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Double covering with amniotic membrane in restrictive strabismus
Doble recubrimiento con membrana amniótica en estrabismo restrictivo
S. Macías-Franco
, C. Costales-Álvarez, P. Rozas-Reyes
Corresponding author
Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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Macías-Franco, C. Costales-Álvarez, P. Rozas-Reyes" "autores" => array:3 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Macías-Franco" "email" => array:1 [ 0 => "sandramacfran@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Costales-Álvarez" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Rozas-Reyes" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Doble recubrimiento con membrana amniótica en estrabismo restrictivo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1840 "Ancho" => 1005 "Tamanyo" => 250678 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Postoperative period 1 week, 1 month, 1.5 years. The pink nasal colouring corresponds to the remains of the non-fibrotic conjunctiva that was preserved to give the pseudocaruncle appearance to this area. The graft has remained unchanged after 26 months of follow-up.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Any periocular surgery can cause restrictive strabismus due to fibrosis induced by tissue manipulation.The management seems straightforward: release adhesions and restore muscle function. In practice, however, it is not so easy, as they do not usually follow a common pattern, which is why it is necessary to know and recognise previous pathologies and surgeries for better surgical planning.The use of amniotic membrane (AM) has become widespread in ophthalmic surgery, especially in the field of ocular surface surgery. In strabismus surgery, there are an increasing number of case reports and series of a limited number of patients in which promising results have been obtained in the treatment of complications and restrictive strabismus.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of restriction secondary to consecutive exotropia surgery that was resolved favourably with a combined double overlay technique with AM.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0015" class="elsevierStylePara elsevierViewall">Female, 42, who had undergone surgery in childhood on her left eye for convergent strabismus. Examination produced visual acuity (VA) of 20/20 in the right eye and 20/20 in the left eye, left exotropia of 50 DP and absence of stereopsis. In view of the diagnosis of consecutive exotropia, surgery was decided following a passive ductility test that confirmed mild restriction to adduction and supraduction, initially attributed to a secondary contracture of the lateral rectus. We opted for reinsertion of the medial rectus at 5.5 mm from the limbus (original insertion) and recession of the lateral rectus at 8 mm with good immediate postoperative results without restriction. One week after the operation, the patient showed orthotropia with no fixation discomfort.</p><p id="par0020" class="elsevierStylePara elsevierViewall">One month after surgery, the patient had a feeling of tightness in the operated eye and hyperemia in the nasal region. At 3 months she also reported intermittent horizontal diplopia. Examination revealed diplopia in levoversion, limitation of abduction and supraduction of the operated eye with an incomitance of fixation, esotropia being 10 PD when fixating with the left eye (LE) (operated eye) and 4 PD when fixating with the right eye (RE). Biomicroscopy revealed a highly hyperemic and very retracted nasal conjunctival scar. Topical corticotherapy was then prescribed, which improved the hyperemia, but in successive check-ups an increasing restriction was observed that caused her ocular discomfort, especially when she attempted levoversion. The patient was aware that she had left eye suppression so she controlled the diplopia herself. The nasal scar continued to be retracted and hypertrophic and the incomitant esotropia had increased, so in view of the worsening symptoms, it was decided to perform surgery.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The preoperative examination (6 months after the first operation) showed esotropia with a strong discomfort of 10 PD when fixed with RE and 35 PD when fixed with LE, as well as limitation of abduction of the LE of 2+ and of supraduction of 2 +.</p><p id="par0030" class="elsevierStylePara elsevierViewall">First, an intraoperative forced duction test was performed, confirming the restriction to abduction and supraduction of the LAA. Dissection of the medial conjunctiva, which appeared very fragile and thin, Tenon and scar tissue was then carried out until the medial rectum was isolated, which had a rounded and defined cystic lesion on its surface over the previous 5/0 inferior vycril suture area. This was resected and sent fresh for analysis. The report described it as a cyst consisting of non-keratinised stratified squamous squamous epithelium together with goblet cells (conjunctival tissue) surrounded by a thick wall of thick fibrotic tissue attached to muscle fibres. The serous contents were cultured without growth of microorganisms.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After release of the medial rectus, the rectus medius was covered with MA, using a "wrap" technique with the epithelial surface towards the sclera and covering the distal end of the muscle extensively. Finally, a recession of the retracted medial conjunctiva was performed to form a new caruncle appearance and the conjunctival defect was covered with another layer of MA which was fixed with fibrin tissue adhesive (Tissucol®) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">At subsequent check-ups (follow-up of 26 months), the patient reported great satisfaction with the aesthetic result and significant subjective improvement with the absence of pain and tightness (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Currently, she persists with diplopia in extreme supradextroversion, which she manages to control thanks to the suppression of the LE. The examination shows an esotropia with discomfort of 0 DP when fixed with RE and 10 DP when fixed with LE without limitation and a slight limitation of the LE in supradextroversion of 1 +.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">It must be borne in mind that, when operating consecutive exotropia, we are faced with a previously manipulated conjunctiva, tenon and muscles, which means that we are already facing surgery with an unpredictable outcome. In the present case, a subconjunctival cyst was found, an extremely infrequent complication<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and which in turn could contribute to abnormal scarring and alteration of the adjacent conjunctiva, so the restriction for this reason was perhaps even greater.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It was decided to use the Wrap technique with MA due to its anti-inflammatory properties and barrier effect, thus providing an extra sheath to the medial rectum and isolating it from the sclera on its posterior side as well as from the fibrotic tissues and remains of the previously altered tenon and conjunctiva. The external coverage was also decided with another layer of MA, in this case with its stromal side towards the sclera and epithelial side towards the conjunctiva with a great esthetic result and functional improvement. This second graft integrated perfectly with the conjunctiva and there were no complications in its transition zone towards the limbar region.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The management of restrictive strabismus secondary to ophthalmological surgery is controversial and without consensus. The use of periocular and subconjunctival corticosteroids is not recommended due to the risk of increased intraocular pressure, and we also believed that this measure would not simply solve the problem and that it was necessary to explore the tissues directly. As for the use of antimetabolites such as mitomycin C and 5-fluorouracil, we have experience in glaucoma surgery and dacryocystorhinostomy, but when faced with an already affected and friable conjunctiva, we preferred the option of MA, which would also be useful both for the muscle and for covering the ocular surface. We believe that the collagen implant (Ologen®) may be a good alternative, as suggested by the studies in mice by Yoo YJ et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> But many more studies have shown that the use of cryopreserved AM decreases adhesion between the intervened muscles and adjacent tissues as well as the expression of inflammatory cytokine.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In humans, satisfactory results with cryopreserved AM have extended its use. On the other hand, no benefits have been found with freeze-dried AM, and several authors even suggest a predisposition to fibrosis and adhesion,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> which is why we would advise against its use in this type of surgery.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding the wrap technique, several authors seem to agree that the size of the graft should be large and provide as much coverage as possible to the muscle and that the orientation of the epithelial and stromal side is irrelevant, obtaining good results independently in terms of motility and reduction of adhesions and fibrosis.·</p><p id="par0070" class="elsevierStylePara elsevierViewall">The group of Kassem et al. has been working on this subject for more than a decade, experimentally in mice and later in humans, presenting the series with the largest number of patients operated on with this technique, which is why we consider their work to be a valuable reference in this article.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our case, there are several peculiarities. The first, as mentioned above, is the presence of the inclusion cyst. The second is the decision and modification of the technique by incorporating a second graft with amniotic membrane on the ocular surface, thus replacing the conjunctiva, offering an additional barrier and protection and providing the already described and known benefits, i.e., easy availability and handling, excellent anti-inflammatory properties and tolerance in all types of patients including children.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0080" class="elsevierStylePara elsevierViewall">After the excellent result obtained in the present case, a restrictive strabismus that was difficult to manage, we consider the Wrap technique with MA an interesting technique to consider in this type of case. It has also provided us with a solution to the ocular surface problem presented herein.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies, commercial sector or non-profit organisations.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1853064" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1610933" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1853063" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1610934" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-08-03" "fechaAceptado" => "2022-10-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1610933" "palabras" => array:5 [ 0 => "Restrictive strabismus" 1 => "Inclusión cyst" 2 => "Amniotic membrane" 3 => "Strabismus surgery" 4 => "Wrap" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1610934" "palabras" => array:5 [ 0 => "Estrabismo restrictivo" 1 => "Quiste de inclusión" 2 => "Membrana amniótica" 3 => "Cirugía de estrabismo" 4 => "Wrap" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A case of severe restrictive strabismus after a consecutive exotropia surgery is presented.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We describe the exitous managment through a technique consist of wrapping with amniotic membrane (AM) the affected muscle where we add a second AM graft in the reconstruction of the ocular Surface.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El manejo del estrabismo restrictivo sigue siendo un problema no resuelto hoy en día.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se presenta un caso de estrabismo restrictivo postquirúrgico severo tras una cirugía de exotropia consecutiva. Describimos a continuación el manejo exitoso mediante una técnica que consiste en envolver el músculo afectado con membrana amniótica (MA) o “wrap” en la que añadimos un segundo injerto de MA en la reconstrucción de la superficie ocular.</p></span>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1077 "Ancho" => 1505 "Tamanyo" => 251728 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intraoperative images: Predissection, inclusion cyst, muscle overlay, superficial overlay.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1840 "Ancho" => 1005 "Tamanyo" => 250678 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Postoperative period 1 week, 1 month, 1.5 years. The pink nasal colouring corresponds to the remains of the non-fibrotic conjunctiva that was preserved to give the pseudocaruncle appearance to this area. The graft has remained unchanged after 26 months of follow-up.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment and prevention of ocular motility restrictions with amniotic membrane transplantation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Fernández Jiménez-Ortiz" 1 => "R. Sampedro Yañez" 2 => "B. Villarrubia Torcal" 3 => "B. Maroto Rodriguez" 4 => "S. Nava Pérez" 5 => "N. 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