Successful use of preserved sclera of eyelid reconstruction

ARTICLE

Auteur(s) : Hideki KAMIYA, Yasuo KITAJIMA

Department of Dermatology, Gifu University School of Medicine, Tsukasa‐mach 40, Gifu 500‐8705, Japan

Article accepted on 18\03\2003

Eyelid surgery involving resection of more than half the eyelid and formation of a full‐thickness defect requires not only reconstruction of the anterior lamella using a dermal flap, but also reconstruction of the posterior lamella, including the tarsal plate and palpebral conjunctiva which requires lining with palatal grafts. In order to reconstruct eyelids with a moderate stiffness and elasticity, we have been using preserved sclera and experienced five cases over the past few years. From our experience of the 5 cases and literature, we compared the results of this method of eyelid reconstruction using preserved sclera to those using nasal septal cartilage or auricular cartilage. Out of the these five cases, we present a case with meibomian gland carcinoma in both eyes, who underwent eyelid reconstruction using preserved sclera because of a typically successful case.

Case report

The patient was a 70‐year‐old worman. In 1993, the patient noticed a nodule in the left upper eyelid which was removed by a local ophthalmologist. The patient suffered from recurrence one year later and was referred to our department. The tumor occupied the entire left upper eyelid, and a walnut‐sized granulomatous tumor protruded from the innner side of the eyelid to the outside of the eye, covering the optic fissure (Fig. 1). Although CT and MRI examination did not indicate metastasis to other organs or lymph nodes, partial intraorbital infiltration was suspected. Because of the extent of tumor invasion, orbital exenteration was performed in 1994. Histologically, the tumor consisted of mostly cytoplasm‐rich clear cells intermixed with basaloid cells, and its periphery was composed of mainly cytoplasm‐poor undifferentiated cells. These findings suggested stereotypical meibomian gland carcinoma. No recurrence or metastasis was seen for the next seven years. In 2001, however, a soybean‐sized nodule formed in the right upper eyelid (Fig. 2a). Biopsy of the nodule lead to a diagnosis of meibomian gland carcinoma. With a safety margin of 1 cm, full‐thickness resection was performed (Fig. 2b). Preserved sclera was used for posterior lamella reconstruction without lining of any mucosal membrane.

Discusssion

To treat a full thickness defect of eyelids created by palpebral resection, reconstruction of the posterior lamella is essential, and any tissue used as lining material needs to support the upper eyelid and protect the anterior surface of eyeball [1, 2]. Various reconstructive techniques have been developed: 1) composite grafting using nasal septal cartilage and mucous membrane; 2) buccal dermal flap grafting using auricular cartilage as lining material: 3) composite grafting using posterior auricular skin and cartilage; 4) buccal and palatal mucous membrane transplantation; 5) reconstruction using an artificial tarsal plate; and 6) reconstruction using preserved sclera.

Techniques 1) and 2) are most commonly employed [3]. We also have used these methods of eyelid reconstruction in our hospital. The use of cartilage ensures proper support of the eyelid, and numerous studies have shown that transplanted cartilage remains in the target area without being absorbed. After long‐term monitoring of patients who underwent these 2 techniques, we conclude that nasal septal catilage and auricular cartilage are strong enough to replace the tarsal plate.

Preserved sclera was first utilized in eyelid reconstruction by Quickert [4] and Dryden [5] in 1971, and has been widely used since then. The advantages obtained by using preserved sclera include: 1) preserved sclera and dermal flap are usually biocompatible, and tissue reactions are rarely seen; 2) the degree of corneal damage is mild, and transplanted sclera protects the anterior surface of the eyeball; 3) preserved sclera is easily obtained and manipulated; and 4) at 3 months post‐surgery, preserved sclera is covered spontaneously by regional mucous membrane [6, 7].

It remains, however, unresolved how long the transplanted preserved sclera is maintained and can support the eyelid with its moderate and resilient stiffness. In this regard, the fate of transplanted preserved sclera has been the focus of several clinical and animal studies. In clinical studies, Beyer [8], Tanabe [9] and colleagues found that transplanted sclera was replaced by host fibroblasts over a lengthy period of time[10]. Similarly, in a study using mice, Takahashi[11] and colleagues found that the transplanted sclera was degraded and replaced by connective tissues, so that it became undistinguishable from the surrounding tissues after 3 months. This may suggest that transplanted sclera lacks an ability to support the eyelids for extended periods of time. They reported that even when inflammatory reactions were observed, typical exogenous granulomatous reactions accompanied by the presence of giant cells were not seen. In other words, the degradation and absorption of preserved sclera represents no immunological rejection.

Although we could follow these 5 patients (Table I), including the case presented here in detail, only for 2 years, we can reasonably expect the allograft to function as a scaffold for epithelial regeneration, judging from the excellent results obtained by our experience of all these cases. Furthermore, eyelids transplanted with preserved sclera appear to have maintained their moderate and resilient stiffness for the past two years in contrast to the results obtained in mouse experiments [11], as far as determined by palpation. We believe that this method is much easier than transplantation of nasal septal catilage and palate mucous membrane due to the lack of necessity of a surgical operation to prepare the donor grafts.

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