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First Author: M.Giannico ITALY
Co Author(s): R. Fasciani G. Savino J. Bondì E. Balestrazzi
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To report on the efficacy of the surgical treatment performed in an infant affected by total bilateral anckyloblepharon (ANCK).
Clinical and surgical practice was performed at the Ophthalmology Department of the Catholic University of Sacro Cuore in Rome, Italy.
A 8-year old African female, coming from Burundi, presented with complete post infective lid-corneo-conjunctival adhesion in both eyes, dating back 6 years before, due to an unintentional fall in a septic tank. She referred light perception through the lids in both eyes. No eye movements were allowed. Preoperative ultrasound evaluation of anterior and posterior segment showed the bulbar integrity and the maintenance of anterior and posterior ocular segment. Electrophysiological examinations showed low responses. A manual dissection of the complete adhesion between upper tarsus, fornix - tarsal conjunctiva and corneal stroma was performed, followed by removal of symblepharon and conjunctival adhesions. Firstly, a cleavage plane between the cornea and the neovascular pannus covering corneal and sclero-limbal surface was searched; then the fibrovascular tissue from the sclero-corneal surface was dissected manually and a superficial keratectomy was completed to smooth the cornea and the limbus, finally covered with a multiple layer of human amniotic membrane (HAM) graft. A sliding plastic of the residual bulbar conjunctiva was performed and a second HAM was used as a bandage of the entire ocular surface, fornices and tarsal conjunctiva. Two silicon rod conformers were used to deep the fornices.
The patient showed no residual ANCK, upper and lower tarsal conjunctiva reconstitution with excellent width of fornices and lid motility restoration in both eyes. Bilateral corneal superficial neovascularization, probably due to limbus deficiency, and diffuse stromal opacity were present. Corneal epithelium appeared complete and tropic. Stromal cloudiness progressively improved during the follow up (six months). The child referred bilateral hand movement perception, but she showed no visual interest and was affected by horizontal nystagmus and bilateral hypertropia. During the first month postoperatively, eyes were able to maintain the primary and the secondary position of gaze except ocular depression, which seemed to be impossible (the irregularity of the ocular surface probably caused pain on attempt of downgaze). Month after month, recovery of ocular motility was established in both eyes. Electrofuntional examinations recorded decreased values, but were not extinct.
Even in the presence of deep deprivation amblyopia, total anckyloblepharon surgical removal and anatomic restoration of ocular surface is mandatory in infants. Subsequent surgery including corneal keratoplasty or keratoprosthesis implant should be taken into consideration after an accurate evaluation of the cost/benefit ratio. Furthermore, these young patients could be enrolled in specific visual rehabilitation programs to enhance residual visual abilities as better as possible.