OSLI Retina

October 2016

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October 2016 · Vol. 47, No. 10 949 Figure 1. Color slit-lamp photograph on presentation (A) showing redness and injection temporally corresponding to the exposure site. The patient was complaining of irritation and discomfort in the temporal area. Follow-up photograph at 3 months following amni- otic graft placement (B) shows a white and quiet conjunctiva; the patient was asymptomatic. Under a peribulbar block, the tire and sleeve were removed through the existing conjunctival opening after cutting the tire. The sub-Tenon's space was ir- rigated with an antibiotic rinse. The superotemporal conjunctival defect could be closed primarily after undermining the edges. However, there was forma- tion of significant granulation tissue and conjunc- tival scarring, which prevented primary closure of the 10 mm × 12 mm inferotemporal defect. Due to the extensive conjunctival fibrosis, the presence of a large defect, and the location close to the inferior fornix, it was not possible to mobilize the required conjunctival length despite undermining the edges. This resulted in significant tension on the sutures leading to suture breakage when attempting primary closure. A 15-mm disc of 100–µm-thick dehydrated amni- otic membrane was trimmed to 1 mm larger than the conjunctival defect. The bare sclera was then dried completely and fibrin sealant (TISSEEL; Baxter In- ternational, Westlake Village, CA) was applied over the defect. The amniotic membrane was placed over the defect and secured to the sclera with the fibrin sealant. The graft edges were tucked under the sur- rounding conjunctiva with the stromal side facing down as assessed by the watermark impression. The adherence of the graft to the sclera was confirmed by lack of movement upon manipulation with a cotton tip applicator (video available at www.Healio.com/ OSLIRetina). Topical dexamethasone/neomycin/ polymyxin B drops were used postoperatively, four times a day during a 2-week period. Gram stain and culture of the buckle elements were negative. On the first postoperative day, the amniotic membrane graft was visualized in position with complete coverage of the conjunctival defect (Figure 2B). At 3 months' fol- low-up, the eye was white and quiet with resolution of symptoms (Figure 1B), and the conjunctival defect had completely healed (Figure 2C). DISCUSSION Exposed scleral buckles are at risk for getting in- fected and explantation is often required, since ob- servation alone with topical broad-spectrum antibi- otic ophthalmic solutions is generally found to be inadequate. Recurrent retinal detachment after scler- al buckle removal has been reported to be around 3.4%. 8 Although the scleral buckle can be removed by opening only one quadrant of conjunctiva or using a pre-existing site of exposure, the closure of the con- junctival defect can often be challenging. We describe the use of a dehydrated amniotic membrane graft for closure of a large conjunctival de- fect that failed primary closure following removal of an extruded scleral buckle. Accurate graft placement and manipulation with respect to the defect was eas- ily achieved with the basement membrane surface externalized to facilitate epithelialization and incor- poration into the host tissue. Amniotic membrane is commonly used in con- junctival reconstruction to facilitate healing with less inflammation and minimal scarring. 9,10,11 The amni- otic membrane graft is an allograft harvested from the innermost layer of the placenta, with anti-inflammato- ry, anti-fibrotic, and antiangiogenic properties. 12 It is approved by the U.S. Food and Drug Administration for wound covering and healing. Amniotic membrane grafts are commonly used in a spectrum of ocular surface disorders, such as corneal ulcers, superficial punctate keratitis, chemical and thermal burns of the cornea, persistent epithelial defects, symblepharon removal, fornix reconstruction, conjunctival replace- ment after conjunctival lesion removal, and pterygi- um excision surgery. 13,14 The amniotic membrane al- lograft (Ambio5; IOP Ophthalmics, Costa Mesa, CA) comprises native amniotic membrane tissue layers,

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