Oral Mucosal Graft to Correct Lid Margin Pathologic Features in Cicatricial Ocular Surface Diseases

EDITOR: THE ARTICLE BY FU AND ASSOCIATES EVALUATING THE

mos by buccal mucosal graft would aid in healing of corneal lesions.

SAURABH KAMAL SUSHIL KUMAR

New Delhi, India

oral mucosal graft in cicatricial ocular surface reconstruction is very interesting.1 The lamellar division of the eyelid at the grey line with repositioning is used for corrections of entropion and lid margin keratinization. We also have found the technique very useful for such cases. In addition to the correction of lid margin deformity, the procedure also corrects lid retraction and lagophthalmos. However, the technique at our center differs from that of Fu and associates in the following respects. We carry out the splitting of anterior and posterior lamella just short of superior fornix along with the passage of 3 mattress sutures from the conjunctiva toward the skin. These sutures prevent retraction of the posterior lamella in the postoperative period and are removed at the third week. Second, in the presence of lid retraction, we perform the recession of the Mller muscle by freeing it from the superior tarsus border and conjunctiva. This produces slight ptosis and corrects retraction as well as lagophthalmos. In the present series, for eyes with incomplete closure, the oral mucosal graft was obtained intentionally with more stromal fat so that the tarsal height could be lengthened. In 3 of 12 cases, the residual incomplete closure could be attributed to fat resorption that required oral mucosal graft to both the upper and lower lid. For such cases with severe scarring, our technique may be used. The cicatricial diseases usually cause contraction and shortening of posterior lamella with severe entropion. Therefore, some may advocate the use of posterior lamella as a substitute in such situations, rather than tarsoconjunctiva advancement. A stiff replacement such as hard palate mucosal graft, nasal septal cartilage with mucoperichondrium, and ear cartilage can cause signicant morbidity at the donor site. However, if the surface of the tarsal conjunctiva is severely keratinized and rough, it may be better to replace it with healthier mucosa. Therefore, we prefer posterior lamella graft in such patients. We routinely use topical antibiotics and copious lubrication for healing of the epithelial defects. Ten eyes (45.4%) in present study had persistent epithelial defect diagnosed before surgery. Their postoperative treatment included topical 0.1% dexamethasone drops. By decreasing inammation, corticosteroids may facilitate epithelial migration2 and may suppress sterile ulceration by reducing proteolytic enzymes.3 Hence, their use by the authors may have altered the course of the corneal ndings. Nevertheless, the correction of blink-related microtrauma and lagophthal386 AMERICAN JOURNAL
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CONFLICT OF INTEREST DISCLOSURES: ALL AUTHORS HAVE completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest and none were reported.

REFERENCES

1. Fu Y, Liu J, Tseng SC. Oral mucosal graft to correct lid margin pathologic features in cicatricial ocular surface diseases. Am J Ophthalmol 2011;152(4):600 608. 2. Wagoner MD, Kenyon KR, Gipson IK, Hanninen LA, Seng WL. Polymorphonuclear neutrophils delay corneal epithelial wound healing in vitro. Invest Ophthalmol Vis Sci 1984; 25(10):12171220. 3. Kao WW, Ebert J, Kao CW, Covington H, Cintron C. Development of monoclonal antibodies recognizing collagenase from rabbit PMN; the presence of this enzyme in ulcerating corneas. Curr Eye Res 1986;5(11):801 815.

REPLY
I THANK DRS KAMAL AND KUMAR FOR THEIR INTEREST IN

our recently published article.1 I am pleased to learn that they also found our surgical technique useful in correcting lid margin deformity, lid retraction, and lagophthalmos. Although the proposed surgery starts from lamellar division of the involved eyelid at the grey line and ends with posterior repositioning of the anterior lamella, our splitting of anterior and posterior lamella does not reach the level that they stated, that is, just short of superior fornix. As a matter of fact, ours only reaches the level that is sufcient to allow the anterior lamella to be recessed from the tarsal margin, that is, approximately 3 to 5 mm. They found it benecial to pass 3 mattress sutures from the conjunctiva toward the skin, presumably in a manner similar to the Quickert procedure, which is known to prevent retraction of the posterior lamella and to correct entropion. They also performed the recession of the Mller muscle to create slight ptosis and to correct retraction as well as lagophthalmos. Notwithstanding the fact these steps have their own merits, however, we did not do so and have not noted such a shortcoming in our patients. We suspect that our patients may have different underlying causes from theirs because the main pathologic features reside at the lid margin, exhibiting keratinization, distichiasis, scarring, and contour decit, instead of entropion or retraction. Because topical steroids had been used before the lid margin reconstruction in most patients, the main reason leading to improvement of all persistent corneal epithelial OPHTHALMOLOGY FEBRUARY
2012