|Year : 1964 | Volume
| Issue : 2 | Page : 75-81
Auto-peritoneum as a conjunctival substitute
K Nath, BR Shukla, HV Nema, D Kumar
M. U. Institute of Ophthalmology and Gandhi Eye Hospital, Aligarh, India
|Date of Web Publication||14-Feb-2008|
M. U. Institute of Ophthalmology and Gandhi Eye Hospital, Aligarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Nath K, Shukla B R, Nema H V, Kumar D. Auto-peritoneum as a conjunctival substitute. Indian J Ophthalmol 1964;12:75-81
Partial or total destruction of the conjunctiva occurs following ulcerative conjunctivitis, pemphigus, Steven Johnson syndrome, Sjorgen's syndrome, avitaminosis A, burns, cicatrising skin diseases, xerophthalmia, submucous fibrosis or as a sequela of trachoma. These diseases, when at their worst, produce almost total blindness due to variable amount of cicatrizations and adhesions between the palpebral and bulbar conjunctiva or cornea. The cornea gets keratinised and opacified, due to lack of nutrition and ulcerations. The conjunctival and corneal epithelium becomes xerotic and anterior or posterior, partial or total symblepherons are formed.
Various conjunctival substitutes which have been tried are buccal mucosa (Van Milligen, 1887), nasal mucosa (Weiner, 1939), amniotic membrane (Sorsby and Symon, 1946). Prepuce, mucosa of labium minor and rectal mucous membrane have also been tried. Allen (1953) used peritoneum in cases of contracted sockets and keratinised corneas. Erbakan (1958, 1960) used it in a case of conjunctival navus, which was getting malignant and in cases of socket repairs. Malhotra (1957) utilised it in a variety of conditions as a substitute for conjunctiva.
Inspite of the excellent results obtained with peritoneum, this tissue has not gained due favour with ophthalmologists, probably because of the abdominal surgery involved. We have obtained very good results by using auto-peritoneum from greater omentum in a case of total symblepheron with xerophthalmia in both eyes and in two eyes of two cases of partial symblepheron with xerophthalmia following trachoma. Therefore we feel that a large number of eyes can be saved if more frequent use is made of this tissue.
A Hindu girl, aged 10, in the month of August 1959, had suffered from epileptic seizures for the first time for which she was given sodium-dilantin. After taking these tablets for a fortnight she developed maculopapular rash all over the body in which her eyes also got involved. She developed ulcerations of the cornea and conjunctiva in both eyes in spite of treatment and she had to be admitted on October 5, 1959 at Tirath Ram Shah Hospital, Delhi. At the above hospital a tendency for symblepharon formation was noticed. The left eye had corneal ulcer as well. The vision in her right eye was 6/24 and in the left eye finger counting at 3 meters. Medical treatment gave some improvement. Certain fibrous adhesions were excised in both the eyes on October 10, 1959, under general anesthesia and on February 10, 1960, an egg-membrance was placed in the cul-de-sacs. Thereafter it appears that adhesions were reforming after two operations and she was advised Beta-radiations and later parotid duct transplant. She now came to the Gandhi Eye Hospital, Aligarh on February 15th 1961, with almost total loss of vision in both eyes, that is an year and a half since the commencement of her present condition.
Examinations: On her first visit she was found to have unequal palpebral apertures [Figure - 1],[Figure - 2], the right eye [Figure - 2] being narrower (5 mm) than the left. The lids were rather thick and some lashes in the lower lids were rubbing against the cornea [Figure - 1],[Figure - 2] due to cicatricial entropion. On attempting closure, the lids in both eyes, could not be approximated. There was no lower fornix in either eye thus causing total symblepheron of the lower conjunctival cul-de-sacs. The upper fornices were only 2 mm deep and thus there was almost total symplepheron of both the upper lids as well. The only conjunctival tissue left, was in the region of the narrowed palpebral fissures and that too was completely dry, lustreless, partly keratenised and wrinkled. Similar was the condition of both the corneas. Only the lower part of the cornea could be seen in the right eye which was hazy and opacified superficially in the centre. The rest of it was covered by the lid which was adherent to it. In the left eye the upper part of the cornea was hidden from view while the lower had all grades of corneal opacities. On the nasal side and in the centre there were big leucomas. Anterior chambers could not be seen in either eye due to the keratnised opacified corneas. The vision in R. E. was hand movement and in L. E. was finger counting at 9 inches. R.E. was also slightly divergent [Figure - 1].
Reconstruction : Considering, the dry state of conjunctival cul-de-sacs. complete absence of lower fornices and the previous two attempts at breaking the adhesions, it was thought that parotid duct transplant could not be done at that stage and that any attempt at repairing the fornices was bound to fail due to subsequent contractures in the partially repaired fornices. The total repair of the whole conjunctival cul-de-sac was desirable in one sitting before undertaking the parotid duct transplant. Therefore, on March 7th, 1961, a big piece of greater omentum was taken out by Lang's abdominal incision for appendix which was removed simultaneously. The xerotic conjunctiva was excised completely, adhesions of the symblepharon were freed and lids mobilised. Xerotic corneal epithelium was scraped. After freshening and complete debridement of the whole area and separation of the lids, the omental peritonuem was spread. with its serous surface outwards, so as to line and reform the whole conjunctival cul-de-sac anew [Figure - 3]. To prevent peritoneal displacement, three fixation sutures were passed through the whole thickness of the lids and peritoneum in the fornices, and were tied on the skin side. Peritoneum was left loose so as to compensate for the subsequent contractures. It was finally sutured at the lid margins and the excess was excised. This was followed by introduction of large contact lenses and a broad median tarsorraphy in both eyes. [Figure - 4]. Finally binocular bandage was given after applying an antibiotic ointment.
Post Operative: The fornix and tarsorraphy sutures were removed on the eighth day and lid sutures on the tenth day. Later on, contact lenses were removed once a week and antibiotic ointments were applied twice daily. (See Follow-up table p. 78)
Results: In the left eye both fornices were well formed [Figure - 5] while in the right eye there was a tendency for shallowing of the upper fornix and slight keratitis and vascularisation. It was due to the touch by the contact lens at 12 o'clock as was discovered later.
Present condition (Aug. 63) : After three years of peritoneal transplant and complete replacement of conjunctiva in the left eye it has no entropion, no trichiasis and both the fornices are well formed and maintained. The new coniunctival surface does not have the natural lustre due to lack of secretion. At places it is wrinkled particularly in the region of the palpebral apertures. There is a dense corneal opacity on the nasal side with few nebulae all over. The condition of right fornices [Figure - 6] is similar after a minor reconstruction of the upper fornix performed one and a half years ago. The right eye has corneal opacities and a few blood vessels in the upper and outer part where she suffered from keratitis. The vision in the right eye is 6/60 and that in the left eye is 6/24 with contact lenses. There is no other complaint except that of epiphora in the right eye in which Stenson's duct was transplanted on November 11, 1961. In L.E. she uses gelucil drops to keep it moist.
Future outlook : It is hoped that fornices will remain intact and if so it is intended to do a lamellar corneal grafting in the right eye (the worse eye) and if successful a total penetrating graft will be put in both. Finally it is proposed to transplant the parotid duct in the left eye as well.
A Muslim male [Figure - 7] aged 17, was admitted at Gandhi Eye Hospital, Aligarh, on October 13, 1963, with the complaint of almost total loss of vision in both the eyes at the age of 9, following prolonged 'redness' which lasted for about six months.
On examination, the right eye had entropion of both the lids almost total symblepharon [Figure - 8]. One could only see the lower part of the cornea with a 2 mm. wide clear rim surrounding the leucomatous corneal opacity part of which was hidden. The cornea was vascularised as well. The fornices were barely 2 mm deep and the vision was hand movements. Both eyes had nystagmus.
Left eye had marked scarring of the lids, Herbert's pits and thick leucomatous opacity covering the whole of cornea except for a small temporal part. There was evidence of healed pannus, but fornices were well formed. The vision in this eye was finger counting at 9 inches.
Treatment: With a mind to perform subsequent Stenson's duct transplant and keratoplasty in the right eye, it was decided to reconstruct the fornices in the right eye by auto-peritoneum. The operation was performed on October 27, 1963 by the same technique, as in case I, with the modification that the entropion was also corrected in the same sitting by releasing the pull on lid margins and adjusting the hair lines. On February 3, 1964, the parotid duct was also transplanted and to date there is no complication. A preparatory lamellar keratoplasty followed by a penetrating one is intended for this eye. If everything goes well, only a moderate degree of visual improvement is expected, due to long standing visual handicap and nystagmus. His fornices are well maintained, eight months after the first operation.
A Hindu male aged 30, whose left eye was phthisic following trachoma, ulceration and perforation of cornea, was admitted at Gandhi Eye Hospital, Aligarh, on October 15, 1963, with the complaint of gross diminution of vision in the right eye following treatment for trachoma which he took at his village.
On examination, the patient had large bands of fleshy adhesions from the inner half of lower lid which extended to the corneal surface covering its nasal part and lower half [Figure - 9]. Similar bands extended from the undersurface of the outer half of the upper lid and were attached to the upper and temporal parts of the cornea [Figure - 9]. Thus he had complete partial types of symblepharon in both the lids in the only seeing eye following extensive applications of caustics for the treatment of trachoma. Only a hazy outline of cornea was seen and the vision in this eye was hand movement.
To salvage the only eye, all the fibrovascular tissue was excised and both the lids were mobilised. Omental peritoneum was transplanted by the same technique as in case I on October 27, 1963. At the time of discharge on February 5, 1964, the patient had a vision of 3/60 with contact lens in this eye which also had superficial corneal opacities. Both the fornices were well formed and maintained [Figure - 10]. The eye was dry, a parotid duct transplant has been advised for which he would come again in July, 1964. He is using gelucil drops as artificial tears.
| Discussion|| |
Auto-peritoneum is not used very often as a conjunctival substitute.
Allen (1953), Erbakan (1958, 1960) and Malhotra (1957) have used it in cases of xerosis, symblepharons, socket repairs and as a new conjunctival surface after excision of new growth. It is for the first time that autoperitoneum has been used to replace the diseased conjunctiva completely in both the eyes in one case and the right eyes of two patients thus making a total of four eyes.
Case I came with hand movements in the right eye and finger counting at nine inches in the left eye. Now with the help of contact lenses her vision is 6/60 and 6/24 in the right and left eyes respectively. The progress in the left eye has been very satisfactory while the right eye showed a tendency for recurrence and obliteration of the upper fornix. This was due to a badly fitting contact lens which was touching the right upper cornea causing keratitis and which obliterated the right upper fornix. The defective lens was not discovered earlier otherwise this recurrence might have been avoided.
The cause of the severe ulcerative kerato-conjunctivitis in this case is not clear. Probably she suffered from Stevens Johnson's syndrome after taking sodium dilantin. Stevens Johnson's syndrome has been reported occasionally after taking certain drugs (Sorsby, 1951). This patient too had ulcerative kerato-conjunctivitis and maculopapullar rash all over the body with fever following the administration of dilantin. During this illness her eyes remained closed.
In the second case, besides reconstructing the conjunctival cul-de-sac completely in the right eye, entropion in both the lids was corrected in the same sitting. Reconstruction was followed by parotid duct transplant and the eye has been alright during the past eight months. Similarly total reconstruction was achieved in the third case where both obliterated fornices of the right eye were reconstructed. The vision in this case has improved from hand movements to 3/60. There has been no recurrence.
The experience in the above three cases teaches us that a large number of eyes, suffering from total symblepharon and xerophthalmia, can be salvaged by doing peritonem transplants and entropion correction followed by parotid duct transplants. Later on keretectomy or kerotoplasty has to be undertaken. This treatment has to be spread over a period of 2-3 years and persistent efforts can be rewarding.
The technique described in case one is advocated and it has been observed that lesser the fat in peritoneum the better and quicker is the healing. Further, the peritoneal graft has to be very loose.
| Summary|| |
Total reconstruction of conjunctival cul-de-sac was undertaken, in a young girl with total xerophthalmia following Stevens-Johnson syndrome and the right eyes of two patients following trachoma. The reconstruction of fornices was successful. The operation has to be followed by Stenson's duct transplant and keratectomy or keratoplasty in appropriate cases. For better results fatless omentum is loosely grafted and is supported by contact lenses. In the first case of total xerophthalmia in both eyes, a vision of 6/60 and 6/24 could be given with the help of contact lenses. The technique gives us another weapon in fighting xerophthalmia which commonly occurs as a sequela of trachoma in our country.
| References|| |
Allen, J. H. (1953), Amer. J. Ophthal. 36. 1249.
Callahan, A. (1950), Surgery of the Eye: Injuries, Thomas, Springfield, Illinois.
Erbakan, S. (1958). Goz, klin. (Istanbul), 4,2
Erhakan, S. (1960), Brit. J. Ophthal. 44, 558-561.
Malhotra, M. (1957), Brit. J. Ophthal. 41. 616.
Mackenzie. C.M. (1946). Amer. J. Ophthal. 29, 867-869
Sorsby, A. and Symons, H.M., (1946), Brit. J. Ophthal. 30, 337-45.
Sorsby, A. (1951). Systemic Ophthalmology. Butterworth. Lond. p. 587.
Wiener. M. and Alvis, B. Y. (1939) Surgery of the Eye, Saunders. Philladelphia.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11]
[Table - 1]