Intact Conjunctiva Research Articles

Hemophilus influenzae subconjunctival abscess in an adult patient: A case report

Subconjunctival abscesses following bacterial conjunctivitis are rare as few bacterial species can penetrate intact conjunctiva. This case reports a Hemophilus influenzae (HI) subconjunctival abscess in an immunocompetent adult. This case presented as unilateral bacterial conjunctivitis, with significant redness and discharge. However, the presumed conjunctivitis did not show any improvement with the initial topical antibiotics treatment. Further examination revealed a superior conjunctival abscess with purulent discharge; hence, the patient was started on topical and oral antibiotics, with complete resolution in 4 weeks. Bacteriological cultures of the discharge revealed HI. This case highlights the importance of a comprehensive clinical examination and the use of microbiology investigations to aid in the diagnosis of atypical conjunctivitis cases.

Imminent Perforation of a Post-Traumatic Scleromalacia

Scleromalacia is a degenerative thinning of scleral tissue. Their general causes are dominated by inflammatory rheumatism and systemic vasculitis. The traumatic cause is very rare. We report a rare case of scleromalacia following a minor trauma with localized hernia of the uveal tissue covered by an intact conjunctiva.

Surgical Approach to the Treatment of Upper Eyelid Retraction Caused by Prominent Filtration Bleb

Objective: To report on the technique of upper eyelid lengthening in patients with upper eyelid retraction not associated with Graves' disease but associated with bleb exposure and exposure keratitis. Case series: We present three patients (four eyes) with a history of glaucoma who underwent trabeculectomy with an active bleb with symptoms associated with bleb and corneal exposure due to retraction of the upper eyelid not associated with Graves' disease. All patients underwent surgical treatment to lengthen the upper eyelid by percutaneous complete blepharotomy with complete dissection of the orbicularis muscle, aponeurosis of levator palpebral muscle, Muller’s muscle and dissection of nasal and temporal conjunctiva reaching the superior border of the tarsus. In addition, the lateral horns of the levator muscle were resected, while preserving a strip of intact conjunctiva directly above the bulging bleb. Before and after surgery, the following measurements were made: including, visual acuity, retraction measurement, presence symptoms of dry cornea and bleb, MRD, and upper eyelid contour. Results: Preoperative upper lid marginal reflex distance (MRD) was measured. In addition, conjunctival staining of the bleb and cornea was recorded. Visual acuity ranged from 6/12 to 6/36. Upper eyelid retraction ranged from 3mm to 7.5mm, this was measured by calculating the marginal reflex distance (MRD) of the upper retracted eyelid minus 4.5 mm, representing the normal MRD. Amounts of lubricating drops used by patients per day was also recorded and quantified. The following postoperative measurements were recorded: MRD of upper eyelid; specifically including upper eyelid contour and position, present or absence of upper eyelid ptosis. Visual acuity improved by one line in the first postoperative week and maximum up to three lines after a month. A good cosmetic result was achieved. Conclusion: Blepharotomy is a surgical procedure suitable for the treatment of severe eyelid retraction. Preservation of the bridge of the intact conjunctiva over the bleb protects the bleb from traumatization in the postoperative period. This makes possible to use the blepharotomy in cases of eyelid retraction with exposure of the filtration bleb, and also maintain the correct contour of the upper eyelid.

Inferior Removal of Dislocated Polymethyl Methacrylate Intraocular Lens and Scleral Refixation in Glaucomatous Eyes.

IntroductionThe aim of this study was to report a technique for the removal of dislocated polymethyl methacrylate (PMMA) intraocular lenses (IOLs) in glaucomatous eyes.MethodsDislocated PMMA IOLs were removed from the inferior sclerocorneal incision, and sutureless intrascleral fixation of each IOL was performed to preserve the intact superior conjunctiva and sclera for future trabeculectomy or to maintain a functional filtering bleb of trabeculectomy. ResultsIn two cases, the condition of the bleb did not change, while the intraocular pressure improved or did not change after the procedures. IOL fixation was stable with no complications, such as tilt, decentration, or extrication of the IOL haptics.ConclusionThis procedure of preserving the superior conjunctiva and sclera can maintain the function of the bleb, superior cornea and sclera and may contribute to the success of future trabeculectomy.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-022-00477-z.

Elevated levels of Merkel cell polyoma virus in the anophthalmic conjunctiva

The human ocular surface hosts a paucibacterial resident microbiome and virome. The factors contributing to homeostasis of this mucosal community are presently unknown. To determine the impact of ocular enucleation and prosthesis placement on the ocular surface microbiome, we sampled conjunctival swabs from 20 anophthalmic and 20 fellow-eye intact conjunctiva. DNA was extracted and subjected to quantitative 16S rDNA PCR, biome representational karyotyping (BRiSK), and quantitative PCR (qPCR) confirmation of specific organisms. 16S ribosomal qPCR revealed equivalent bacterial loads between conditions. Biome representational in silico karyotyping (BRiSK) demonstrated comparable bacterial fauna between anophthalmic and intact conjunctiva. Both torque teno virus and Merkel cell polyoma virus (MCPyV) were detected frequently in healthy and anophthalmic conjunctiva. By qPCR, MCPyV was detected in 19/20 anophthalmic samples compared with 5/20 fellow eyes. MCPyV copy number averaged 891 copies/ng in anophthalmic conjunctiva compared with 193 copies/ng in fellow eyes (p < 0.001). These results suggest that enucleation and prosthesis placement affect the ocular surface flora, particularly for the resident virome. As MCPyV has been shown to be the etiologic cause of Merkel cell carcinoma, understanding the mechanisms by which the ocular surface regulates this virus may have clinical importance.

Segmental scleral buckling without sling sutures around the muscles.

To introduce a modified technique for segmental buckling through a small in situ conjunctival opening without rectus muscle traction for minimally invasive repair of uncomplicated rhegmatogenous retinal detachment. This technique was performed in 15 eyes of 15 selected patients with primary retinal detachment. Conventional traction sutures placed beneath rectus muscles were replaced by an absorbable translimbal traction suture at lesion quadrant. The conjunctival incision was made 8-9 mm posterior and parallel to the limbus. After cryopexy, a minimal explant was fixed with one to two sutures through the conjunctival opening, expanded by a pediatric speculum. Retinal reattachments were achieved with correct buckle positions in all patients, with rapid cosmetic recovery. This modified buckling technique simplifies the buckling procedure, minimizes surgical invasiveness, preserves intact limbal conjunctiva, and relieves discomfort.

Clinical observation of a novel technique: transscleral suture fixation of a foldable 3-looped haptics one-piece posterior chamber intraocular lens implantation through scleral pockets with intact conjunctiva

BackgroundTo present the follow-up outcomes of a modified technique of transscleral suture fixation of posterior chamber intraocular lens (PCIOL) in eyes with inadequate capsule support.MethodsA retrospective chart review of 21 patients underwent transscleral suture fixation of a foldable 3-looped haptics one-piece PCIOL implantation through scleral pockets was conducted. Preoperative data and follow-up data for at least 3 months were collected for all patients.ResultsThe mean operative duration was 36.62 ± 10.70 min. The mean pre- and post-operative LogMAR uncorrected distance visual acuity was (1.25 ± 0.50 vs. 0.41 ± 0.22, P < 0.01). The mean pre- and post-operative LogMAR best corrected visual acuity was (0.48 ± 0.25 vs. 0.33 ± 0.24, P < 0.01). The mean proportion of postoperative endothelial cell loss was 11.46 ± 4.78%. The mean postoperative anterior chamber depth was 3.05 ± 0.44 mm. The mean postoperative IOL tilt degree was 2.81 ± 1.41°, and the mean postoperative IOL decentration degree was 0.31 ± 0.13 mm. Four patients with transient corneal edema (19.0%) and three patients with transiently elevated IOP (14.3%) were observed after operation, and such complications were resolved within 1 week. No severe complications were observed.ConclusionsThe modified technique was a feasible method of PCIOL implantation.

A new instrument to simplify encircling buckle placement.

The purpose of this study is to describe a new surgical instrument that simplifies 360° silicone band placement, alone or in combination with pars plana vitrectomy, for the treatment of rhegmatogenous retinal detachment. The instrument has a straight shank and a curved component in the form of a partial helix, whose purpose is to encircle the perimeter of the eye globe below the rectus muscles. The distal tip of the helix is inserted through a small conjunctival incision in the superior temporal quadrant, and the shank is rotated 360° on its axis until the tip emerges from the insertion point. One end of the silicone band is sutured to the tip, and the instrument is rotated in the opposite direction until both ends of the band are positioned in the same scleral quadrant. The band is sutured to the sclera and the conjunctival incision is closed. Pars plana vitrectomy can then be performed using transconjunctival microincision techniques through the intact conjunctiva. Our experience using the instrument in more than 100 procedures has shown that the new technique considerably reduces surgical trauma: wide opening of the conjunctiva is obviated, there is little manipulation of the extraocular musculature, and only a few sutures are needed. The duration of the procedure is considerably shorter because of the smaller number of surgical maneuvers. We describe a new scleral technique facilitated by this surgical instrument, whose objective is safe and effective placement of an encircling silicone band with minimum trauma and a reduction in operating time.

A Biological Tissue Adhesive and Dissolvent System for Intraocular Tumor Plaque Brachytherapy.

To examine a novel technique for simplified placement and removal of plaque brachytherapy by fibrin glue and urokinase (medac Gmbh, Hamburg, Germany). In six enucleated porcine eyes, plaques were placed on the episclera and fibrin glue was applied to cover it. Urokinase was used to dissolve the glue in three eyes and saline was used in three eyes. Adhesion strength was measured further on 15 plaques affixed to porcine eyes (glued in five with intact conjunctiva, glued in five with removed conjunctiva, and sutured in five). Saline had no effect on the glue-plaque-eye complex, whereas the urokinase (0.38 mL ± 0.08 mL) easily dissolved the adhesion between the glue layer and surrounding tissues. The weight required to detach the plaques was 0.349 kg ± 0.173 kg for glued eyes with intact conjunctiva, 0.405 kg ± 0.083 kg for sutured eyes (P = .59), and 0.032 kg ± 0.004 kg for glued eyes without intact conjunctiva (P ≤ .015). The usage of the biological adhesive and dissolvent system was applicable for plaque surgery in an ex vivo animal model.

Minimal in situ conjunctival incision for segmental scleral buckling surgery.

To introduce a modified technique for minimal segmental buckling through a small in situ conjunctival opening for minimally invasive repair of uncomplicated rhegmatogenous retinal detachment. This technique was performed in 46 eyes of 46 patients with primary retinal detachment. Transconjunctival traction sutures were placed in four rectus muscles after retrobulbar anesthesia was administered. After transconjunctival location of the retinal break, a 5- to 6-mm radial conjunctival incision was performed corresponding to the retinal break without cutting the limbal conjunctiva-Tenon's capsule. After cryopexy, a minimal explant was fixed with one to two sutures through the conjunctival opening, expanded by a pediatric speculum. The incision was closed via layered closure. Retinal reattachments were achieved with correct buckle positions in all 46 cases, with rapid cosmetic recovery. This modified minimal segmental buckling technique simplifies the buckling procedure, minimizes surgical invasiveness, and preserves an intact limbal conjunctiva.

Long-term Results After Transconjunctival Resuturing of the Scleral Flap in Hypotony Following Trabeculectomy

To present the 4-year follow-up results in the surgical treatment of hypotony following trabeculectomy with mitomycin C in glaucoma patients with additional flap sutures. Retrospective interventional case series. Since 2006, 53 patients with hypotony maculopathy attributable to overfiltration following glaucoma surgery (trabeculectomy with mitomycin C) were included in this institutional study. We were able to follow up intraocular pressure (IOP) and distance-corrected visual acuity in 33 (62%) over 4 years, whereas all were followed over 2 years. To elevate IOP, we placed tangential transconjunctival sutures through the scleral flap and connected them to the adjacent sclera in all 53 patients. Mean IOP prior to surgery was 3.55 mm Hg (± 2.05; range 0-8 mm Hg), 20.08 mm Hg (± 12.48) on the first postoperative day, 10.69 mm Hg (± 4.73) after 1 month, 10.12 mm Hg (± 3.95) after 6 months, 10.42 mm Hg (± 4.17) after 2 years, and 9.5 mm Hg (± 3.93) after 4 years. Mean visual acuity (VA) improved from 0.8 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.5 after 1 month, and remained stable after 6 months at 0.3. Macular folds resolved in all patients and choroidal detachment in 51 patients (96%) after 6 months. IOP increase and vision improvement were statistically significant (<.05). Even 4 years after resuturing of the scleral flap through the intact conjunctiva, there is evidence that this surgical method is an effective and simple technique to treat hypotony maculopathy after glaucoma surgery.

Spontaneous Subconjunctival Abscess Because of Haemophilus influenzae

To report a case of a spontaneous subconjunctival abscess in a patient with no previous ocular surgery or trauma. Case report. We report a case of a subconjunctival abscess caused by Haemophilus influenzae after several days of worsening conjunctivitis. Computed tomography scans of the orbits confirmed an abscess cavity adjacent to the globe without orbital extension. The abscess was spontaneously draining at presentation and resolved completely with topical and oral antibiotic therapy. To our knowledge, this is the first-described case of spontaneous subconjunctival abscess formation in an immunocompetent individual unrelated to preexisting ocular pathology, previous ocular surgery, or trauma. H. influenzae species may possess the ability to penetrate an intact conjunctiva and develop subconjunctival abscess. We recommend that patients presenting with bacterial conjunctivitis be closely examined to rule out subconjunctival abscess, which may require additional aggressive medical or surgical management.

Flap suture - a simple technique for the revision of hypotony maculopathy following trabeculectomy with mitomycin C

A serious complication following trabeculectomy with mitomycin C (MMC) is intraocular hypotony with hypotony maculopathy, papilledema, flattening of the anterior chamber, corneal decompensation and a decrease in visual acuity. We describe a new simple surgical technique for the treatment of hypotony maculopathy following trabeculectomy with MMC. In a prospective consecutive case study, 16 patients with hypotony maculopathy following trabeculectomy with MMC were included. Through the intact conjunctiva, additional 10.0 nylon sutures were placed through the scleral flaps into the adjacent sclera. Assessment of visual acuity, intraocular pressure (IOP) measurement and fundoscopy were performed on the 1st and 7th day postoperatively and 1, 3 and 6 months postoperatively. Photography of the bleb and the posterior pole and optical coherence tomography imaging of the posterior pole were performed. Before surgery (flap suture), the mean IOP was 2.8 mmHg (+/-1.1; range from 1 to 4 mmHg). It was 24.9 +/- 11.7 mmHg (range; 9-48 mmHg) on the 1st postoperative day, 15.7 +/-8.1 mmHg (range; 5-35 mmHg) on day 7, 11.1 +/-4.1 mmHg (range; 5-20 mmHg) 1 month after surgery, 9.3 +/-3.9 mmHg (range; 2-20 mmHg) after 3 months, and 9.6 +/-4.2 mmHg (range; 2-20 mmHg) after 6 months. The best corrected mean visual acuity was 20/50 before trabeculectomy and 20/160 before flap suture. It improved to 20/63 at 6 months postoperatively. Clinical signs of hypotony maculopathy disappeared in all patients. No bleb leakage was observed in any patient during follow-up. Resuturing the scleral flap through the intact conjunctiva is an effective and minimally invasive method to treat hypotony maculopathy following trabeculectomy with MMC. Thus, opening the conjunctiva can be avoided.

Transconjunctival penetration of mitomycin C

The study was performed to estimate transconjunctival penetration of mitomycin C (MMC) to Tenon's tissue following application over the intact conjunctiva before routine trabeculectomy. Institution-based case series. In 41 eyes of 41 patients, MMC (0.4 mg/ml for 3 min) was applied over the intact conjunctiva before beginning trabeculectomy. Tenon's capsule directly beneath the site of application was excised during trabeculectomy and was homogenized, centrifuged and MMC concentrations were analyzed using high-performance liquid chromatography (HPLC). Statistical analysis was performed using STATA 8.0 version software (STATA Corporation, Houston, TX, USA). In this study, P -values less than 0.05 were considered as statistically significant. The average weight of the sample of Tenon's tissue excised was 5.51+/-4.42 mg (range: 0.9-17.1) and the average estimated MMC concentration found to be present in Tenon's tissue using HPLC was 18.67+/-32.36 x 10(-6) moles/kg of the tissue (range: 0.38-197.05 x 10(-6)). In 36 of the 41 patients (87.80%), the MMC concentration reached above 2 x 10(-6) moles/kg of the tissue concentration required to inhibit human conjunctival fibroblasts. Mitomycin C does permeate into the subconjunctival tissue after supraconjunctival application for 3 min. Application of MMC over the conjunctiva may be a useful alternative to subconjunctival or subscleral application during routine trabeculectomy and as an adjunct for failing blebs.

Do not try this at home: trash can intracapsular cataract extraction

The authors present a 39-year-old woman who sustained blunt trauma from a metal garbage can to her left eye and presented with her intact crystalline lens luxated subconjunctivally after expulsion through a scleral wound. External photographs show the lens found under intact conjunctiva and a computed tomography scan demonstrates the extrascleral lens. The patient had a ruptured globe repair and intraoperative photographs showed removal of the lens.

Giant inclusion cyst of the cornea following filtering surgery

Various trans-conjunctival ophthalmic procedures are reported to cause inclusion cyst of conjunctiva, due to the accidental inclusion of viable conjunctival epithelium, under intact conjunctiva. We report a case of histopathologically confirmed inclusion cyst of the cornea following filtering surgery. There was no recurrence in 24 months of postoperative period.

Amniotic membrane transplantation to reconstruct the conjunctival surface in cases of chemical burn

Purpose: To evaluate the efficiency of preserved human amniotic membrane transplantation for conjunctival surface reconstruction in cases of chemical burn. Methods: Preserved amniotic membrane transplantation was performed in 6 patients (6 eyes) having symblepharon and fornix insufficiency due to chemical burn. Amniotic membrane was sutured to the intact conjunctiva after the fibrotic tissue was excised. The fornix was reconstructed in cases having fornix insufficiency. These cases were followed up for 4–24 months. Results: During the mean follow-up period (10±7.37 months) adequate bulbar conjunctiva and fornix depth was achieved in 5 patients without recurrence and with mild fibrosis. In 1 patient who did not have a healthy conjunctiva preoperatively, conjunctival fibrosis and symblepharon recurred. Conclusions: Preserved human amniotic membrane transplantation is a good alternative treatment method for conjunctival surface reconstruction in those cases with some healthy peripheral conjunctival tissue.

Conjunctival dysfunction and mitomycin C-induced hypotony.

To determine the role of a physically intact conjunctiva in the development of chronic hypotony after mitomycin C-enhanced trabeculectomy. Three patients with mitomycin C-related hypotonic maculopathy, but without a leak on Siedel test, had a thorough evaluation of the bleb area and an anterior segment fluorescein angiography. The bleb was excised and a pedicle flap, rotated from the temporal conjunctiva, was sutured to cover the defect superiorly. The scleral flap and its sutures were not disturbed. The excised bleb was subjected to light and electron microscopy. The Seidel test result was negative in all patients, but late phases of the anterior segment angiography showed a generalized seepage of aqueous from the bleb. After revision of the bleb, there was a gradual increase in the intraocular pressure, a reversal of the hypotonic maculopathy, and consequent improvement in visual acuity in all three patients, stable up to a minimum follow-up of 18 months. On histopathologic examination, the basement membrane was thickest under thin areas of the epithelium and thinnest below thicker epithelial layers. A dysfunctional conjunctival barrier, as evidenced by the "sweating" of the bleb and histopathologic alterations in the epithelial barrier, could be responsible for the hypotonic maculopathy in these patients. Excision of the conjunctiva alone and replacement by a pedicle conjunctival graft offers a safe and effective method of treating chronic hypotony after mitomycin C-augmented trabeculectomy in such patients.

Transconjunctival Application of Mitomycin C in Combination with Laser Sclerostomy ab interno: A Long-Term Morphological Study of the Postoperative Healing Process

The precise mechanism whereby mitomycin C enhances IOP reduction in glaucoma filtering surgery still eludes us. Ten rabbits received full-thickness Nd:YAG laser sclerostomy ab interno and adjunctive intraoperative treatment with mitomycin C (MMC) applied topically over the intact conjunctiva (0.5 mg ml−1for 5 min). A systematic ultrastructural analysis of the fistulas and surrounding tissue was then conducted in conjunction with clinical observations, over the ensuing 10 weeks. In order to investigate also the extent to which MMC impedes fistula occlusion in the absence of percolating aqueous humour, we created non-perforating (‘half-thickness’) sclerostomies ab interno in three additional rabbits, one with and two without MMC therapy. Transconjunctival MMC application resulted in no serious complications. Eight of the ten full-thickness fistulas remained patent throughout the study, maintaining significant IOP reduction; the other two sclerostomies were compromised by iris incarceration. The MMC-treated, half-thickness canal remained as a tissue-free cul de sac; the two non-treated ones became completely occluded within one week without having recourse to extraocular cell populations. MMC suppressed the migration and proliferation of fibroblasts, macrophages and clump cells from the episclera, sclera, ciliary body and iris root. Repolymerization of heat-damaged collagen was abortive; neosynthesis was not observed. Myofibroblasts were encountered in the vicinity of the sclerostomy canals, and, after the fifth week, these cells were also found to be deployed as a canal-lining layer, delimiting the lumen from the surrounding stroma along most of the fistula length. Towards the external ostium, this layer of myofibroblasts was incomplete or absent. Near the internal ostium, lining cells were derived from the corneal endothelium.The transconjunctival mode of applying MMC appears to be efficient. This antifibrotic drug exerts its inhibitory influence by suppressing not only cell migration and proliferation, but also phagocytic and synthetic activities. However, exposed tissues are not acellular, and amongst the populations present, myofibroblasts are found to dominate the scene. The canal-delimiting cellular lining may play a role in maintaining fistula patency in MMC-treated eyes.

Metabolism of [des-Gly10, D-Trp6]LHRH ethylamide in the rabbit conjunctiva.

It was the objective of this study to determine whether [des-Gly10, D-Trp6]LHRH ethylamide, an LHRH agonist known as deslorelin, is degraded by the rabbit conjunctiva. Intact conjunctiva was incubated with deslorelin either alone or in the presence of 0.1 mM ouabain, 0.1% 2,4-dinitrophenol, 0.1 mM phosphoramidon, 0.1 mM N-tosyl-L-phenylalanine chloromethylketone (TPCK), 2% EDTA, 1% ZnCl2, 0.1% dithiothreitol (DTT), or 0.1% N-ethylmaleimide (NEM) at 37 degrees C. Furthermore, deslorelin alone was incubated with conjunctiva at 4 degrees C. All incubation solutions were made isotonic, and the pH was adjusted to 5.0. A reversed-phase HPLC was used to analyze supernatants collected at the end of 90 min. Deslorelin metabolism was inhibited at low temperature, as suggested by the disappearance of metabolite peaks at low temperature. Both ouabain and dinitrophenol failed to alter the intact drug remaining in the supernatant, indicating that energy-dependent cellular uptake of deslorelin is unlikely in the conjunctiva. Phosphoramidon- and TPCK- sensitive endopeptidases did not contribute to the observed metabolism, as suggested by the lack of effect of phosphoramidon and TPCK on deslorelin levels. DTT and NEM also failed to affect deslorelin levels. On the other hand, EDTA and ZnCl2 significantly elevated the intact deslorelin levels by 61 and 53%, respectively, and almost completely abolished the metabolite peaks, indicating a possible role for either metaldependent peptidases or metallo-peptidases in the conjunctival metabolism of deslorelin.