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New Surgical Approach for Limbal Dermoids in Children: Simple Excision, Corneal Tattooing, and Sutureless Limboconjunctival Autograft

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New Surgical Approach for Limbal Dermoids in Children: Simple Excision, Corneal Tattooing, and Sutureless Limboconjunctival Autograft TECHNIQUES New Surgical Approach for Limbal Dermoids in Children: Simple Excision, Corneal Tattooing, and Sutureless Limboconjunctival Autograft Jinho Jeong, MD, PhD,* Young-Jin Song, MD,† Seung-Il Jung, MD,† and Ji-Won Kwon, MD, PhD† is an elevated yellow or white round mass overlying both the Purpose: fi To evaluate the ef cacy of combined surgery of simple cornea and conjunctiva. The growth rate of these masses is excision, corneal tattooing, and a sutureless limboconjunctival very slow or even stationary.2,3 autograft in pediatric patients with grade 1 limbal dermoids. Anatomically, they have been classified into 3 grades. Methods: The grade 1 limbal dermoid is a superficial lesion ,5mmin We treated 4 eyes of 4 patients with combined surgery of 4–6 corneal tattooing and a sutureless limboconjunctival autograft with diameter and localized on the corneal limbus. For a small simple excision of limbal dermoids. Preoperative and postoperative asymptomatic grade 1 limbal dermoid, it is recommended that visual acuity, postoperative recovery time, cosmetic improvements, these children undergo close clinical observation with serial patient compliance, and complication rates were reviewed. examinations because even a simple excision may cause a wound scar and pseudopterygium.7 Parents may want Results: The mean follow-up period in this study was 27.3 6 2.8 surgical correction performed, whereas their children are (range, 24–30) months. Visual acuity was stable during the follow- growing and going to school. From a psychosocial standpoint, up period. Resolution of patient discomfort and wound epithelial- surgery could be considered because cosmetic improvement is ization was achieved in 1 week. Cosmetic outcomes improved in important for the whole family.8 Progressively increasing view of corneal opacity and conjunctival vascularization. All patients anisometric astigmatism is also another indication to prevent were satisfied with the cosmetic results with no complications. amblyopia secondary to severe astigmatism.7 Conclusions: The surgical combination of simple mass excision and Corneal tattooing and a sutureless limboconjunctival corneal tattooing proved to be a good alternative method, with autograft after simple excision of limbal dermoids can lead to good cosmetic results without significant complications, a satisfactory cosmetic outcome, better compliance, and early especially when a donor cornea is not available.9 However, postoperative recovery without complications for grade 1 limbal surgical complications, including epithelial defects and dermoids in pediatric patients. peripheral corneal vascularization, may occur with focal Key Words: limbal dermoid, corneal tattooing, limboconjunctival marginal limbal cell deficiency. Modified simple limbal autograft epithelial transplantation using a cryopreserved amniotic membrane proved effective for the treatment of limbal stem (Cornea 2015;34:720–723) cell deficiency.10 Lamellar keratoplasty is another surgical option, but the fibrin glue–assisted amniotic membrane transplantation method also showed several advantages over limbal dermoid is a congenital benign choristoma, which lamellar keratoplasty because it gives long-term ocular Acomprises tissues of ectodermal and mesodermal origins. surface cosmesis with better compliance and faster recovery, Choristomas make up approximately 3% of conjunctival and avoiding the risks associated with immune suppression.5,11 1 corneal tumors. It occurs most commonly in the inferotem- In this study, we report 4 cases of patients who poral quadrant as a solitary lesion but occasionally occurs as underwent combined surgeries, with simple excision, corneal multiple lesions. The typical morphology of a limbal dermoid tattooing, and a fibrin glue–assisted sutureless limboconjunc- tival autograft for limbal dermoids. We monitored the cosmetic outcomes of the corneal and conjunctival lesions, Received for publication December 23, 2014; revision received February 21, the rehabilitation period, and patient compliance. We also 2015; accepted February 24, 2015. Published online ahead of print April evaluated the efficacy and possible complications of this new 20, 2015. From the *Department of Ophthalmology, Jeju National University College of technique. Medicine, Jeju, Korea; and †Department of Ophthalmology, Seonam University College of Medicine, Myongji Hospital, Goyang, Korea. The authors have no funding or conflicts of interest to disclose. MATERIALS AND METHODS J. Jeong and Y.-J. Song contributed equally to this article. Reprints: Ji Won Kwon, MD, PhD, Department of Ophthalmology, Myongji Patients Hospital, Seonam University College of Medicine, 697-24, Hwajung- Dong, Deokyang-Gu, Goyang-Si, Gyeonggi-Do 412-270, Korea (e-mail: A retrospective chart review was conducted on 4 eyes [email protected]). of 4 pediatric patients who underwent corneal tattooing and Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. sutureless limboconjunctival autografts after simple excision 720 | www.corneajrnl.com Cornea Volume 34, Number 6, June 2015 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 34, Number 6, June 2015 A New Surgical Approach for Limbal Dermoids of limbal dermoids in our hospital. All patients were referred patient was satisfied with the cosmetic outcome, and there to our clinic for cosmetic improvement. was no postoperative complication (Fig. 1). This study was initiated after being approved by the appropriate institutional review board. All patients provided Case 2 written informed consent. This study adhered to the tenets of A 4-year-old female patient was referred because of the Declaration of Helsinki. a congenital limbal dermoid in the inferotemporal area. There was focal sectoral epithelial depigmentation of the ’ Surgical Methods iris at the 5 o clock position. Limbal dermoid excision, corneal tattooing, and a sutureless limboconjunctival auto- One surgeon (J.W.K.) performed all of the surgeries. graft from the superior conjunctiva, using fibrin glue, were All procedures were conducted under general anesthesia. The performed. The cosmetic outcome was satisfactory, and border of the limbal dermoid was marked at a shallow depth there was no postoperative complication, such as conjunc- using a #69 Beaver blade along the limbal margin. The tivalization of the limbus (Fig. 1). Recurrence did not occur corneal part of the dermoid was excised using a straight during the 30-month follow-up period. Beaver blade and Westcott scissors. A tissue-marking dye (Bradley Products Inc, Minneapolis, MN), which had been sterilized in an autoclave at 134°C for 6 minutes before surgery, was used for black coloring.12 With the bevel up, the RESULTS anterior stromal punctures were made using a 1-mL disposable The average age of the patients was 9.3 (range, 2–15) 6 syringe with a 30-gauge needle, creating a relatively long years. The mean follow-up period was 27.3 2.8 (range, – puncture canal. Because the corneal surface was obscured by 24 30) months. All patients had grade 1 limbal dermoids, and the dye after several punctures, the dye spread was confirmed the dermoid lesion did not occlude the visual axis. The mean by vigorous irrigation with balanced salt solution to visualize diameter of the limbal dermoids was 3.5 mm, and the location the staining. The conjunctiva was then dissected to expose the of the dermoid was mostly in the inferotemporal area (75%). dermoid. Shaving was performed on the conjunctival part of Mean preoperative corneal astigmatism was 1.3 (range, the dermoid using a straight Beaver blade. The superior 0.5–2.2) D. The preoperative BCVA was 20/20 in all cases. conjunctiva, including the limbus margin for the autograft, The postoperative BCVA remained unchanged during the was marked with gentian violet at the size of 4.0 (horizontal) · follow-up period. Resolution of patient discomfort and wound 3.0 mm (vertical). Lidocaine solution was injected into the epithelialization was achieved within 1 week. Cosmetic marked subconjunctival space. The limboconjunctiva was outcomes improved in view of corneal opacity and conjunc- carefully harvested, and the graft was immediately transferred tival vascularization. The sutureless limboconjunctival auto- onto the base sclera. Fibrin glue (Tisseel; Baxter Inc, graft increased compliance in these pediatric patients Deerfield, IL) was then applied under the conjunctival graft, postoperatively, and the wound showed no dehiscence. All fi giving firm adhesion between the sclera and the autografted patients and parents were satis ed with the cosmetic results. conjunctiva. The wounds were covered with therapeutic Neither dermoid recurrence nor limbal pannus formation contact lenses, and patients received levofloxacin (Cravit; occurred in any patient during the follow-up period. Santen Pharmaceutical Company, Osaka, Japan) and 1% prednisolone acetate (Pred Forte; Allergan, Irvine, CA) 4 times per day for 1 month. Applied therapeutic contact lenses were DISCUSSION removed at postoperative 1 week. Surgery for limbal dermoid removal has been variable The patients were followed up on postoperative day 7 from simple excision, lamellar graft, to simple excision with and at 1, 2, 6, 12, 18, and 24 months after surgery. corneal tattooing. The main sequelae of these operations were Ophthalmic examinations, including the best-corrected visual remaining corneal opacity and conjunctivalization as a result acuity (BCVA) tests, anterior segment photography,
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