Mucous membrane graft for severe atopic conjunctivitis
Richard C. Allen, MD, PhD, FACS
Additional Notes: Length 05:06
This video demonstrates treatment of a patient with severe atopic conjunctivitis on the left. This has resulted in punctal and canalicular stenosis as well as severe irritation secondary to the upper palpebral conjunctiva. The patient has failed all medical intervention by the external disease physician and continues to complain of severe photophobia. The upper punctum is dilated with a punctal dilator. A Bowman probe is then placed through the canaliculus which appears to be tight. A hard stop can be appreciated. The same is then performed on the lower eyelid where again the canaliculus appears to be very tight. A hard stop appears to be appreciated and the probe is attempted to be placed down the nasolacrimal duct with difficulty. Again the native lacrimal system is attempted to be palpated. The upper lid canaliculus is again inspected. After multiple attempts, it is determined that a small ostomy will be made with the Bowman probe. This is performed with back-and-forth motions through the posterior portion of the lacrimal sac fossa. A Crawford stent is then placed through the ostomy and retrieved from the nose. I consider this to be a small endonasal dacryocystorhinostomy that definitely is not ideal. The stents are retrieved from the nose and a 4-0 silk suture in placed through the upper eyelid at the level of the tarsus to provide traction.
The eyelid is then everted over a shoehorn speculum were the irregular, scarred palpebral conjunctiva is appreciated. This extends to the superior border the tarsus. It is determined that the conjunctiva will be excised from the posterior surface of the tarsus. This is performed with Westcott scissors. As one can see, the surface of the conjunctiva is very irregular and scarred. After excision of the conjunctiva, the posterior surface of the tarsus is inspected. The tarsus is then scraped with a 15 blade to remove any residual conjunctival epithelium as well as smooth out the surface of the tarsus. This is performed to the eyelid margin. Residual conjunctiva is excised. A mucous membrane graft will be placed over the posterior surface of the tarsus. This has been harvested from the patient's buccal mucosa. This is sutured into position with a running 7–0 Vicryl suture. This will give the patient a new mucous membrane surface on the surface of his tarsus. At the conclusion of the case, the eyelid appears to be in appropriate position. The eye will be patched with a double eye pad and the patient will return in approximately 1 week.
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