Year : 1999 | Volume
: 47 | Issue : 2 | Page : 129--131
Rectal mucous membrane graft for dry eye syndrome
Vikas H Mahatme
Mahatme Eye Bank and Eye Hospital, Nagpur, India
Vikas H Mahatme
Mahatme Eye Bank and Eye Hospital, 16 Central Excise Colony, Ring Road, Near Sai Mandir, Nagpur - 440 015
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Mahatme VH. Rectal mucous membrane graft for dry eye syndrome.Indian J Ophthalmol 1999;47:129-131
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Mahatme VH. Rectal mucous membrane graft for dry eye syndrome. Indian J Ophthalmol [serial online] 1999 [cited 2023 Mar 20 ];47:129-131
Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1999/47/2/129/22787
Treatment of dry eye poses a definite challenge; use of rectal mucosal graft to populate conjunctiva with goblet cells is likely to facilitate production of tears and mucin.
Dry eye syndrome results from a deficiency of the aqueous layer, meibomian secretion or mucin layer. Although various tests can determine the integrity of different components of the tear film, in conditions such as chemical burns, Steven-Johnson Syndrome (SJS) erythema multiforme, pemphigoid, trachoma, and vitamin-A deficiency, there is extensive conjunctival damage resulting mainly in deficiency of the mucin component of the tear film which is secreted by the goblet cells of the conjunctiva. Artificial tears and lubricants can compensate for this mucin deficiency only to a certain extent.
This is the only treatment available currently to replace mucin deficiency. Buccal mucosa if grafted does not fulfil the function of mucin secretion as it does not contain goblet cells. Since goblet cells are abundant in the rectal mucosa the author decided to use it for transplantation. Our initial experience with this technique is reported herein.
Materials and Methods
This study was carried out at Mahatme Eye Bank & Eye Hospital, Nagpur, from January 1993 - March 1996. Fifteen eyes of 8 patients suffering from severe degree of dry eye resulting from chemical burns and drug induced SJS, were selected for this study. The remaining cases of dry eye were excluded. Symptoms such as pain, photophobia, and foreign body sensation were graded from 0 (no symptom) to 3 (severe) using a subjective scale which was validated. Preoperatively only those patients having all the three symptoms of grade 3 nature were selected for this study. Concomittant artificial tears were instilled. In all patients other surgical procedures like correction of entropion and tarsorrhaphy were carried out at least 2 months prior to rectal mucosal graft surgery.
Rectal mucosal graft was taken out from the same patient by a general surgeon under spinal anaesthesia. Due care was taken in pre-operative bowel preparation. After stretching the anal sphincter, a self-retaining retractor was placed in the anal canal. A wheal was raised by injecting normal saline beneath the rectal mucosa and 30×30 mm of rectal mucosa was removed from the posterior wall. The bare area of rectal wall was closed by 2-0 chromic catgut by interrupted horizontal sutures. The graft so obtained was placed in 1% povidone iodine solution for at least half an hour. The submucosal tissues were then cleared from the graft, avoiding buttonholing.
Grafting was done in following way (Figure). Conjunctival incisions were made in upper and lower fornix. The graft, measuring 15×30 mm, was placed in the fornices and sutured to the cut edges of conjunctiva.
To maintain the graft in a stretched position, fornix-deepening sutures were taken. The procedure was similar to any fornix-deepening procedure and mucous membrane graft for shallow fornix, as in contracted socket. But this procedure was done here without regard to the depth of the fornix so as to form a new deep fornix by rectal mucous graft. No confirmer was used. This was all done after achieving good haemostasis. In 11 eyes suturing was done by 6-0 vicryl with interrupted sutures. In the last 4 eyes 8-0 vicryl was used. The fornix-deepening sutures were left in place for 2-4 weeks. The conjunctiva was not excised in any of the cases.
The graft was taken up well in all 15 eyes as was evident from its vascularity and pink colour. Cosmetically, the eye nearly resembled a natural conjunctiva after about a month. However, under the slitlamp it was easy to recognise the graft portion by its greater vascularity. Graft retraction was slight and occurred only up to 3 months.
There were no areas of deficient mucosa left. In this study all 15 eyes had grade 3 pain preoperatively. Of these, 8 eyes had grade 1 and 7 eyes had grade 2 pain postoperatively (Table).
All 15 eyes had photophobia of grade 3 preoperatively. After the surgery 3 eyes had grade 1, while 11 eyes had grade 2 and 1 eye had grade 3 photophobia. Foreign body sensation was of grade 3 in all 15 eyes preoperatively. After the operation 12 eyes had grade 1 and 3 eyes had grade 2 foreign body sensation. Paired t-test values were 11.5 (p<0.0001) for pain, 8.5 (p<0.0001) for photophobia, and 16.84 (p<0.0001) for foreign body sensation.
Thus the difference between pre-and post-operative grades of all the three symptoms was highly significant statistically. There was not much change in the grade of symptoms after 1 month and 6 months. All the patients needed artificial tears postoperatively.
We know that patients with dry-eye syndrome have a lifelong problem of using drops and suffer from many complaints. However, this is the only currently available means of replacing mucin. It is preferable, however, to have a continuous natural source of moisture to take care of this problem. In mucin-deficient dry eyes, replacement of goblet cells appears to be the most logical approach. Goblet cells are more abundant in bowel mucosa than in nasal and oral mucous membranes. There have been previous attempts to use bowel mucosa to replace skin elsewhere on the body, but not in place of conjunctiva. Several types of mucous membrane grafts have been tried, including nasal mucosa, and buccal mucosa. However, rectal mucous membrane is rich in mucin-secreting goblet cells and so should be more effective. The operative procedure is time-consuming, involves a team of general surgeon, ophthalmologist and anaesthetist. While these are obvious limitations, there appears to be no better alternative to treat these patients.
This study showed that the procedure provides the patient with considerable relief from foreign body sensation, photophobia and pain. As all these patients showed a severe degree of dry eye, the specific test for mucin deficiency, i.e., tear film break-up time could not be assesed preoperatively due to gross photophobia. Further cytological study may help.
Patients with dry-eye syndrome will not find themselves in a totally helpless and hopeless situation if an alternative to the mucin-secreting conjunctiva is sought. Rectal mucous membrane has goblet cells similar to the conjunctiva and can be a source of mucin secretion. Although this study has symptomatically satisfied the use of rectal mucous membrane graft in dry-eye syndrome, the procedure needs further evaluation.
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