Selective Localized Tenonplasty for Corneal Burns Based on the Findings of Ocular Surface Fluorescein Angiography

TECHNIQUES

Seyed Ali Tabatabaei, MD, Mohammad Soleimani, MD, Reza Mirshahi, MD, Mehdi Zandian, MD, Hamed Ghasemi, MD, Mohammad Naser Hashemian, MD, and Zahra Ghomi, MD

angiography (FA) can play a key role in localization of Purpose: To report the results of a selective localized tenonplasty nonperfused tissue. procedure based on findings of ocular surface fluorescein Various treatments have been discussed in the literature angiography (FA). as countermeasures to prevent and remedy stem cell loss, Methods: Six consecutive patients with severe chemical burns including the use of autologous serum, umbilical cord serum, were included in this study. Using fluorescein angiogram images, Tenon advancement procedures, conjunctival amniotic membrane, or mucous membrane.3,4 Tenonplasty as a relatively patients underwent selective localized tenonplasty to cover the 5 identified ischemic areas in FA. new surgical method was introduced by Teping and Reim in 1989 to treat severe chemical burn injuries. This approach Results: FA 1 week after surgery showed a perfused ocular surface includes the advancement of a viable and nonischemic Tenon in all eyes except for 1 quadrant of limbal ischemia in 1 eye. After the sheet from the deep orbit to cover the area of ischemia up to second tenonplasty, recirculation was also detected in that quadrant. the corneal limbus. The procedure is preceded by 360-degree None of the eyes perforated during the follow-up period. peritomy of the limbal conjunctiva. Upon tenonplasty, in addition to coverage of burned sclera and conjunctiva, corneal Conclusions: We observed acceptable outcomes in our patients reepithelialization is also facilitated.6 after selective tenonplasty based on ocular surface angiography. In this study, we report the outcomes of a selective and Key Words: tenonplasty, ocular surface fluorescein angiography, localized tenonplasty procedure based on the findings of surgery, method ocular surface FA. (Cornea 2017;36:1014–1017) PATIENTS AND METHODS lthough encountered rarely, ocular chemical burns can The study was performed in adherence to the tenets of Aresult in devastating outcomes if not dealt with in a timely the Declaration of Helsinki, and the local ethics committee manner. One of the most important aspects of the insulting approved the methodology. Six consecutive patients sustain- injury is the annihilation of limbal resident stem cells. This ing unilateral chemical burns of grade V or VI (Dua fi 3 further jeopardizes corneal integrity by precluding epithelium classi cation) referred to Farabi Eye Hospital, Tehran, Iran, regeneration and causing the corneal stroma to become hazy.1 were included in the study. Informed consent was obtained In addition to the chemical injury itself, limbal ischemia from all patients before enrolling them in the study. can be a contributing factor to stem cell deficiency. Slit-lamp After copious irrigation of the ocular surface and fornices examination can be useful for determination of ischemic and removing remnant chemical particles, appropriate medical areas, but conjunctival chemosis and necrosis can sometimes therapy according to available guidelines was initiated. We prevent visualization of deeper vessels. However, sometimes prescribed frequent lubrication and nonpreserved topical corti- the vessels are stagnant and without effective perfusion. costeroid, prophylactic topical antibiotics, autologous serum Seeking an objective method to document effective drops, topical sodium citrate, oral doxycycline 100 mg twice circulation among these patients, ocular surface angiogra- a day, 2 g/d supplementary oral vitamin C, and intraocular phy has been proposed to confirm the ischemic areas.2 In pressure-lowering agents in case of a rise of intraocular pressure. this condition, limbal and ocular surface fluorescein Ocular surface FA was performed using the anterior segment mode of the Heidelberg Retina Angiograph 2 (Heidelberg Engineering GmbH, Dossenheim, Germany), after intravenous injection of 2.5 mL fluorescein sodium. Focusing on the Received for publication February 17, 2017; revision received April 17, 2017; ’ accepted April 18, 2017. Published online ahead of print June 5, 2017. patient s ocular surface in all quadrants and in-between was From the Ocular Trauma and Emergency Unit, Eye Research Center, Farabi achieved by eye movement. In cases of protective ptosis and Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran. edema, the lids were opened using cotton swabs. Angiograms The authors have no funding or conflicts of interest to disclose. were recorded with a resolution of 1600 · 1200 pixels and Reprints: Mohammad Soleimani, MD, Ocular Trauma and Emergency Unit, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, a frame rate of 2 images/s. Areas of limbal ischemia and scleral Tehran, Iran; postal code:1336616351. (e-mail: [email protected]). ischemia (bulbar ocular surface ischemia) were determined using Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. these fluorescein angiogram images, and the surgical plan was

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Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 36, Number 8, August 2017 Selective Localized Tenonplasty Procedure Results precisely selected based on the findings. The extent of chemical Postoperative Management burns based on FA imaging was matched to the slit image(s), After tenonplasty, the patients underwent complementary and the regions of interest of the corneal limbus were medical treatment. FA was repeated for the assessment of marked preoperatively. possible recirculation after 1 week. All other procedures needed All patients underwent selective tenonplasty under for final visual rehabilitation are documented in Table 1. general anesthesia, and limbal peritomy was performed only at corresponding foci of nonperfusion of the limbus and sclera based on FA. Frankly necrotic tissues were debrided. RESULTS Relaxing incisions were made radially and circumferentially Six patients with unilateral severe chemical burns were on the Tenon capsule to release extensive tension on flap included in this study. Table 1 shows demographic data and advancement. Tenon sheets detected to be perfused during FA the cause of the chemical burn among these cases. were brought forward to cover ischemic areas and were All eyes underwent selective localized tenonplasty to secured to episclera and limbus by 8-0 Vicryl sutures. The cover identified ischemic areas on FA. All operations were advanced and exposed Tenon capsule was covered by an performed during the first week of the chemical burn by an amniotic membrane; a fornix-to-fornix amniotic membrane experienced corneal surgeon (M.S.). In the next week, FA was sutured to the eyelid margin using 8-0 Vicryl sutures and was repeated, which showed a perfused ocular surface except attached to the fornices using fibrin glue. Both upper and in 1 eye, in which, FA showed persistent limbal ischemia in lower puncta were cauterized, and drawstring blepharorrha- a single quadrant and slit-lamp examination revealed Tenon phy was used to facilitate ophthalmic examination.3 tissue retraction in the same quadrant. However, after the It would have been better to include the eyes that second tenonplasty, that region was also recirculated. None underwent tenonplasty without angiography as a control group. of the eyes were perforated during the follow-up period. However, this could be difficult to perform in this pilot study. For final visual and structural rehabilitation, some other

TABLE 1. Patient Demographics, Surgical Procedures, and Outcomes After the Follow-up Period Scleral Ischemia Limbal Ischemia Scleral Ischemia Limbal Ischemia Age/ Cause of Before Surgery Before Surgery Before Surgery Before Surgery Patient Sex the Burn (SLE) (SLE) (OSFA) (OSFA) 1 23/M Cement More than 75% 270-degree limbal ischemia 50%–75% 210-degree limbal ischemia 2 36/M Car battery More than 75% 270-degree limbal ischemia 50%–75% 270-degree limbal explosion ischemia 3 42/F Cleaning agent More than 75% More than 270-degree limbal 50%–75% 210-degree limbal ischemia ischemia 4 19/M Firework sparkler More than 75% 330-degree limbal ischemia More than 75% 210-degree limbal ischemia 5 28/M Cement 100% 360-degree limbal ischemia 100% 270-degree limbal ischemia 6 30/M House bleach 100% 300-degree limbal ischemia More than 75% 270-degree limbal ischemia Perforation First Final Patient Extent of Tenonplasty After Surgery and Melting Other Surgeries BCVA BCVA 1 Approximately 210 degrees No limbal and scleral ischemia No AMT + corneal scraping + CLAU CF 50 cm 20/40 2 3 quadrants of tenonplasty No limbal and scleral ischemia No Free conjunctival graft + AMT + HM CF 40 cm except for 1 quadrant of limbal corneal scraping + fornix ischemia reconstruction + CLAU + DALK + KLAL + PKP + AGV 3 Approximately 210 degrees No limbal and scleral ischemia No AMT + corneal scraping + inferior CF 10 cm 20/40 fornix reconstruction 4 Approximately 3 quadrants to No limbal and scleral ischemia No Corneal scraping + CLAU + AMT CF 2 m 20/60 cover both limbal and scleral ischemia 5 360 degrees to cover both limbal No limbal and scleral ischemia No AMT + corneal scraping + fornix HM 20/30 and scleral ischemia reconstruction + CLAU + DALK + 6 Approximately 3 quadrants No limbal and scleral ischemia No AMT + corneal scraping + 1/3 CF 40 cm 20/60 lateral tarsorrhaphy AGV, Ahmed glaucoma valve; AMT, amniotic membrane transplantation; CF, counting fingers; CLAU, conjunctival limbal autograft; DALK, deep anterior limbal keratoplasty; F, female; final BCVA, best-corrected visual acuity after 2 years; HM, hand motion; KLAL, keratolimbal allograft; M, male; OSFA, ocular surface fluorescein angiography; PKP, penetrating keratoplasty; SLE, slit-lamp examination.

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FIGURE 1. A, A middle-aged patient with a severe chemical burn caused by a cleaning agent. B, FA of the ocular surface showing limbal and scleral ischemia particularly in the superior temporal and inferior sections. C, Prominent perfusion in the ischemic area 1 week after selective tenonplasty. D, Slit photograph 2 months after selective tenonplasty. After corneal scraping, amniotic membrane transplantation, and inferior fornix reconstruction, the patient maintained a visual acuity of 20/40, 4 months later. procedures were performed (mentioned in Table 1). The Tenonplasty has proven to be a useful resort for visual acuity after 2 years of follow-up is listed in Table 1. refractory limbal ischemia in early management of severe ocular chemical burns. It is considered as a globe-saving procedure that helps and accelerates the reepithelialization of DISCUSSION the cornea and conjunctiva through limbal perfusion.5–7 Severe ocular chemical burn is a serious injury Combined with an oral mucosa graft, it can prevent scleral and a harbinger of poor prognosis. The primary goal melting.5,8 However, similar to every invasive intervention, it of surgery in these cases is usually globe preservation has its own complications and drawbacks. Extensive surgery and paving the way for future reconstruction and in the ﬁeld of an already inﬂamed ocular surface can result in visual rehabilitation. severe scar formation postoperatively. Such adhesions can be

FIGURE 2. A, A young man was referred because of chemical burns. It should be noted that this patient was not a participant in this study. B, Despite the slit photograph, FA in the ﬁgure showed nearly good limbal perfusion. C, Slit photograph showing a marked decrease in corneal haziness 6 months later without tenonplasty.

Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 36, Number 8, August 2017 Selective Localized Tenonplasty Procedure Results problematic later during the anticipated reconstructive proce- It is important to note that despite using selective dures and can also deteriorate the course of symblepharon tenonplasty, 3 eyes in our study ultimately underwent fornix development and cause shortening of fornices. Kuckelkorn reconstruction for the symblepharon, and in 4 eyes, a con- et al6 reported a rate of 26% for symblepharon formation junctival limbal autograft was needed. However, we believe after tenonplasty. that this may not be a drawback of the procedure itself, We believe that using selective tenonplasty can mitigate mainly because of the severity of the ocular burn (actually the risk of exposing a previously irritated eye to more surgical these are the 2 main reasons for advocating selective localized stress. One important point is that sometimes the superficial tenonplasty). It is also arguable that the cascades of ocular conjunctiva is white and thickened because of the burning, surface injuries are activated immediately on chemical and thus the surgeon cannot clearly judge the extent of limbal exposure, and even under ideal circumstances, these severely and scleral ischemia; thus FA could potentially better burned eyes would eventually develop limbal stem cell determine sites of scleral ischemia. However, sometimes the deficiency significant enough to warrant a conjunctival vessel is stagnant and somewhat segmented, so it is hard to limbal autograft. determine the exact etiology of the ischemia. There is debate Further studies can illuminate different aspects of regarding limbal peritomy further damaging the remaining selective tenonplasty and its outcomes. However, it should colonies of vital stem cells residing in the palisades of Vogt, be noted that in some cases with a severe chemical burn, so 360-degree limbal peritomy should be performed under deeply involving the periocular structures, harvesting a per- intensive precautions.9 Obviously, using a selective approach fused Tenon tissue could be impossible. in limbal peritomy reduces the need for complete peritomy and spares the perfused areas (with probably healthy stem cells) from surgical manipulation. Another complication REFERENCES encountered is the retraction of the Tenon flap. Tarsorrhaphy 1. Eslani M, Baradaran-Rafii A, Movahedan A, et al. The ocular surface can help in preventing this complication by controlling lid chemical burns. J Ophthalmol. 2014;2014:196827. movements and excessive tension.7,10 2. Kuckelkorn R, Remky A, Wolf S, et al. Video fluorescein angiography of the anterior eye segment in severe eye burns. Acta Ophthalmol Scand. Implementation of FA in assessment of ocular surface 1997;75:675–680. injury after chemical burns was first described by Kuckelkorn 3. Liu T, Zhai H, Xu Y, et al. Amniotic membrane traps and induces et al2 in 1997. They performed FA in patients who sustained apoptosis of inflammatory cells in ocular surface chemical burn. Mol Vis. chemical burns and normal healthy subjects and planned their 2012;18:2137–2146. surgical treatment based on angiography findings. Our 4. Lin A, Patel N, Yoo D, et al. Management of ocular conditions in the burn unit: thermal and chemical burns and Stevens-Johnson investigation also adds to the existing literature regarding syndrome/toxic epidermal necrolysis. J Burn Care Res. 2011;32: the benefits of angiography-based tenonplasty. 547–560. Possible complications associated with fluorescein dye 5. Teping C, Reim M. Tenonplasty as a new surgical principle in the early injection are a concern in every angiographic procedure. treatment of the most severe chemical eye burns [in German]. Klin Monbl fl Augenheilkd. 1989;194:1–5. These complications include discoloration of body uids, 6. Kuckelkorn R, Redbrake C, Reim M. Tenonplasty: a new surgical erythema and pruritus at the injection site, anaphylaxis, and approach for the treatment of severe eye burns. Ophthalmic Surg Lasers. even death.7 However, considering that such serious compli- 1997;28:105–110. cations are extremely rare, FA can safely be performed in 7. Iyer G, Srinivasan B, Agarwal S, et al. Visual rehabilitation with various clinical settings. Designing a well-controlled clinical keratoprosthesis after tenonplasty as the primary globe-saving procedure for severe ocular chemical injuries. Graefes Arch Clin Exp Ophthalmol. trial for evaluation of the effectiveness of a surgical approach 2012;250:1787–1793. in ocular chemical burns can be challenging. We observed 8. Wang S, Tian Y, Zhu H, et al. Tenonplasty combined with free oral favorable outcomes among our patients (Fig. 1). The rationale buccal mucosa autografts for repair of sclerocorneal melt caused by for reducing the invasiveness of the classic tenonplasty chemical burns. Cornea. 2015;34:1240–1244. 9. Ophthalmology AAO. Pediatric Ophthalmology and Strabismus. San procedure, and minimizing the risk of damaging surviving Francisco, CA: Ophthalmology AAO; 2014:165. residual stem cells, sufficiently justifies using this method 10. Casas VE, Kheirkhah A, Blanco G, et al. Surgical approach for scleral (Fig. 2). ischemia and melt. Cornea. 2008;27:196–201.