Edward J. Holland, W. Barry Lee and Mark J. Mannis

Introduction

The management of patients with severe ocular surface disease requires a systematic and stepwise approach to treatment. Choosing the most appropriate management option for the patient is of utmost importance in providing optimal results in rehabilitation of the ocular surface. In addition, tear dysfunction, abnormal eyelids, and other significant ocular co-morbidities must be addressed prior to surgical treatment of the ocular surface for successful postoperative results. Examples would include the correction of lagophthalmos, trichiasis, severe dry eye disease, or glaucoma prior to undertaking any form of ocular surface transplantation. Important considerations in the choice of a treatment regimen include the nature of any underlying pathology; the extent and severity of ocular surface disease, including the degree of stem cell damage; unilaterality or bilaterality of the pathology; the presence or absence of conjunctival inflammation; whether tear production is normal, significantly altered or absent; the age of the patient; and systemic co-morbidities that may be relevant to the use of systemic immunosuppression.

The options for ocular surface stabilization using medical treatment are outlined in Box 54.1. While medical therapy can be both helpful and often necessary for restoration of the integrity of the ocular surface, it may not be suitable as a long-term treatment option, especially if there is severe stem cell damage. In conditions resulting from severe stem cell deficiency, management options shift to surgical alternatives. The flow diagrams outline our approach to decision-making in the surgical treatment of ocular surface disease based on whether the pathology is unilateral (Fig. 54.1) or bilateral (Fig. 54.2).

Surgical Treatment Options

The primary considerations for decision-making in the surgical management of ocular surface disease from stem cell deficiency include: (1) the laterality of disease, (2) the degree of stem cell involvement, (3) the level of tear production/baseline tear status, and (4) whether or not there is conjunctival inflammation. The presence of conjunctival inflammation is a particularly important finding and may have significant bearing on the surgical planning for repair of the damaged ocular surface. Treatment strategies are outlined in the flowcharts for unilateral disease (Fig. 54.1).