|Year : 2021 | Volume
| Issue : 1 | Page : 106-107
A complicated case of symblepharon managed with Goretex
Anitha Venugopal, Meenakshi Ravindran
Aravind Eye Hospital, Tirunelveli, Tamil Nadu, India
|Date of Submission||16-Apr-2020|
|Date of Acceptance||17-Jul-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Anitha Venugopal
Aravind Eye Hospital, S.N High Road, Tirunelveli Junction, Tirunelveli - 627 001, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The objective of this study was to report a complicated case of chemical injury with symblepharon, LSCD, and pseudo pterygium managed successfully with ePTFE (Goretex) a novel method of treatment to prevent recurrence of symblepharon. A 10-year-old girl presented to us with progressive symblepharon and pseudopterygium encroaching the visual axis leading to defective vision, strabismus amblyopia, and motility restriction. The challenge, in this case, was the recurrence of symblepharon and fleshy growth. Goretex is a biocompatible and inert material. Along with Amniotic membrane transplantation (AMT), it creates a strong mechanical barrier between tenons, sclera, and tarsus. Thereby it prevents the recurrence of symblepharon, Goretex is a novel treatment approach that is simple and effective in preventing symblepharon.
Keywords: AMG, e-PTFE, Goretex, symblepharon
|How to cite this article:|
Venugopal A, Ravindran M. A complicated case of symblepharon managed with Goretex. Indian J Ophthalmol Case Rep 2021;1:106-7
Symblepharon is the condition resulting from adhesion of two raw surfaces in the fornix (lid and the ocular surface) following chemical injury or autoimmune diseases. The adverse effect of symblepharon is dry eyes, diplopia due to the restriction of extraocular movements and secondary lid abnormalities. In our case, the patient developed strabismic amblyopia due to mechanical esotropia. The management of symblepharon and the prevention of its recurrence are quite challenging, even for an experienced surgeon. We managed progressive symblepharon by intraoperative insertion of e-PTFE, expanded polytetrafluoroethylene (Goretex) between the bulbar and palpebral conjunctiva. Goretex is kept in place for 4 weeks until the epithelisation of the raw conjunctival surfaces occurs. Goretex is an alloplastic material used in vascular and abdominal patch grafts. This material is inert, biocompatible, has excellent rigidity and now being used in ocular reconstructive surgery. The clinical application of e-PTFE for the prevention of symblepharon recurrence has given a good result in our case.
| Case Report|| |
A 10-year-old girl presented to us with complaints of fleshy growth in the left eye. She gave the history of accidental fall of acid, one year ago, for which she took medical treatment. On examination, her vision in the right eye was 6/6, and the left eye was 6/18 in the Snellen chart, not improving with pinhole. Slit-lamp examination of the right eye was within normal limits, whereas the left eye showed nasal pseudopterygium with symblepharon involving medial canthus and inferior medial quadrant of the cornea [Figure 1]a with normal punctum. We planned, left eye symblepharon lysis with SLET and amniotic membrane implantation, but the patient did not review. She came after 2 years with further deterioration of vision in the left eye from 6/18 to 5/60 in the Snellen chart. On slit-lamp examination, the left eye revealed pseudo pterygium, invading the visual axis. There was a complete restriction of abduction, esotropia, and strabismus amblyopia [Figure 1]b. The progressive nature of pterygium indicates a high probability of recurrence after symblepharon lysis surgery. Thus, we proceeded with symblepharon lysis, pseudopterygium excision, along with careful dissection of fibrovascular tissue from the corneal surface.
|Figure 1: (a) First Visit with vision 20/50. (b) Second visit with progressive pseudopterygium involving visual axis, vision 20/250. (c) Goretex with AMT done. (d) Final follow-up visit with epithelised ocular surface|
Click here to view
The surgical steps include autologous mini SLET over the involved limbus and the implantation of Goretex, sandwiched between amniotic membranes in the inferior medial bulbar conjunctiva. The 10-0 nylon suture was used to anchor the Goretex with the episclera [Figure 1]c. Postoperatively, the patient was treated with topical steroids in tapering doses for 6 weeks, along with lubricants, and antibiotic eye drops four times a day for 4 weeks, and for the right eye, occlusion therapy was given. Goretex was removed after 4 weeks, and the underlying conjunctiva is completely epithelised [Figure 1]d. No recurrence was noted after 8 months. The vision in the left eye improved to 6/18 with glasses at a one-year follow-up.
| Discussion|| |
Symblepharon is one of the most challenging problems following chemical injury due to a high chance of recurrence even after extensive removal of fibrovascular tissue. The predicting factors for recurrence are not known fully in the literature. We report our experience of symblepharon lysis, Goretex, with AMT (Amniotic membrane transplantation) as the novel treatment approach to prevent the recurrence of symblepharon.
A variety of adjuvants are known for successful surgical management of symblepharon. Glass rods, symblepharon rings, conformers, AMT used in acute conditions of chemical injuries to prevent the formation of symblepharon but fail to treat chronic sequelae, as they do not reach the deep fornix to prevent the recurrence., Although AMG is a safe and effective method to prevent symblepharon, it has a high recurrence rate of 3.8 to 40.9%, as reported by Arani et al. and Moreno-Lopez et al., Our Patient is in the pediatric age group, and AM grafting may require multiple procedures due to its property of spontaneous resorption and frequent fall from the ocular surface. Ridley et al. had described symblepharon rings as early as in 1967. He proposed that it can be used only in acute cases and not in severe pathologic corneas. Other techniques such as usage of MMC, CLET, AMT, and CAU (Conjunctival autograft) do not give satisfactory results in eyes with progressive recurrence and fibroproliferative tendency. Hurtado et al. had reported that CLAG (Conjunctival limbal autograft) in the treatment of symblepharon was associated with the highest index of recurrence and oral mucosal graft with the lowest index of recurrence. Shimazaki et al. achieved a stable ocular surface in four patients of recurrent pterygium with symblepharon after AMT and a limbal autograft transplant. An oral mucosal graft is an effective procedure for preventing symblepharon, but considering the age of our Patient, the difficulty in harvesting the graft, limited availability, and potential complications at the donor site triggered us to consider an alternative procedure.
The principal aim of prevention of recurrence of symblepharon is to have a mechanical barrier to keep potentially adhesive surfaces apart until the initial phase of inflammation and fibrosis subsides, to prevent the recurrence of the growth. Goretex acts as an effective mechanical barrier separating tenons, sclera, and the palpebral conjunctiva, to prevent fibrosis. During the initial phase of healing, the proliferation of fibroblasts and extracellular matrix accumulation starts, and lasts for 3-6 weeks. The Goretex is placed in the bulbar conjunctiva, separating it from palpebral conjunctiva for 3-4 weeks. It acts as a mechanical barrier and prevents exaggeration of fibrosis and angiogenesis. The AMG helps epithelial migration, adhesiveness, and differentiation. Kim et al. had established a novel approach of inserting multimicroporous e-PTFE (Goretex) for treating intractable multirecurrent pterygium. The mechanism of fibrosis and inflammation is similar in both pterygium and symblepharon formation. Goretex is available as a white surgical membrane and made microporous with 30 G needle at multiple sites to allow oxygen diffusion to the tissue underneath during the phase of wound healing to reduce the exaggeration of fibroblastic activity (Kim et al.). We had many challenges, age of the patient, recurrence, the amblyopia management, and the extensive involvement of the ocular surface. Eight months after the Goretex procedure, our patient did not develop a recurrence of symblepharon and showed considerable improvement in ocular motility, which helped us in treating the strabismus amblyopia. The patient's visual acuity improved to 6/18 with glasses during her last visit.
| Conclusion|| |
Successful treatment of the ocular surface post chemical injury remains incompletely defined in the literature. Goretex can be considered as a novel method in preventing recurrence of symblepharon.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kheirkhah A, Blanco G, Casas V, Hayashida Y, Raju VK, Tseng SC. Surgical strategies for fornix reconstruction based on symblepharon severity. Am J Ophthalmol 2008;146:266-75.
Lee YJ, Khwarg SI. Polytetrafluoroethylene as a spacer graft for the correction of lower eyelid retraction. Korean J Ophthalmol 2005;19:247-51.
Karesh JW. Biomaterials in ophthalmic plastic and reconstructive surgery. Curr Opin Ophthalmol 1998;9:66-74.
Kara N. Sutureless amniotic membrane transplantation with a modified ocular surface ring. Can J Ophthalmol 2018;53:e46-8.
Arain MA, Yaqub MA, Ameen SS, Iqbal Z, Naqvi AH, Niazi MK. Amniotic membrane transplantation in primary pterygium compared with bare sclera technique. J Coll Physicians Surg Pak 2012;22:440-3.
Moreno-Lopez R. Comparative study between primary pterygium excision using conjunctival autograft, amniotic membrane, and primary closure. Rev Mex Oftalmol 2004;78:291-7.
Girard LJ. Symblepharon Prevention. Arch Ophthalmol 1991;109:1196.
Kim KW, Kim JC, Moon JH, Koo H, Kim TH, Moon NJ. Management of complicated multirecurrent pterygia using multimicroporous expanded polytetrafluoroethylene. Br J Ophthalmol 2013;97:694-700.
Hurtado OB, Guel TA, Magaña BF, Pelayo FB. Surgical treatment for symblepharon secondary to chemical injuries. Invest Ophthalmol Vis Sci 2009;50:1486.
Shimazaki J, Shinozaki N, Tsubota K. Transplantation of amniotic membrane and limbal autograft for patients with recurrent pterygium associated with symblepharon. Br J Ophthalmol 1998;82:235-40.