pterygium recurrence. Current nonsuture techniques using fibrin gel successfully reduce surgically induced inflammation and shorten surgical time.

2.4 Limbal and Conjuntival Dermoids

2.4.1 Background of the Disease

A limbal dermoid is a congenital disorder, seen mostly at the lower-temporal limbus, and its size becomes slowly larger in proportion to the size of the cornea. It is often associated with a conjunctival dermoid at the temporal area, the size and thickness of which vary in each patient. It can cause both cosmetic abnormality and decreased visual acuity by causing astigmatism. An amblyopic eye must be treated properly by visual rehabilitation, such as the wearing of an eye patch or corrective eye glasses as removal of the limbal dermoid itself does not change the best corrected visual acuity. In addition, preoperative penalization treatment improves the postoperative visual acuity.

cornea. A donor cornea of the same size is then placed in that area and fixed with 10–12 interrupted 10–0 nylon sutures. If the dermoid is large, the conjunctiva is treated with 0.04% MMC for 3 min. It is preferable to remove the conjunctival dermoid at the same time. However, a conjunctival dermoid that has penetrated deeply into the upper-temporal sclera should be left as it is and should not be excised extensively, to avoid severe postoperative complications. Cosmetic recovery is easily achieved.

2.4.4 Postoperative Follow-Up

After keratoplasty, topical antibiotics (e.g., 0.3% ofloxacin eye drops four times daily) and corticosteroids (e.g., 0.1% dexamethasone or 0.1% fluorometholone drops four times daily) are applied for approximately 6 months. Intraocular pressure should be checked regularly as children often suffer from steroid-induced glaucoma. Systemic steroids are not usually necessary for children. Penalization treatment is not usually effective after surgery, and sutures are usually removed during the initial six postoperative months.

2.4.2 Basic Concept of Surgery

To remove limbal dermoid tissue completely and to prevent the occurrence of pseudopterygium after surgery, peripheral tectonic lamellar keratoplasty over the limbus and its adjacent conjunctiva is preferable. Both fresh and preserved donor corneas may be used for this surgery. Limbal dermoids that receive a simple resection frequently develop pseudopterygium due to adjacent conjunctival over-proliferation on the residual dermoid tissue in the cornea. Furthermore, a simple resection cannot remove all the dermoid tissue from the cornea due to corneal thinning. Patients usually undergo the operation when they are 4–6-years-old due to the ease of postoperative care at that age.

2.5 Strabismus Surgery (Fig. 2.7)

Debate can surround the question of the incision size of the conjunctiva in strabismus surgery. It can be proposed that a wider incision, and thus a wider field of operation, must be made to perform a safe and secure surgery. Conversely, it can be argued that a smaller/narrower incision will result in minimizing the amount of conjunctival damage, thus resulting in rapid cosmetic, recovery, with white conjunctiva that is good in appearance. In fact, it has been found that careful management of the outer eye muscles through a small incision can be satisfactorily performed once a physician gains adequate experience with this type of surgery.

First, a minimal conjunctival resection is performed before lamellar keratoplasty. Then, the dermoid is marked by a trephine of appropriate size, and the lamellar dissection is performed from the central

In general, a surgery tends to evolve in the direction of becoming less and less invasive. The same holds true for ophthalmic surgery. The purpose of performing

Fig. 2.6 Surgical steps of operation for limbal dermoid. Preoperative limbal dermoid (1) is marked with a slightly over-sized trephine (2), dissect out a limbal dermoid and a diseased peripheral cornea with one-half thickness from a central cornea (3), through an adjacent sclera (4). A lamellar cornea graft of the same size is created from a donor cornea (5), placed on the keratectomized bed (6), and sutured with 10–0 nylon interrupted sutures (7). Postoperative manifestation (8)

minimally invasive surgery is to avoid excessive postoperative wound healing, especially in areas with fibrovascular overgrowth. As the conjunctiva is a soft, delicate tissue, surgeons must avoid using invasive surgical modalities that promote excessive wound healing

after surgery. One such approach is the use of a small incision. The other approach is the use of AM, MMC treatment, and the postoperative use of immunosuppressives that presumably suppress the TGF-beta signaling pathway and inflammatory cytokine release.

Fig. 2.7 Small incision made at the bulbar conjunctiva is seen at strabismus surgery

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