|Year : 1980 | Volume
| Issue : 4 | Page : 201-205
Peritoneal graft as conjunctival replacement
Y Dayal, G Ghosh, KS Ratnakar, IM Bhatia
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dayal Y, Ghosh G, Ratnakar K S, Bhatia I M. Peritoneal graft as conjunctival replacement. Indian J Ophthalmol 1980;28:201-5
Successful management of extensive symblepharon, gross degrees of entropion, contracted socket and many such conditions still pose a problem to the ophthalmologist. Often extensive conjunctional replacement becomes a necessity, requiring suitable material in large amount. A number of tissues have been used for the purpose, which include conjunctiva, skin, foetal membranes, mucous membranes and peritoneum.,,,,,
No experimental study about the role of peritoneum for grafting was available until Collin reported successful auto-peritoneal grafts in rabbits. These studies have prompted us to evaluate the fate of homo-peritoneal grafts in an experimental set up and take the way for wider clinical acceptance.
| Materials and methods|| |
Pilot studies both in normal and acid burnt conjunctiva revealed that total (360°) or three quadrant (270°) grafting had adverse effects on the corneal nutrition resulting in oedema, infiltration, ulceration and even perforation [Figure - 1]. The graft itself showed gross shrinkage. However, with a 180° graft these hazards could be avoided. Thus this was taken up as the standard amount of conjunctival replacement in one eye for the experimental model.
Sixteen rabbits, weighing between 2-2.5 kg. were divided into 2 groups - Group A Normal conjunctiva was replaced by homo peritoneal grafts. Group B : Peritoneal grafting was done after producing an acid burn by 0. 1 to 0.2 ml of N Hcl placed in the conjunctival sac.
Peritoneum : Parietal peritoneum was dissected out from rabbits killed with 100 mg of I/V Nembutal. The aponeurosis of transversalis muscle was dissected away from the parietal peritoneum and a thin, transparent membrane obtained. The transversalis fascia could not be separated from the peritoneum.
Grafting : Grafting was carried out under Nembutal (?0 mg i.v.) anaesthesia. Bulbar and Palpebral conjunctiva was excised from upper half of conjunctival sac (180°). The graft, 25-30% larger than the defect, was then placed to cover the defect and sutured all round with 8-0 silk. The graft was so placed that the mesothelial surface lined the conjunctival sac. Fornix j was formed with one or two deeply placed double arm sutures. Postoperatively frequent local antibiotic drops were used for the first 5 days; later antibiotic and steroid ointment were used twice daily. The eyes were observed at regular intervals to know the host reaction and the graft reaction. At intervals of 3 days, I week, 2 weeks, 3 weeks, 4 weeks, 2 months, 3 months and 6 months, the grafts were taken out and processed for histopathology examination.
| Observations|| |
(A) Host Reaction
Host reaction in the form of lid oedema and hyperaemia along with conjunctival chemosis started from the 1st day, was maximum between the 3rd and 5th day and largely disappeared after 1 week. Conjunctival congestion was also present from the 1st postoperative day, was maximum between 3rd and 7th day and disappeared only after 3rd week. The host reaction was somewhat more severe in group B than in group A but no gross difference existed.
(B) Graft Reaction Clinical Observation:
Oedema was seen from 1st day onwards reaching its peak by 5 days.
Graft necrosis was seen in all cases. Started on 5th day, reached maximum level at I week and continued at least for another week, but in some cases upto fourth week [Figure - 2].
Vascularisation : Vascularisation appeared in the graft only after 2 weeks in group A and 3 weeks in group B [Figure - 3].
Epithelialisation : Epithelialisation started from the periphery after the peak phase of necrosis was over; somewhat later in group B. Epithelialisation was complete in both groups by 2 months but still did not have the moist, glossy, refractile healthy look of the normal conjunctiva. By 6 months the conjunctiva was completely covering the original defect and appeared functionally healthy as well [Figure - 3]. Thus no gross difference in the behaviour of the graft in the two groups existed. Only one case, from Group B, showed complication in the form of symblepharon formation.
By 3rd day mesothelium was almost totally intact ; submesothelial tissue showed infiltration by inflammatory cells and necrosis which was more in group B than in group A.
At 1 week mesothelium was lost, necrosis was more marked and replacement fibrosis with vascularisation had already started. At 2 weeks necrosis was still evident and epithelialisation, at host graft junction, with partial migration of single layered epithelium was seen. At 3 weeks replacement fibrosis was complete with surface lined by single layered flattened epithelium. By 4 weeks surface and epithelium had started to grow multilayered at places, vascularisation and epithelialisation were evident. By 2 months epithelialisation was seen to be completed, though the epithelium was flattened irregular and no goblet cells were seen.-At 3 months epithelium was almost normal in pattern but still goblet cells were absent. Normal healthy conjunctival epithelium with regular cellular pattern and goblet cells were noted only at 6 months [Figure - 4].
It was observed that there was no gross difference between the two groups, except that the initial reaction in the form of graft necrosis, inflammation and vascularisation was more marked in group B.
| Discussion|| |
From clinical point of view, use of hemoperitoneum is a more practical approach than auto peritoneum. The material can be had in plenty from patients undergoing an abdominal surgery or surgeries for hernia or hydrocele. For obtaining autoperitoneum the patient has to undergo the trauma of a second surgery which is accompanied by all the possible hazards of opening the abdominal cavity. Keeping these in mind we selected hemoperitoneum as the material of choice.
Hitherto, no experimental work has been done with this material. Thus ours is the first experimental model to evaluate homoperitoneal graft in replacing the conjunctiva.
From the pilot studies, it is seen that replacing whole or three-fourth of the conjunctiva at one sitting, has had adverse effects on cornea and also the graft did not take. This could be avoided when only half the conjunctiva was replaced by the graft at a time. Based on this observation the surgery can be graded as follows, if we divide the conjunctival sac into four quadrants :
Grade I Replacing 90° or less
Grade II Replacing between 90° and 100°
Grade III Replacing between 180° and 270'
Grade IV Replacing between 270° and 360°
As grade III or IV surgery adversely affects the cornea it is advocated that grade II replacement is optimal and grade I is desirable. If more than 180° replacement is required, it should preferably be done in two stages. This has been well seen in our experimental set-up.
Graft necrosis is a consistent feature in all the rabbits in both the groups. The graft oedema was maximum between 3rd and 5th day. Necrosis was at its peak at 1st week. Vascularisation started from periphery only after 2nd week. So graft necrosis in all probability was an ischaemic process.
Epithelialisation is a gradual and slow process. Initially, it starts from periphery and is flat, irregular not properly attached to basement membrane and is not healthy looking. It is only after 3 months that the whole defect is covered by multilayered epithelium which clinically appears normal. It is only between 3rd and 6th month that goblet cells appear, as seen histologically and the epithelium becomes healthy. This correlates well with study of Collin.
Many types of tissues have been used as grafts to replace conjunctiva, but the mechanism, as to how they act, may not be the same. In general, either they may retain their original character or change themselves to adapt to the surrounding.
In our experiments none of the grafts retained their original characteristics but were finally replaced by healthy conjunctival epithelium. Thus we agree with the view expressed by Collin that peritoneum acts as a `Scaffold graft', but some amount of normal conjunctiva should be present in the surrounding for successful epithelialisation.
In our experiments, normal conjunctiva appeared by 3 months cosmetically and functionally was observed only by 6 months.
Thus studying the advantage of homoperitoneal graft, its use should be encouraged.
| Summary|| |
The experimental evaluation of homoperitoneal graft as conjunctival replacement has been done.
| References|| |
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Alberth, B., 1968, Surgical Treatment of caustic injuries of the eye, Akdemias Kiado, Budapest.
Collin, J.R.O., 1975, Brit. J. Ophthalmol., 5:288.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]