Transplantation of the autologous submandibular gland for most severe cases of keratoconjunctivitis sicca

Abstract

This study aimed to examine the long-term qualitative and quantitative function of the secretion of transplanted autologous submandibular glands in patients with most severe keratoconjunctivitis sicca. The study design was clinical. The authors performed 26 operation in 22 patients. A complete ophthalmologic examination was performed in 16 eyes of 13 patients 1 week and 3 months and in 8 eyes of 8 patients 1 year after surgery. The submandibular gland was moved from its natural site into the temporal fossa. The glands supplying vessels were connected to the temporal artery and vein, and its secretory duct was implanted into the conjunctival fornix. Scintigraphy with Tc 99m Pertechnetate was used to document the graft vitality. Subjective symptoms and application frequency of artificial tears were recorded. Baseline as well as stimulated secretion and breakup time were measured and rose bengal staining and ocular ferning test were performed. In selected cases, the secretory product could be sampled for the detection of electrolytes, amylase, and secretory immunoglobulin A (SIgA). Scintigraphy showed vital gland tissue in 14 of 16 grafts at 3 months and 6 of 8 grafts at 1 year after surgery. Two of the 16 transplants were lost completely during the first 3 postoperative months, 1 because of an underlying autoimmunopolyendokrinopathy and the other because of an insufficient vascular anastomoses. In eyes with a vital transplant, baseline secretion and breakup time were increased significantly at 3 months and 1 year after surgery. Patients with a vital transplant reported a strong relief of symptoms and were able to stop taking artificial tear substitution at 1 year. Electrolytes showed a fluctuating concentration. A year after transplantation, the SIgA and amylase concentrations were more than ten times increased compared to normal tear values. Microvascular transferral of an autologous, paralytic submandibular gland results in a significant relief of subjective symptoms, a reduction of artificial tear applications, and an increase of baseline secretion over the first postoperative year. The composition and volume of the secretory product fluctuate, but high values of SIgA and amylase show an actively secreting graft. Although the authors' long-term experience still is limited, they believe that the procedure is a promising alternative approach for desperate dry eye conditions.