Successful treatment of cicatricial entropion requires control of fibrotic process
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Patients with cicatricial entropion and fornix scarring represent a significant reconstructive challenge.
Unfortunately, by the time such patients reach me, they have often already had several unsuccessful surgeries, and with each failed procedure comes additional scarring.
Cicatricial entropion is caused by conjunctival scarring pulling the eyelid margin inward toward the eye. The first step is to identify the scar. Sometimes it is a visible band of scarring, possibly caused by prior surgery or trauma; other times, such as in the context of ocular cicatricial pemphigoid or Stevens-Johnson syndrome, it can involve much of the conjunctival surface. If untreated, the underlying cicatrizing process will lead to treatment failure even in the context of expertly conducted reconstructive surgery. To address the problem, I have learned to take a multipronged approach, with the expectation that any tissue augmentation performed onto an inflamed, actively cicatrizing process is doomed to fail.
First, I treat the ongoing fibrotic/cicatrizing process using serial injections of 5-fluorouracil directly into the conjunctival scar. As I recently published, four to five serial injections of 5-FU into conjunctival scars lead to scar remodeling, improve eyelid position and enhance success of subsequent surgical interventions.
The next step is to excise the scarred, diseased tissue, including underlying thickened connective tissue matrix (Figures 1a to 1c). This allows the eyelid margin to return to a normal position, but it also typically creates a large conjunctival defect that may involve the eyelid margin, fornix and even bulbar conjunctiva.
Source: Alon Kahana, MD, PhD
Because chronic scarring usually involves loss of local tissue stem cells, I address the defect using mucous membrane free graft from either the inner cheek (buccal) or lip. I thin it as much as possible before placing it over the defect, positioning the graft to ensure good vascular supply for tissue integration and healing (Figures 2a to 2e). The graft brings with it its own stem cells that can proliferate to cover the defect. However, the defect is frequently larger than the safely available mucous membrane graft. To fully cover the rest of the defect, I use AmnioGuard cryopreserved umbilical cord amniotic membrane (UC-AM) (BioTissue), which is thick and robust enough to easily suture to surrounding conjunctiva and skin (Figure 3a). In order to further facilitate healing, I layer the rest of the UC-AM graft over the entire surgical site, often covering the cornea as well, and place a temporary suture tarsorrhaphy and a pressure patch (Figure 3b). The AmnioGuard AM facilitates epithelialization while reducing inflammation, hypervascularization and scarring, and it serves as a matrix on which patients’ mucus membrane cells can grow and repopulate the missing mucosa over the area of the defect. Like all AM grafts, UC-AM is acellular, avoiding an immune system response. Additionally, it has no specific orientation, so it provides its full benefits regardless of which side is laid down, which reduces surgical complexity and saves time.
If a patient’s conjunctival scar is smaller and more focal, UC-AM grafting alone may be sufficient. In an eye that is otherwise healthy and has plenty of conjunctival stem cells, I will lay a UC-AM graft over the defect, suture it into position at the fornix and along the edges, potentially place a symblepharon ring, and place a temporary tarsorrhaphy. If needed, fornix sutures may be added, tied over foam bolsters on the skin. Over a few weeks, conjunctival stem cells proliferate to repopulate the matrix and reform healthy conjunctiva, while inflammation and hypervascularity are reduced by the long-chain hyaluronic acid proteins in the UC-AM graft.
Whenever using a graft, it is important to ensure that the graft is large enough to cover the defect without tension. If there is tension, graft tissue will die, and the scarring will recur. Thus, if I were repairing a 2.5 cm × 2 cm defect following scar release and excision, I might suture a 1.2 cm × 0.8 cm buccal graft to one edge of the defect, and then suture a piece of AmnioGuard right next to it to fully cover the defect (Figure 3). Then I would layer the entire area of reconstruction with a patch of AmnioGuard to provide additional anti-inflammatory support throughout the healing process (Figure 4).
Among the most critical steps in the overall process is ensuring that the scar tissue is fully released. If it is not, it will result in a failed surgery and an even larger defect.
- References:
- Jovanovic N, et al. Ophthalmic Plast Reconstr Surg. 2021;doi:10.1097/IOP.0000000000001717.
- Koreen IV, et al. Ophthalmic Plast Reconstr Surg. 2009;doi:10.1097/IOP.0b013e3181a13f0e.
- Slentz DH, et al. Ophthalmic Plast Reconstr Surg. 2019;doi:10.1097/IOP.0000000000001264.
- Slentz DH, et al. Ophthalmic Plast Reconstr Surg. 2020;doi:10.1097/IOP.0000000000001555.
- Tseng SCG. Invest Ophthalmol Vis Sci. 2016;doi:10.1167/iovs.15-17637.
- Tseng SCG, et al. Ocul Surf. 2004;doi:10.1016/s1542-0124(12)70059-9.
- For more information:
- Alon Kahana, MD, PhD, professor and vice chair of ophthalmology, Oakland University William Beaumont School of Medicine, can be reached at Kahana Oculoplastic and Orbital Surgery, 25500 Meadowbrook Road, Suite 260, Novi, MI 48375; email: alon.kahana@beaumont.org.
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