Restoration of Fornix Tear Reservoir in Conjunctivochalasis With Fornix Reconstruction.

PURPOSE: To determine whether conjunctivochalasis (CCh) obliterates the fornix tear reservoir and to discern whether there is concomitant aqueous tear deficiency (ATD) dry eye. METHODS: Retrospective review of 18 eyes of 12 patients with CCh and ATD (CCh + ATD) and 18 eyes of 13 patients with CCh without ATD (CCh - ATD). Changes were compared before and after fornix reconstruction regarding symptoms, basal tear volumes, use of medications, conjunctival inflammation, and corneal staining. RESULTS: Fornix reconstruction with conjunctival recession and amniotic membrane transplantation effectively restored the fornix tear reservoir as evidenced by a significant increase of the basal tear volume in both CCh - ATD and CCh + ATD groups. Multivariate regression analysis confirmed that such improvement was significantly correlated with symptomatic resolution (r = 1, P < 0.001), which was also accompanied by significant resolution of corneal staining, conjunctival inflammation, and reduction of topical medications. Intriguingly, the prior diagnosis of ATD was no longer existent in 10 of the 18 eyes (56%) with CCh + ATD suggesting that ATD could be secondary to obliteration of the fornix tear reservoir by CCh. CONCLUSIONS: Obliteration of the fornix tear reservoir is a common pathogenic process regardless of whether CCh is associated with ATD dry eye. Restoration of the tear reservoir by fornix reconstruction with conjunctival recession and amniotic membrane transplantation results in significant resolution of symptoms and signs associated with ATD that is secondary to CCh and helps identify genuine ATD dry eye that is independent of CCh.

Accelerated Restoration of Ocular Surface Health in Dry Eye Disease by Self-Retained Cryopreserved Amniotic Membrane.

PURPOSE: To evaluate the clinical efficacy of self-retained cryopreserved amniotic membrane in treating dry eye disease. METHODS: Retrospective review of 10 patients treated with self-retained cryopreserved amniotic membrane (PROKERA® Slim [PKS], Bio-Tissue, Miami, FL) for moderate-to-severe dry eye refractory to conventional maximal medical treatments. Patients' symptoms, use of medications, conjunctival inflammation, corneal staining, and visual acuity were compared before and after treatment. RESULTS: PKS was placed in 15 eyes of the 10 patients for 4.9 ± 1.5 days. All patients experienced symptomatic relief for a period of 4.2 ± 4.7 months (P<.001). Such improvement was accompanied by reduction of OSDI scores (P<.001), use of topical medications (P<.001), conjunctival hyperemia (P<.001), corneal staining (P<.001), and improvement of the visual acuity (P=.06). Linear regression analysis estimated that the optimal duration of PKS placement was 5 days to achieve an average symptom-free duration of 4 months in patients with dry eye. Surprisingly, PKS placement also generated improvement in the contralateral eyes. CONCLUSION: This pilot study suggests that self-retained cryopreserved amniotic membrane via PKS can be used to treat moderate dry eye diseases and warrants further prospective controlled studies.

Sealing of the gap between the conjunctiva and tenon capsule to improve symblepharon surgery.

PURPOSE: To report the surgical outcome of "sealing the gap" in treating symblepharon caused by various etiologies other than recurrent pterygium. DESIGN: Retrospective, interventional case series. METHODS: Sixteen eyes of 14 patients with pathogenic symblepharon were consecutively operated by conjunctival recession, sealing the gap between recessed conjunctiva 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 conjunctival shortening, oral mucosa graft was added. Outcome measures include ocular surface inflammation, fornix reformation, 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), thermal burn (n = 1), following excision of conjunctival squamous cell carcinoma (n = 1), conjunctival scarring following exposed buckle (n = 1), and immune dysregulation (n = 1). Twelve eyes (75%) had an average of 1.6 ± 0.9 previous surgeries. Before surgery, ocular motility restriction 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 with immune dysregulation had failure (6.3%). There was no correlation between the success rate and the severity of symblepharon. After surgery, the ocular motility and inflammation were significantly improved. Visual acuity had improved in 2 of 15 eyes. CONCLUSIONS: Sealing the gap between the conjunctiva and Tenon capsule is an important step in the surgical management of pathogenic symblepharon. This method not 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 full ocular motility.