Intraoperative Mitomycin C in the Treatment of Recalcitrant Ankyloblepharon

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Ankyloblepharon is characterized by partial or total fusion of the eyelid margins. It may be congenital due to failure of the eyelids to separate during the antenatal development, or acquired, mainly in the context of conditions causing cicatrizing conjunctivitis, including ocular mucous membrane pemphigoid, Steven Johnson syndrome, chemical injuries, or herpetic infection. The authors describe a case of a recurrent acquired ankyloblepharon in the absence of conjunctival cicatrization, managed successfully with adjuvant intraoperative mitomycin C (MMC).
A 68-year-old woman, referred with a 4-year history of left lower eyelid margin redness, was found to have extensive left lower eyelid and lateral canthal basal cell carcinoma (Fig. 1A). Her history included blepharitis and Guillan Barre syndrome. The lesion was completely excised and reconstruction with periosteal flap, cheek myocutaneous advancement flap, and Hughes flap was carried out. Two months after opening of the Hughes flap, she was noted to have reduced horizontal palpebral aperture, lateral ankyloblepharon formation, and rounding of the lateral canthal angle (Fig. 1B).
Subsequently, the area of adhesion was divided, but despite good early postoperative result, the ankyloblepharon reformed after 1 month. Two further revision operations with division of the scar tissue resulted in a similar outcome with only a few weeks of improvement, before recurrence of an aggressive scarring response in the lateral canthal area. Five years after initial surgery, the patient continued to experience discomfort due to adherence of the eyelid over the conjunctiva and temporal cornea accompanied by a small degree of lagophthalmos. At this stage, the ankyloblepharon was redivided in addition to intraoperative application of MMC (0.4 mg/ml via a sponge) applied to the involved upper and lower eyelid margins. A custom-made scleral contact lens with a central ridge was also placed aiming to keep the upper and lower eyelids parted in the immediate postoperative period. This resulted in a satisfactory outcome, with resolution of symptoms and no evidence of recurrence after 2 years follow up, postoperatively (Fig. 2).
Treatment of ankyloblepharon consists of division of the bands holding the eyelids together, although additional reconstructive surgery such as amniotic or mucous membrane grafting may be required based on the extent and severity of the adhesions.
Topical MMC is extensively utilized in the treatment of ocular surface malignancy such as primary acquired melanosis with atypia, ocular surface squamous neoplasia, superficial conjunctival melanoma, or even sebaceous gland carcinoma.1 Moreover, intraoperative application of MMC to conjunctival fornices combined with mucous membrane, amniotic membrane graft, or conjunctival autograft has been found to be effective in controlling recurrent symblepharon in patients with severe cicatrizing conjunctival disease, including cases with superior and inferior forniceal obliteration leading to ankyloblepharon formation.2,3 Furthermore, an application of intraoperative MMC without mucous membrane grafting has been associated with favorable outcome in the setting of pseudopemphigoid-related symblephara.4
In this case, the main focus of cicatrization was on the eyelid margin, without any conjunctival or forniceal involvement. Additionally, the MMC was applied only to the affected eyelid margin surface following cicatrix lysis. To the authors’ knowledge, this therapeutic modality has not been documented in the setting of iatrogenic ankyloblepharon, in the absence of conjunctival involvement. MMC may be utilized as a relatively safe adjunct in preventing recurrence of aberrant eyelid margin cicatrization following tumor excision and reconstructive surgery.
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