Microvascular autologous submandibular gland transplantation in severe cases of keratoconjunctivitis sicca

Abstract

Dry eye syndrome is a relatively common disease of the tears and ocular surfaces that results in discomfort, visual disturbance, and tear film instability with possible damage to the ocular surfaces. Microvascular submandibular gland (SMG) transfer offers a surgical alternative for a permanent autologous substitution of tears using the basal secretion of a transplanted SMG. Long-term follow-up reveals that this technique is a lasting and effective solution for patients with severe dry eye syndrome. The uncomfortable symptoms were relieved, and the frequency of use of pharmaceutical tear substitutes was reduced. Objective examination showed significant improvement in tear film and some features of ocular surface such as breakup time of tear film and corneal staining. Patients may suffer from obstruction of Wharton's duct or epiphora after surgery. Activation of secretion-related receptors could improve the early hypofunction of the denervated SMG and prevent the duct obstruction. Reduction surgery, partial SMG transplantation, uses of atropine gel or Botulinum toxin A could be the choices of treatment for epiphora.

Keywords: Keratoconjunctivitis sicca; Obstructive sialadenitis; Submandibular gland transplantation.

Figure 1

Surgical procedures of autologous microvascular submandibular gland transplantation. (A) Incision in the temporal region. (B) Dissection of the superficial temporal vessels. (C) Dissection of the facial artery and its accompanying vein. (D) Dissection of the Wharton’s duct and a cuff of mucosa around the opening. (E) Bleeding from the anterior facial vein which attached to the submandibular gland was observed to evaluate the state of venous drainage from the gland. (F) The submandibular gland was removed together with the facial vessels and Wharton’s duct. (G) Anastomosis of the vessels. (H) A nylon tube was inserted into the duct.