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Conjunctival flap surgery an option for calcified scleromalacia after periocular surgery
Study finds cosmetic results are satisfactory in most patients, especially with the use of collagen matrix and fibrin glue.
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Long-term clinical outcomes of conjunctival flap surgery to treat calcified scleromalacia after periocular “eye whitening” surgery suggest that it may be a satisfactory treatment, according to a South Korean study.
In a study of 60 eyes of 43 patients with a mean follow-up of 26.5 months, the mean morphological score at final examination was 2.2 and the mean patient-reported cosmetic outcomes score was 2.9, representing results that were almost “good.”
“There are about 2,000 people in Korea who have received cosmetic wide conjunctivectomy, mostly with postoperative mitomycin C with or without bevacizumab injection,” co-author Kyoung Yul Seo, MD, PhD, said of the eye whitening procedure. “Thus, it is important to observe them carefully over time in an effort to prevent late complications and devastating loss of vision.”
Procedure
The conjunctival flap procedure involves applying topical anesthesia with proparacaine eye drops and subconjunctival anesthesia with lidocaine/epinephrine, followed by calcified plaque removal using forceps, a pterygium knife and, recently, calcium plaque scissors.
“If the thickness of remaining sclera was too thin, we used Ologen collagen matrix (Body Organ Biomedical),” Seo told Ocular Surgery News.
Next, a relaxing incision is made on the intact superior conjunctiva, adjacent to the bare sclera, and the conjunctival flap is transposed to cover the bare sclera. Several Vicryl sutures and possibly Tisseel fibrin glue (Baxter) are applied to the conjunctival flap.
“Especially among the later cases, when we used Ologen or Tisseel, patients are happy with their cosmetic results,” Seo said.
The authors of the study, which appeared in Cornea, believe that a wide conjunctivectomy disrupts the normal physiology of the ocular surface.
“The area of the resected conjunctiva for cosmetic eye whitening surgery is about 10 mm in diameter, and the concomitant use of MMC contributes to the high incidence of complications of cosmetic surgery,” Seo said, noting that the scleral stroma is composed of collagen bundles of varying sizes and shapes and is normally avascular.
“The episcleral and choroidal vascular networks supply the sclera with nutrients,” Seo said. “Thus, suppressing re-epithelialization and vascularization leads to avascular necrosis of the sclera and calcification. Our conjunctival flap surgery with calcified plaque removal can restore the ocular surface and supply vascular supply from autologous normal conjunctiva.”
The authors’ initial indications for conjunctival flap surgery were progressive scleral calcification enlargement and an increase in patient complaints, such as irritation, foreign body sensation and redness around the calcification, after periocular surgery.
“However, cosmetic wide conjunctivectomy combined with topical MMC causes earlier and more damage to the sclera compared with routine pterygium surgery,” Seo said. “In later cases, we performed the surgery slightly earlier. This resulted in better surgical outcomes and patient satisfaction.”
Advantages
The chief advantage of treating calcified scleromalacia with conjunctival flap surgery is that there is no need for donor tissue or amniotic membrane to cover a wide bare scleral area. Furthermore, the higher vascular supply from autologous normal conjunctiva “can restore nutrition to avascular sclera,” Seo said. “A higher success rate, low recurrence rate, low cost and fewer postoperative complications are advantages to this surgery.”
Slit lamp photographs were taken at every visit to evaluate any recurrence or complications. No cases of progressive sclera thinning or serious complications, such as flap necrosis or sclera perforation, were noted. Only three surgical areas with an inferior flap required additional flap placement, due to avascular sclera exposure.
Some study patients, before and after flap surgery, were treated with artificial tears (86%), punctal plugs (2.3%), lid therapy with warm compression or lid scrub (67.4%) and minocycline oral medication for meibomian gland dysfunction (7%).
“The proportion of patients who were treated with these ocular surface managements was high, considering their mean age (41 years at initial visit),” Seo said. “This could be the result of cosmetic wide conjunctivectomy; on the other hand, it might be the cause of conjunctivectomy.”
Seo and colleagues plan to publish complications of the conjunctival flap surgery when using Tisseel or Ologen. – by Bob Kronemyer
Reference:
Jung JW, et al. Cornea. 2015;doi:10.1097/ICO.0000000000000326.For more information:
Kyoung Yul Seo, MD, PhD, can be reached at Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, South Korea; email: seoky@yuhs.ac.Disclosure: Seo reports no relevant financial disclosures.