autograft or allograft after removal of the flap may be necessary to provide a permanent source of normal epithelium before an optical corneal transplant.

Khodadoust A, Quinter AP. Microsurgical approach to the conjunctival flap. Arch Ophthalmol. 2003;121(8):1189–1193.

Conjunctival Biopsy

Indications

A conjunctival biopsy can be helpful in evaluating chronic conjunctivitis and unusual ocular surface diseases, including the following:

squamous lesions of the conjunctiva (eg, conjunctival intraepithelial neoplasia) cicatrizing conjunctivitis

conjunctival lymphoid tumors lichen planus

pemphigus vulgaris graft-vs-host disease

superior limbic keratoconjunctivitis

Surgical technique

After an anesthetic eyedrop (eg, proparacaine hydrochloride 0.5%) is instilled, a pledget wet with the same or a similar agent is applied to the lesion or site for approximately 30 seconds. Subconjunctival anesthesia can also be given but is usually unnecessary. A drop of topical phenylephrine 2.5% can blanch the conjunctival vessels and reduce bleeding. The surgeon uses forceps and scissors to snip a conjunctival specimen. Lesions may be completely excised (excisional biopsy), if possible. For a subepithelial lesion, a wedge or block is excised. Tissue crushing must be minimized by grasping only the edge of the biopsy specimen. Gentle cauterization can be used to facilitate hemostasis after the specimen has been removed.

Tissue processing

The sample is placed in the proper anatomical orientation on a carrier template (eg, filter paper) and inserted into the appropriate fixative, such as 10% formalin (for histology), 3% glutaraldehyde (for electron microscopy), or Michel’s Transport Medium (Zeus Fixative) (for immunofluorescence microscopy). A preoperative consultation with the pathologist is advised to ensure proper handling and staining of specimens.

American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Pattern Guidelines. Conjunctivitis: Limited Revision. San Francisco: American Academy of Ophthalmology; 2011. Available at: www.aao.org/ppp.

Conjunctivochalasis Excision

Conjunctivochalasis is characterized by the presence of redundant conjunctival folds positioned between the globe and the lower eyelid margin. (See Figure 12-4 and discussion of conjunctivochalasis in Chapter 12.) The surgical procedures that have been used to remove these redundant folds include the following:

Superficial cauterization. A topical anesthetic (eg, proparacaine hydrochloride 0.5%) is administered. The patient is instructed to look upward and remains in this position throughout