eye drop (1% prednisolone acetate) should be used four times a day, tapered over 3 to 4 weeks. At 3 to 4 weeks postoperatively, subconjunctival injection of triamcinolone acetonide may be needed for cases with continued focal inflammation around the surgical site.
And a pearl: The use of fibrin glue shortens the surgical time, hence allowing topical anesthesia and avoiding suture-related complications.
For more information:
- Thomas John, MD, can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com. Dr. John has no proprietary interest in any aspect of this article. Scheffer C.G. Tseng, MD, PhD, can be reached at 7000 SW 97 Ave., Suite 213, Miami, FL 33173; 305-274-1299; fax: 305-274-1297; e-mail: stseng@ocularsurface.com. Dr. Tseng has a financial interest in TissueTech, which owns patents on the method of preparation and clinical uses of human amniotic membrane distributed by Bio-Tissue Inc.
References:
- Kheirkhah A, Casas V, et al. Amniotic membrane transplantation with fibrin glue for conjunctivochalasis. Am J Ophthalmol. 2007;26(6):685-691.
- Meller D, Tseng SC. Conjunctivochalasis: literature review and possible pathophysiology. Surv Ophthalmol. 1998;43(3):225-232.
- Meller D, Maskin SL, Pires RTF, Tseng SC. Amniotic membrane transplantation for symptomatic conjunctivochalasis refractory to medical treatments. Cornea. 2000;19(6):796-803.
- Otaka I, Kyu N. A new surgical technique for management of conjunctivochalasis. Am J Ophthalmol. 2000;129(3):385-387.
- Yokoi N, Komuro A, et al. Clinical impact of conjunctivochalasis on the ocular surface. Cornea. 2005;24(8 Suppl):S24-S31.