The procedure in this video demonstrates repair of an eyelid cicatricial entropion with an oral mucous membrane graft in a patient with cicatricial entropion secondary to radiation therapy for uveal melanoma.
Procedure: The procedure in this video demonstrates repair of an eyelid cicatricial entropion with an oral mucous membrane graft in a patient with cicatricial entropion secondary to radiation therapy for uveal melanoma.
Introduction: Cicatricial entropion can lead to ocular discomfort and damage of the ocular surface secondary to exposure keratopathy as well as keratinization and scarring of the palpebral conjunctival epithelium. In more severe cases, various types of grafts can be used to repair the entropion. An oral mucous membrane graft can be used as an effective option.
Indications/Contraindications: Indications for this procedure include mild to moderate cases of cicatricial entropion. Contraindications include systemic conditions that would preclude induction of general anesthesia, bleeding or clotting disorders, and acute inflammation such as patients with ocular cicatricial pemphigoid who are not on immune modulated therapy.
Materials/Methods: Standard eyelid surgical instrumentation is used for this procedure, as well as a second Westcott scissor and suction for harvesting of the mucous membrane graft.
Results: Improvement or resolution of keratopathy and ocular surface irritation secondary to cicatrized eyelid epithelium.
Conclusion: Use of an oral mucous membrane graft is an effective method to treat mild to moderate cases of cicatricial entropion where the tarsus is minimally involved and systemic inflammation is controlled.
The purpose of this surgical technique is to replace cicatrized tarsoconjunctival tissue –which causes internal rotation of the eyelid margin, keratinization, and subsequent damage to the ocular surface – with other healthy epithelial tissue. There are varying methods to treat this condition, depending on the cause and severity of the cicatrized tissue. Cicatricial scarring and concomitant entropion may result from a multitude of causes, including post-radiation scarring as in the case of this patient, autoimmune disease such as ocular cicatricial pemphigoid, inflammatory conditions such as Stevens Johnson syndrome, infections including trachoma and herpes zoster, or scarring from chemical burns, thermal burns, trauma, or post-surgical scarring. This procedure is indicated in mild to moderate cases of cicatricial entropion resulting from any of the above etiologies. Contraindications for this procedure include bleeding or clotting disorders as well as any conditions that are contraindicated for induction of general anesthesia. Surgery is also contraindicated in cases of acute inflammatory or autoimmune conditions, where manipulation of the tissue can cause further inflammation and worsen the condition, such as in cases of ocular cicatricial pemphigoid when patients are not immune modulated. In such cases, systemic treatment is indicated and surgery may be considered when the disease stabilizes.
This procedure is advantageous compared to a tarsal fracture operation in that it does not require a full thickness incision of the eyelid. It is advantageous compared to other forms of mucosal grafts as it spares other tarsal or eyelid tissue, and is less bulky compared to hard palate or ear cartilage grafts. Furthermore, oral mucous membrane heals rapidly and well, and is not externally visible. However, in more severe cases of cicatricial entropion that extensively involve the tarsus, these alternative mucous grafts are often indicated. Complications and risks include bleeding, infection, corneal abrasion, recurrence of cicatricial scarring, or worsening of inflammation in cases of conditions such as ocular pemphigoid.
Instrumentation/Setup: A standard surgical eye instrumentation kit is used for this procedure.
Preoperative workup: A thorough history and complete eye exam with slit lamp biomicroscopy should be performed, with special attention to the structure and function of the eyelids and evaluation of the ocular surface. Digital eversion to inspect for scarring of the tarsal conjunctiva is critical, and digital traction of the eyelids is important to distinguish cicatricial from involutional entropion. In cases of suspected systemic inflammatory or autoimmune conditions, pertinent biopsy or laboratory work-up should be performed.
Anatomy and landmarks: Understanding the anatomy of the eyelid and buccal mucosa is critical for this procedure.
Detailed steps to procedure:
Local anesthetic is infiltrated into the eyelid and a corneal shield is placed over the eye. A 4-0 silk traction suture is placed through the eyelid and the eyelid is everted over a cotton-tipped applicator. The involved portion of the tarsal conjunctiva and margin is marked for excision and incised with an #11 blade. Area to be removed should include keratinized or significantly scarred conjunctiva. Sharp Westcott scissors are then used to dissect the palpebral conjunctiva from the tarsus, and the conjunctival defect is measured. Attention is then turned to the oral cavity. The lower lip is everted to expose oral mucosa, and a strip of mucosa is marked centrally inside the lower lip. Care is taken to avoid damage to avoid the salivary ducts. The area is infiltrated with local anesthetic, then incised with a #15 blade and dissected from the underlying tissues with Westcott scissors. A wet sponge is placed over the donor site and the graft is moved off of the field. Westcott scissors are used to carefully trim excess tissue from the deep surface of the graft. A 6-0 plain gut suture is used in a running fashion to suture the oral mucous membrane graft into the conjunctival defect in the eyelid. Good hemostasis of the eyelid and the oral mucous membrane donor site is obtained with gentle pressure.The corneal shield and traction suture are both removed. A bandage contact lens is placed in the eye and antibiotic drops are instilled.
The goal of an oral mucous membrane graft to repair cicatricial entropion is to remove abnormal scarred or keratinized tissue of the posterior lamella and eyelid margin that is causing cicatricial entropion and ocular surface irritation. Post-operatively, there should be improvement or resolution of keratopathy and ocular surface pain, and the eyelid should remain in good position. On eversion, the mucous membrane graft should remain flat and without cicatricial scarring or keratinization. Potential negative outcomes include post-operative complications such as infection or hematoma, dehiscence of the mucous membrane graft from the donor site, persistent ocular surface irritation either from initial disease or from sutures, worsening of inflammation in cases of systemic disease such as ocular pemphigoid, or recurrence of disease with may necessitate additional surgery.
Use of an oral mucous membrane graft is one of several methods used to repair cicatricial entropion and its sequelae. Critical steps of this procedure include demarcation and excision of the of the entire affected area of cicatrized epithelium as well as a thin lamella of underlying tarsus from the affected eyelid, measurement of the defect with deliberate overestimation of approximately 30% in size as the graft will shrink after harvesting, dissection of the graft with care to leave behind and submucosal tissue and further dissection of the acquired graft over a gloved figure with care to avoid button-holing, and finally suturing the graft to the donor site with a running suture and buried knot to avoid corneal irritation. Common pitfalls include harvesting a graft that is too small for the donor site, harvesting a graft with too much underlying submucosal tissue or causing a buttonhole when thinning the graft, or not burying knots which may lead to further corneal irritation.
An oral mucous membrane graft has several advantages over other existing techniques, including sparing of other eyelid tissue such as in a tarsoconjunctival graft, rapid healing and lack of visibility of the oral mucosa compared to other graft sites, and avoiding external or full thickness incisions of the eyelid as in a tarsal fracture. It is important to note that this procedure is limited to cases of mild to moderate cicatricial entropion. In severe cases where the tarsus is involved, alternative treatments should be considered including tarsoconjunctival grafts, ear cartilage grafts, hard palate mucosal grafts, or preserved scleral grafts. This procedure is also limited to cases of inactive inflammation, as manipulation of the conjunctiva in these cases can lead to exacerbation of disease.