OSLI Retina

October 2016

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October 2016 · Vol. 47, No. 10 951 including the basement membrane, stromal surface, and retained collagen from the placental interface. We selected the thicker 110-µm dehydrated amniotic membrane allograft compared to the thinner 35-µm alternative, hypothesizing that the thicker graft would be sturdier and more appropriate due to the thickness of the fibrosed conjunctival edges, with potentially better uptake. The grafts are sterilized and provided as a 15-mm dehydrated disc for room-temperature storage with no refrigeration required. The allograft has a watermark impression allowing for visual iden- tification of the basement and stromal surfaces. Ha et al. recently described a staining the amniotic mem- brane grafts with a fluorescein strip to enhance visu- alization of the translucent membrane. 15 Conjunctivoplasty is the simplest procedure per- formed in cases with exposed scleral buckle. 16 How- ever, it is effective only in cases with a small area of exposure, since large areas of exposure, especially in the fornices, lead to high wound tension and forni- ceal foreshortening. Healing by secondary intention also carries the potential risk of forniceal foreshorten- ing and conjunctival epithelial ingrowth. 17 In our case, we attempted primary conjunctival closure, which did not hold due to the wound ten- sion. Fibrosis had resulted in shortening of the con- junctiva, causing excess traction on the sutures due to the large exposure. Scleral patch grafting is the most frequently used technique for exposed exoplants. 18-20 Other materials that have been used for conjuncti- val closure following removal of an extruded scleral buckle include processed human cadaveric pericar- dium, 21 autogenous fascial grafts, 22 and retroauricular periosteal patch graft. 23 Heterogeneous tissue, how- ever, carries the risks of transmission of viral and other infectious agents and immunogenic rejection. Conjunctival autograft from the contralateral normal eye is another option but may result in scar tissue, symblepharon, and limbal stem cell deficiency in the donor eye. Another alternative is an oral mucosal graft, which may also lead to unsatisfactory cosmetic results because of the nonconjunctival epithelial mor- phology and discomfort in the mouth during the heal- ing period. With this technique, care must be taken to place the graft flush tight on the recipient bed and the mar- gin of the graft should be tucked under the conjuncti- va after undermining the edges. Infection should also be ruled out before contemplating placement of an amniotic membrane graft. In conclusion, dehydrated amniotic membrane graft can be a viable solution for reconstruction of large conjunctival defects following removal of exposed scleral buckle with good cosmetic and functional results. REFERENCES 1. Deokule S, Reginald A, Callear A. Scleral explant removal: the last decade. Eye (Lond). 2003;17(6):697-700. 2. Deutsch J, Aggarwal RK, Eagling EM. Removal of scleral explant ele- ments: a 10-year retrospective study. Eye (Lond). 1992;6(Pt 6):570- 573. 3. Kazi MS, Sharma VR, Kumar S, Bhende P. Indications and outcomes of scleral buckle removal in a tertiary eye care center in South India. Oman J Ophthalmol. 2015;8(3):171-174. 4. Hahn YS, Lincoff A, Lincoff H, Kreissig I. Infection after sponge implantation for scleral buckling. Am J Ophthalmol. 1979;87(2):180- 185. 5. Russo CE, Ruiz RS. Silicone sponge rejection. Early and late complications in retinal detachment surgery. Arch Ophthalmol. 1971;85(6):647-650. 6. Lincoff H, Nadel A, O'Connor P. The changing character of the in- fected scleral implant. Arch Ophthalmol. 1970;84(4):421-423 passim. 7. Tsui I. Scleral buckle removal: indications and outcomes. Surv Oph- thalmol. 2012;57(3):253-263. 8. Rasouli M, Khuthaila M, Spirn MJ, Garg SJ, Greve MD, Hsu J. Out- comes of scleral buckle removal with and without concurrent prophy- lactic laser retinopexy. Can J Ophthalmol. 2014;49(1):30-34. 9. Liu J, Sheha H, Fu Y, Liang L, Tseng SC. Update on amniotic mem- brane transplantation. Expert Rev Ophthalmol. 2010;5(5):645-661. 10. Li M, Zhu M, Yu Y, Gong L, Zhao N, Robitaille MJ. Comparison of conjunctival autograft transplantation and amniotic membrane transplantation for pterygium: a meta-analysis. Graefes Arch Clin Exp Ophthalmol. 2012;250(3):375-381. 11. Thomasen H, Pauklin M, Steuhl KP, Meller D. Comparison of cryopreserved and air-dried human amniotic membrane for oph- thalmologic applications. Graefes Arch Clin Exp Ophthalmol. 2009;247(12):1691-1700. 12. Shimmura S, Shimazaki J, Ohashi Y, Tsubota K. Antiinflammatory effects of amniotic membrane transplantation in ocular surface disor- ders. Cornea. 2001;20(4):408-413. 13. Espana EM, Prabhasawat P, Grueterich M, Solomon A, Tseng SC. Amniotic membrane transplantation for reconstruction after excision of large ocular surface neoplasias. Br J Ophthalmol. 2002;86(6):640- 645. 14. Tamhane A, Vajpayee RB, Biswas NR, et al. Evaluation of amniotic membrane transplantation as an adjunct to medical therapy as com- pared with medical therapy alone in acute ocular burns. Ophthalmol- ogy. 2005;112(11):1963-1969. 15. Ha J, Martinez JA, Korchak M, Cremers SL. Intraoperative fluores- cein staining of cryopreserved amniotic membrane grafts to improve visualization during and after pterygium surgery: a novel technique. Cornea. 2016;35(3):413-416. 16. Kittredge KL, Conway BP. Management of the exposed scleral ex- plant. Semin Ophthalmol. 1995;10(1):53-60. 17. Colosi NJ, Yanoff M. Intrusion of scleral implant associated with con- junctival epithelial ingrowth. Am J Ophthalmol. 1977;83(4):504-507. 18. Wilson RS, Parker JC. Scleral patch for exposed silicone buckles. Oph- thalmic Surg. 1975;6(3):83-85. 19. Watzke RC. Scleral patch graft for exposed episcleral implants. Arch Ophthalmol. 1984;102(1):114-115. 20. Murdoch JR, Sampath R, Lavin MJ, Leatherbarrow B. Autogenous la- bial mucous membrane and banked scleral patch grafting for exposed retinal explants. Eye (Lond). 1997;11(Pt 1):43-46. 21. Weissgold DJ, Millay RH, Bochow TA. Rescue of exposed scleral buckles with cadaveric pericardial patch grafts. Ophthalmology. 2001;108(4):753-758. 22. Dresner SC, Boyer DS, Feinfield RE. Autogenous fascial grafts for exposed retinal buckles. Arch Ophthalmol. 1991;109(2):288-289. 23. Gupta SR, Anand R, Diwan S, Gupta N. Salvaging recurrent scleral buckle exposure with autologous periosteal patch graft. Retin Cases Brief Rep. 2014;8(3):178-182.

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