A modified surgical technique of fibrin glue-assisted double bipedicle conjunctival flaps for patients with ocular surface diseases

Abstract

This study aimed to describe and investigate the surgical outcome and complications of fibrin glue-assisted double bipedicle conjunctival flaps (CFs) (FADCOF), an alternative surgical technique that restores a stable ocular surface in patients with painful blinding ocular surface disease combined with a shortage of bulbar conjunctiva. Six eyes of six patients with painful blinding ocular surface disease were enrolled in this study. All patients had inadequate superior or inferior conjunctiva tissue to cover the whole corneal surface owing to previous surgeries or ocular surface diseases. These patients received FADCOF between 2009 and 2019. The main outcome included surgical success rate, visual analog scale (VAS) pain score, ocular inflammation score, and postoperative complications. Surgical success was defined as resolution of initial ocular complaints and restoration of a stable ocular surface with no flap melting, retraction, or dehiscence resulting in re-exposure of the corneal surface. All of the six eyes (100%) achieved surgical success. All patients reported significant improvement in subjective symptoms and complete resolution of ocular pain after the surgery (VAS pain score: 6.5 ± 0.5 preoperatively to 0.0 ± 0.0 at 1 month). Ocular inflammation score decreased significantly from a presurgical value of 1.83 ± 0.69 to 0.33 ± 0.47 1 month after the surgery. No postoperative complication was found during the long-term follow-up (range: 12-82 months). FADCOF is a reliable alternative for patients with painful blinding ocular surface diseases unsuitable for single total CF surgery. This surgical technique yields fast ocular surface stabilization, satisfactory recovery, and low complication rates.

Keywords: Conjunctiva; fibrin tissue adhesive; surgical flaps.

Figure 1

Schematic representation of the fibrin glue-assisted double bipedicle conjunctival flaps technique. (a) Place two 6-0 Silk traction sutures over recti muscles. (b) Inject anesthetics subconjunctivally. (c) Incise the superior bulbar conjunctiva 5–6 mm from the limbus. (d) Dissect the conjunctival flap from the underneath Tenon's capsule. (e-g) Repeat the above procedures over the inferior bulbar conjunctiva. (h) Perform 360° peritomy to free the two hemi-bipedicle conjunctival flap. (i) Mobilize and adhere the conjunctival flap to the entire corneal surface with fibrin glue. (j) Anchor the conjunctival flap to the episcleral area

Figure 2

Case demonstration. (a) Severe corneal edema, recurrent corneal erosion, and conjunctival injection in an 82-year-old woman with pseudophakic bullous keratopathy after repeated vitreoretinal surgeries. (b) immediately after the surgery, two hemi-bipedicle conjunctival flaps were spread smoothly by fibrin glue and covered the whole corneal surface. Junction of the superior and inferior flaps (arrows) was strengthened by several anchoring sutures. (c) on postoperative day 1, anterior segment optical coherence tomography demonstrated smooth adherence of the conjunctival flap onto the corneal surface without dehiscence or fluid accumulation at the interface (arrows). (d) smooth corneal surface without inflammation was achieved and maintained 1 year after the operation. The superficial vessels across both conjunctival flaps indicate the complete adhesion of the two conjunctival flaps on the corneal surface