Mucous Membrane Grafting
In the absence of healthy conjunctiva (eg, in bilateral cicatricial conjunctival disease), mucous membrane may be used to restore the conjunctival surface to a more functional state. The goals of restoration are to create a more normal fornix and to reduce ocular surface inflammation, as well as to minimize corneal damage from the abnormal eyelid–globe relationships (eg, entropion, trichiasis), chronic exposure (lagophthalmos), and direct corneal trauma (palpebral conjunctival keratinization) that usually accompany bilateral cicatricial conjunctival disorders (see Table 13-1). Mucous membrane grafts increase ocular surface wetting by improving eyelid movement and distribution of the tear film over the cornea, thereby reducing exposure and evaporation. These grafts also provide suitable extracellular matrix substrate for epithelial cell migration and adhesion, but they are not effective in replacing normal stem cells.
Mucous membrane grafting has produced good results in inactive cicatricial disorders such as late-stage, nonprogressive Stevens-Johnson syndrome and quiescent mucous membrane pemphigoid (MMP). A combination of limbal allografting, amniotic membrane transplantation, and tarsorrhaphy, followed by the use of serum-derived tears and systemic immunosuppression, allows reconstruction of the ocular surface. Patients with advanced, progressive stage III or IV MMP require advanced immunosuppressive treatment to reduce active inflammation prior to any grafting procedure (see the discussion of MMP in Chapter 11). Keratoprosthesis is another treatment for patients with late-stage cicatricial disease (see Chapter 15).
Multiple surgical techniques for mucosal grafting are available; the reader is encouraged to consult a surgical textbook or video for discussion and illustration of these techniques (see the reference list that follows). Potential complications, regardless of the technique, include buttonholing, graft retraction, trichiasis, surface keratinization of the graft, ptosis, blepharophimosis, depressed eyelid blink, lagophthalmos, submucosal abscess formation, and persistent nonhealing epithelial defects of the cornea.
Black E, Nesi FA, Gladstone G, Levine MR, Clavano CJ, eds. Smith and Nesi’s Oculoplastic and Reconstructive Surgery. 3rd ed. New York: Springer; 2012.
Chun YS, Park IK, Kim JC. Technique for autologous nasal mucosa transplantation in severe ocular surface disease. Eur J Ophthalmol. 2011;21(5):545–551.
Fu Y, Liu J, Tseng SC. Oral mucosal graft to correct lid margin pathologic features in cicatricial ocular surface diseases. Am J Ophthalmol. 2011;152(4):600–608.e1.
Liu J, Sheha H, Fu Y, Giegengack M, Tseng SC. Oral mucosal graft with amniotic membrane transplantation for total limbal stem cell deficiency. Am J Ophthalmol. 2011;152(5):739–747.
Sant’Anna AE, Hazarbassanov RM, de Freitas D, Gomes JA. Minor salivary glands and labial mucous membrane graft in the treatment of severe symblepharon and dry eye in patients with Stevens-Johnson syndrome. Br J Ophthalmol. 2012;96(2):234–239.
Takeda K, Nakamura T, Inatomi T, Sotozono C, Watanabe A, Kinoshita S. Ocular surface reconstruction using the combination of autologous cultivated oral mucosal epithelial transplantation and eyelid surgery for severe ocular surface disease. Am J Ophthalmol. 2011;152(2):195–201.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.