Dry eye is a multifactorial disease characterized by the development of a chronic vicious cycle between the tear film and ocular surface epithelium, resulting in tear film instability as well as ocular surface epithelial damage that are respectively observed as shorter fluorescein breakup time and punctate flu-orescein staining of the ocular surface epithelium. The vicious cycle may be related to the other dry eye mechanisms, such as the well known hyperosmolarity or the more recently emphasized inflammation, yet the exact relationship between the three mechanisms (tear film instability, hyperosmolarity, and inflammation) remains unclear. However, numerous risk factors may be related to the three central mechanisms of dry eye mentioned above, and these risk factors may result in or exacerbate the clinically evident dry eye. The conjunctival abnormalities described in this chapter may all be regarded as risk factors for dry eye, and they include: conjunctivochalasis (CCh); superior limbic keratoconjunctivitis (SLK); pterygium and pinguecula, and cicatricial changes associated with severe ocular surface disease, such as in Stevens Johnson syndrome and ocular cicatricial pemphigoid.

CCh, also known as lip like folds, conjunctival pleating , and lid parallel conjunctival folds (LIPCOF), can be both a diagnostic sign and a risk factor for dry eye. From the etiological viewpoint, CCh exacerbates dry eye via the dysfunction of the tear meniscus and mechanical action. CCh is generally located along the lower tear meniscus where it may interfere with the tear meniscus which is known to serve three important functions including: (1) retention of tears (75-90% of the total tear volume rests in the tear meniscus); (2) distribution of tears to the ocular surface, and (3) ocular surface tear routing due to its connection to the lacrimal drainage system. CCh may result in tear film instability and the disruption of tear flow leading to delayed tear clearance, which then in turn may exacerbate dry eye associated inflammation.

A paradoxical consequence of CCh associated tear meniscus dysfunction in mild cases of dry eye is pseudo epiphora. In more severe cases, CCh will not only reduce the retention and distribution of tears but also of tear substitutes applied. Another mechanism exacerbating dry eye or dry eye associated symptoms is CCh related mechanical friction. This occurs between the lax conjunctiva and the lid margin and/or cornea. Ocular surface epithelial damage and conjunctival hyperemia are frequently seen in cases with CCh combined with aqueous tear deficient (ATD) dry eye, and may be attributed to this friction associated mechanical trauma to the ocular surface. This mechanism is also involved in SLK, where there is friction between the lax upper bulbar and palpebral conjunctiva, limbus, and upper part of the cornea. Interestingly, the characteristic changes of advanced SLK include inflammation and inflammation-related focal dry eye, and these can be successfully treated surgically.

Next, when investigating the mechanism that prompts the pinguecula or pterygium to cause or exacerbate dry eye, ectopic menisci formed around pinguecula or pterygium head which invade the cornea should be considered. These ectopic menisci are known to cause thinning of the adjacent tear film resulting in local tear-film instability and focal evaporative dry eye. This mechanism may help explain the superficial punctate keratopathy (SPK) or Dellen found adjacent to the pinguecula or a pterygium head which are often medically uncontrollable; this is especially true in cases with a background of ATD.

Finally, the cicatricial change in conjunctiva seen in severe ocular surface diseases such as Stevens-Johnson syndrome and ocular cicatricial pemphigoid is associated with chronic subconjunctival immunological inflammation. This inflammation involves lacrimal gland ducts and conjunctival epithelium, resulting in ATD and inhibition of the normal differentiation of conjunctival epithelium. This leads to the pathological keratinizationl which transforms hydrophilic surfaces into hydrophobic ones. These mechanisms are found in the severe form of dry eye that is often accompanied by severe ocular surface diseases and is a result of a combination of ATD and evaporative dry eye.

Based on the conjunctiva-associated mechanisms in dry eye described above, several surgical strategies can be considered. For the treatment of CCh, conjunctival resection should be designed to reconstruct the normal tear meniscus to the greatest possible length along the lower lid margin. Ideally, this resection would extend from the lateral canthus to the punctum in order to restore normal tear meniscus function, rather than just a simple resection of the lax conjunctiva. In contrast, in cases of pinguecula or pterygium, resection of the protruding conjunctival lesion, which is thought to induce SPK, should be designed to remove the ectopic meniscus which is the causative factor of focal dry eye. This is usually indicated in cases with ATD.

In cases with severe ocular surface disorders with conjunctival cicatrization associated with dry eye, mitomycin C and/or amniotic membrane can be used at the time of resection of subconjunctival fibrovascular tissues to reduce conjunctival inflammation when anti-inflammatory medical treatment was unsuccessful. However, those cases are sometimes accompanied by corneal stem cell disorders which often necessitate additional reconstruction of ocular surface epithelium.

The previously described treatment modalities are sometimes applied simultaneously, and at other times in a more stepwise approach. The following sections will describe the practical aspects of conjunctival surgery for dry eye, including indications, surgical techniques, and complications.

Surgery of Conjunctivochalasis

Background of the Disease
CCh is a very common ocular disorder that is characterized by a redundancy of bulbar conjunctiva. Although there are two etiological theories associated with this disease (age-related and subconjunctival inflammation-related), our research has demonstrated the breakdown of elastic fibers in the redundant conjunctiva without any inflammatory cell infiltrates , thus supporting the age-related theory. However, it is often clinically experienced that CCh may cause non-specific inflammation, possibly via the redundant CCh-induced mechanical action during blinking and/or eye movement, or an exacerbation of dry eye-related inflammation via the CCh-induced delayed tear clearance.

CCh is unique in that it may induce tear meniscus dysfunction which is a risk factor for both watering eyes and dry eyes. Symptoms of dry eye discomfort and/or corneal epithelial damage may be exacerbated not only as a result of tear meniscus dysfunction, but also because of the mechanical friction created between the redundant conjunctiva and the ocular surface. It has also been reported that LIPCOF can potentially be used as a diagnostic marker for dry eye. Historically, surgery of CCh has been little practiced, yet numerous recent reports support the efficacy of a surgical approach for improving ocular symptoms and ocular surface epithelial damage in cases with or without dry eye.

Concept of Surgery
Although numerous surgical methods for CC have been reported , such as a crescent resection, resection combined with inferior peritomy and radial relaxing incision, and excision with amniotic membrane transplantation (AMT) and scleral fixation, all previous methods involved no firm strategy for tear meniscus reconstruction and most procedures only targeted the redundant conjunctiva inferior to the cornea while redundant conjunctiva in the nasal and temporal areas were ignored. Therefore, the ideal surgical method must be applicable to all variations of CCh and should achieve reconstruction of the entire lower tear meniscus and eliminate ocular surface undulations.

Indication for Surgery
First, surgery for CCh is only indicated when the disorder is symptomatic. Asymptomatic CCh, even if there is excess tissue, is not an indication for surgery. Second, surgery should only be performed if the reported symptoms can be explained by clinically established signs of tear meniscus dysfunction and/or the mechanical action of redundant conjunctiva.

In cases of dry eye combined with CCh, surgery should be performed when medical treatment is found to be ineffective. However, in cases of CCh with unstable tear film and no SPK (often diagnosed as dry eye and ineffectively treated with eyedrops alone), surgery can be expected to produce positive results. Traditionally, punctal occlusion with plugs has been the initial method for treating patients with moderate dry eye and prominent CCh. However, recent results now indicate that CCh surgery should be considered prior to punctal occlusion.

Surgical Procedure
The operation includes the following steps: (1) topical anesthetic eyedrops with epinephrine are applied; (2) planned incision lines are marked using a newly developed marker (Chalasis marker, M-1405; Inami Co., Ltd, Tokyo, Japan). Small eyes require forced bilateral eye movement for correct marking; (3) subconjunctival anesthesia is performed, and an arc-shaped incision is made to the anesthesia-ballooned conjunctiva using scissors (Chalasis scissors, M-1406; Inami Co., Ltd) along the line created by the marker on the lower half of the bulbar conjunctiva; (4) subconjunctival tissues are dissected distal to this arc incision in order to easily stretch the redundant conjunctiva and to obtain firm attachment of the conjunctiva directly to the sclera; (5) radial incisions are then made with the Chalasis scissors in the redundant conjunctiva in order to create three conjunctival sections distal to the arc incision. The conjunctiva in the lower section is then pulled upwards, and any tissue that can be overlaid on the limbal conjunctiva resected and fixed using approximately five 9-0 silk stitches.

For the treatment of the lateral sections, forced bilateral eye movement, henceforth referred to as the 'eye rotation step', are performed when judging the amount of excess tissue to avoid suture breaks due to postoperative eye movement. It is important to resect all redundant conjunctiva of the temporal conjunctiva while less resection is required of the nasal side due to the subsequent resection of the plica semilunaris; (6) the temporal and nasal conjunctival flaps are then sutured with interrupted 9-0 silk; (7) excision of the plica semilunaris and minor temporal adjustment is then performed. The plica semilunaris should be excised at the base and no sutures are necessary. Using these procedures, complete reconstruction of the lower tear meniscus and elimination of conjunctival surface-related undulations associated with CCh can be obtained.

Postoperative Follow-Up, Complications, and Management Postoperatively, patients are advised to wear an eyepatch for 1 week at bedtime to prevent any possible wound dehiscence. Sutures are removed 2 weeks after surgery. During the 2-week postoperative period, 0.1% betamethasone and antibiotic eyedrops should be instilled 4 times daily. Following removal of the sutures, betamethasone should be replaced by 0.1%fluorometholone instilled 4 times daily together with antibiotic eyedrops. Instillation times of the 0.1%fluorometholone should be reduced according to the extent of postoperative inflammation, and fully discontinued within 2 months postoperatively. Dry-eye patients should additionally receive artificial tears (ideally preservative-free) in combination with the above-mentioned postoperative eyedrops. That combination is then substituted with the eyedrops that the patients were using for dry-eye treatment prior to surgery once postoperative inflammation subsides.

Without the 'eye rotation' step, early postoperative complications in our previous study of 168 eyes included secondary lymphangiectasia in 6 eyes (3.5%), dehiscence in 11 eyes (6.5%), and pyogenic granuloma due to a reaction to the 9-0 silk suture in 2 eyes (1.1%). Lymphangiectasia can be managed by needling or excision, and pyogenic granuloma can be managed with topical steroids or surgical removal.

Surgery for Superior Limbic Keratoconjunctivitis

Background of the Disease
SLK is a unique inflammatory disease, first reported by Theodore in 1963, of the superior bulbar conjunctiva, limbus, and upper part of the cornea. The condition may be associated with corneal filaments, SPK, edema hyperemia and papillary hypertrophy of the superior bulbar and palpebral conjunctiva and limbus. The etiology of SLK is not clearly understood, however, there is a mechanical theory which suggests that in SLK the superior bulbar conjunctiva is lax due to congenital or age-related factors. In addition, blink-associated mechanical friction could lead to chronic inflammation of the lax conjunctiva. SLK is reportedly associated with ATD dry eye and thyroid disease, and is accompanied by severe symptoms of irritation. Many non-surgical treatments have been attempted, such as the application of silver nitrate, vitamin A eyedrops, N-acetylcysteine and autologous serum, bandage soft contact lenses, and punctal plugs. Effective surgical treatments include simple resection, thermocauterization, and recession of the abnormal conjunctiva.

Indications for Surgery
Artificial teardrops or low concentration topical steroids, such as 0.1% fluorometholone, should be tried. However, for SLK combined with moderate to severe dry eye, punctal occlusion with punctal plugs is the best method of treatment. SLK cases with myopia are most effectively treated with soft contact lenses in combination with frequent instillation of preservative-free artificial tears. Surgery should only be considered for cases that are unresponsive to medical treatment.

Concept of Surgery
Based on the concept that SLK-associated abnormal findings, such as con-junctival hyperemia, limbal thickening, and SPK, are the result of the friction between the redundant upper bulbar conjunctiva at and around the SLK lesion and the upper palpebral conjunctiva, surgery should aim to eliminate lax conjunctiva without leaving any redundant tissue at the SLK lesion by a crescent excision of the conjunctiva superior to the SLK lesion. Conjunctival redundancy is located mainly at - but not limited to - the SLK lesion. Therefore, we resect the perilesional conjunctiva but not the SLK lesion itself, and leaving intact conjunctiva close to the cornea may be helpful for future cataract or glaucoma surgery. As a result of this procedure, diseased conjunctiva within the SLK lesion is successfully stretched, conjunctival inflammation and positive rose bengal (RB) improve in as late as 1 month, and the amount of goblet cells within the SLK lesion is restored to the normal level.

Surgical Procedure
Our surgical method involves four steps: (1) Prior to surgery, a topical anesthetic with epinephrine and RB staining are applied to determine the localization of the abnormal conjunctival area in SLK. (2) After the administration of subconjunctival local anesthesia, an arc-shaped conjunctival incision is placed from the 2 o'clock to the 10 o'clock position adjacent and distal to the RB-stained lesion. (3) After excision of the subconjunctival connective tissue from the superior conjunctiva to the arc incision, the extent of resection is determined by the amount of redundant conjunctiva with the distal conjunctiva overlaid onto the RB-stained proximal conjunctiva. In accordance with the determined extent of resection, the conjunctiva is resected to form a crescent using the arc incision as the base. (4) The crescent incision of the conjunctiva is closed with interrupted stitches using 9-0 silk suture. Throughout the procedure, it is important that the patient is asked to look down as far as possible. This procedure usually results in complete resolution of SLK-associated hyperemia.

Postoperative Follow-Up, Complications, and Management Postoperative treatment consists of antibiotic eyedrops and 0.1% fluo-rometholone eyedrops, both instilled 4 times daily for 2 weeks and twice daily over the following 2-6 weeks. In cases involving a more invasive removal of subconjunctival tissue, the 0.1 %fluorometholone should be replaced with 0.1% betamethasone. The sutures should be removed 1-2 weeks postoperatively. To date, no early or late postoperative complications have been observed. Our success rate was 100%in 6 eyes of 5 patients.

Surgery for Pterygium
Background of the Disease
Severe progression or recurrence of pterygium sometimes leads to clinical problems such as corneal scarring and irregular astigmatism. Advanced scarring may extend close to the optical zone and extraocular muscles, resulting in visual loss and restriction of ocular mobility, respectively. Rarely does pterygium relate to or coexist with the condition of dry eye, but when thick and irregular pterygium tissue invades the corneal surface it can lead to uneven tear distribution which is responsible for the focal evaporative form of dry eye. Early pterygium and pinguecula are commonly not problematic in normal eyes and should not be considered for surgery.

However, both have the potential to induce epithelial damage in cases of dry eye and during contact lens wear, because the irregular protrusion of these surfaces is insufficiently covered with tear film under the low tear volume. It is common to observe chronic inflammation in pinguecula of hard contact lens wearers because of physical stimulation and unstable tear-film coverage. When an ectopic tear meniscus is formed along the pterygium head, tear-film thinning will result next to it. This can cause tear-film instability which may lead to SPK around the pterygium head. Tear-film thinning is also notable over the prominent parts of the pterygium, and this may result in symptoms of irritation and dry-eye sensation as well as conjunctival hyperemia. Coincidental dry eye magnifies these symptoms, and the chronic epithelial damage caused by the tear evaporation results in chronic non-specific inflammation and may promote the progression of pterygium and pseudo-pterygium.

Indications
There are numerous reports that explore the surgical treatment of pterygium, yet medical treatment should be tried before resorting to surgery. Frequent use of artificial teardrops and hyaluronic acid instillation can improve apical surface damage in pterygium and focal inflammation should be treated with a low dose of fluorometholone unless steroid-induced complications are observed. The indication for surgery is not clearly defined, and sometimes includes the cosmetic and social requirements of the patient. The most important point of pterygium surgery is to inhibit recurrence of the disease, because the need for reoperation substantially reduces the prognosis and increases the risk of complications due to cicatrization. Indication, selection, and timing of the surgical procedure based on the clinical picture (e.g. chronic injection, bilateral pterygium, and thickening of the Tenon's tissue) determine the success of surgery. In dry eyes, corneal epithelial damage resistant to conventional management with artificial teardrops and punctal plugs is a clear indication for surgery.

Concept of Surgery
The purpose of surgery in primary pterygium is to remove hyperproliferat-ing subconjunctival tissue and the abnormal pterygium head and to minimize the risk of recurrence. Attention should focus on the: (1) area of excision; (2) use of intraoperative chemicals; (3) technique of wound closure, and (4) transplantation of tissue to the area of excision to inhibit recurrence.

For advanced and recurrent pterygium, in order to prevent further recurrences and/or to reconstruct surgically induced conjunctival cicatrization, additional concepts have been proposed. These include: (1) reconstruction of the limbal barrier to block pterygium re-invasion, and (2) reconstruction of conjunctival area lost by excessive surgical resection and scarring.

The concept of an autologous limboconjunctival graft taken from the patient's healthy eye has been reported, however this procedure carries the risk of inducing partial limbal deficiency at the donor site. Therefore, keratoep-ithelioplasty using a preserved corneal graft is an alternative procedure that eliminates the risk of damage for the other eye.

Surgical Procedures
Previously, simple resection with bare scleral closure has been used in early or small pterygia. However, a variety of studies have shown a high rate of recurrence for that technique when not accompanied by adjunctive therapy. Slow epithelial wound healing and prolonged postoperative inflammation may activate fibroblasts, resulting in recurrence. It is now widely accepted that adjunctive therapy and creation of a physical barrier dramatically reduces the risk of pterygium recurrence.

The adjunctive intraoperative application of mito-mycin C (MMC) has been commonly used and is found to improve the clinical outcome even in mild cases.MMC is an alkaloid agent capable of suppressing the proliferation of fibroblasts which are thought to be responsible for the etiology of pterygium. The commonly used concentration of MMC ranges between 0.02 and 0.04%, and the duration of application between 1 and 3 min (compared to postoperative topical use). The intraoperative application of MMC is relatively safe, however postoperative complications such as scleroma-lacia and persistent epithelial defects can result from an excessive MMC effect. Therefore, it is important that MMC is not applied to surgically damaged or thin sclera, and that the ocular surface is thoroughly rinsed with 0.9% saline afterwards.

Conjunctival rotational flaps and conjunctival transplantation are commonly used surgical methods to prevent recurrence. Technically, both approaches are relatively simple and do not require the use of any special materials. However, folding of the conjunctiva after rotation can sometimes cause cosmetic problems. Transplantation of a free conjunctival graft is more complicated and time-consuming, yet superior to conjunctival flap rotation in achieving a smooth conjunctival surface. The technique is especially useful in recurrent pterygia, where a large epithelial defect may result from resection. Free conjunctival autografts not only promote epithelial healing, but also act as an epithelial barrier to inhibit recurrence and were found to be superior to AMT in a comparative randomized trial. On the downside, it results in additional scarring of normal conjunctiva.

Amniotic membrane (AM) is now widely accepted as an effective biological tool to inhibit pterygium recurrence. AM promotes epithelial wound healing and prevents inflammation. AMT was first introduced in pterygium surgery in 1997 by Tseng et al, and several reviews have summarized the proposed basic mechanisms of AM. Although the precise biological effects of AM are still unclear, clinical results have indicated that fibroblast growth under the AM is suppressed and that postoperative complications such as persistent epithelial defect and scleromalacia, even after a large-sized resection, are reduced. AMT appears to successfully improve the prognosis of severely recurrent pterygium.

Postoperative Follow-Up, Complications, and Management Complications are subdivided into two categories: intraoperative and postoperative.

Intraoperative complications are rare. The most serious complication is damage to the medial rectus. Sufficient caution should therefore be paid during the removal of subconjunctival tissue, especially in recurrent pterygia with severe scarring and excessive bleeding, and squint hooks or silk threads should be used to simplify the separation. Corneal perforation is a very rare complication, but excessive thinning of the cornea during excision should be avoided. Intraoperative surgical slit-lamp examination is a useful tool for examining the corneal thickness at the time of pterygium removal.

Major postoperative complications of pterygium surgery include infection, corneal ulcers, and scleromalacia. Infection is rare, yet it should be noted that wearing bandage contact lenses after large-area resections dramatically increases the risk of infection.

Appropriate antibiotic instillations should be used until the wound is fully healed. Persistent epithelial defects and Dellen formation are not common, but they may progress to corneal melting. Frequent instillation of artificial tears and ointments are usually sufficient for treatment. Severe cases occasionally require additional treatment using punctal plugs or bandage contact lenses to increase the stability of tear film and promote epithelial healing. Scleromalacia is the most undesirable complication, because it may appear even after years of intra- or postoperative MMC and (3-irradiation. Since scleromalacia is difficult to stop and may require surgical treatment such as scleral patching or lamellar keratoplasty, MMC should always be applied with great care. Although topical instillation of MMC or 5-fluorouracil in the postoperative period have been reported to be efficient, it is wise to remember that these treatments are associated with an increased risk of severe complications such as persistent epithelial damage and scleromalacia.

Surgery for Cicatricial Ocular Surface Disease

Background of the Disease
The majority of cicatrizing diseases of the ocular surface are associated with dry eye. Obstruction of lacrimal ducts opening onto the conjunctival surface due to progressed cicatrization, as well as conjunctival sac shortening and symblepharon formation, all lead to reduced secretion, pooling, and abnormal distribution of tears and tear meniscus. Extensive scar formation and symblepharon also interfere with normal eye-blinking and cause trachiasis and entro-pion which further degrade the ocular surface environment.

Dry-eye patients in need of conjunctival reconstruction can be divided into two groups: (1) cicatrization caused by exogenous reasons such as thermal or chemical injury, or (2) cicatrization caused by endogenous disease such as Stevens-Johnson syndrome and ocular pemphigoid. Although the pathogenesis of cicatrization varies, excessive proliferation of fibroblasts and conjunctival epithelium and the loss of goblet cells are commonly observed in these disorders. Active autoimmune-related inflammation is thought to be the primary reason for the pathogenesis. Therefore, removal of inflamed tissue and activated fibroblasts helps to inhibit the progression of these diseases and stabilizes the ocular surface. Medical treatment using steroids and other immuno-suppressive medications is essential for controlling chronic inflammation and stabilizes the ocular surface. Intensive medical treatment is first considered to reduce inflammation and to inhibit the progression of cicatrization. Although the surgical indication is controversial, the recent advance of ocular surface reconstruction utilizing the intraoperative application of MMC and AMT notably improves the prognosis of severe cases in both the acute and chronic phases.

Concept of Surgery
Reconstruction of the conjunctival sac and removal of scar tissue is the primary rationale for conjunctival surgery when attempting to reestablish a healthy ocular surface. In addition, reduction of chronic inflammation in the subconjunc-tival tissue also helps to prevent progression of cicatrization and dry eye and subsequent corneal complications such as persistent epithelial defect and stem cell deficiency. Thus, concepts of surgery include not only reconstruction of conjunctival tissue, but also removal of activated fibrotic tissue and immunoantigens.

Indications and Surgical Procedures
The surgical procedures, including intraoperative use of MMC and AMT, are identical for upper and lower conjunctival fornix reconstruction. First, conjunctival dissection is performed 2-3 mm from the limbus. After removal of fibrovascular tissue in the subconjunctival area and symblepharolysis, 0.04% intraoperative MMC is applied using a surgical microsponge for 5min. The MMC is then carefully washed out using 200-300ml of 0.9% saline. It is important to coagulate any bleeders to prevent dilution of the MMC and detachment of the AMT. Preserved AM is applied with the epithelial side up to cover the bare scleral area. The AM is then tightly sutured to the scleral surface using 10-0 nylon. If a case requires full coverage with AM, the edge of the AM should be sutured to the lid margin and the fornix should be reconstructed with anchoring nylon sutures. Additional keratoepithelioplasty and transplantation of free conjunctiva should be considered for severe cases.

Recently, cultivated oral mucosal epithelial transplantation (COMET) has been applied as an alternative method. This ex vivo expanded epithelial sheet provides rapid epithelialization and prevents cicatrization without converting to the original oral buccal mucosal tissue structure. Although no comparative studies have yet been performed, our preliminary clinical results indicate that the viable oral mucosal epithelial lining was able to maintain the reconstructed conjunctival space even in cases with recurrent severe cicatrizing ocular surface diseases after conventional AMT. COMET is a newly developed cell-sheet transplantation procedure which uses cultivation technology and AM as a substrate. A small amount of oral mucosa is excised, and from this epithelial cells are isolated by EDTA and enzymatic treatment. The cell suspension obtained is cultured on AM using a co-culture system with 3T3 fibroblasts to generate a stratified epithelial sheet suitable for transplantation. The advantage of this procedure is that it uses autologous epithelium and is independent of the presence of ocular donor tissue, which may be unavailable in severe bilateral disease. Compared to simple tissue transplantation of full-thickness oral buccal mucosa, the oral mucosal epithelium cultivated on AM is composed of 5-7 stratified epithelial layers, similar to corneal and conjunctival epithelium. This epithelial structure is also maintained after transplantation onto the ocular surface without converting to the original tissue structure.

Concepts for Conjunctival Fornix Reconstruction
The concepts include: (1) reconstruction of conjunctival area; (2) prevention of cicatrization through inactivation of conjunctival fibroblasts and inflammatory cells using intraoperative MMC; (3) AMT; and (4) epithelial transplantation, i.e. (a) limbal transplantation, (b) conjunctival transplantation, and (c) cultivated mucosal epithelial transplantation.

Postoperative Follow-Up, Complications, and Management The appropriate use of postoperative medication is mandatory to achieve and maintain a successful surgical result. Since the primary pathogenesis is frequently exacerbated by the surgical procedure, it is important to limit any inflammatory response during the early phase. Systemic steroids and topical cyclosporin are effective for most cases. Epithelial healing should be promoted for rapid stabilization of the ocular surface using artificial tears and punctal plugs. Effective long-term immunosuppression is required to maintain the reconstructed conjunctival fornix, and this is most important in ocular cicatricial pemphigoid.

In summary, management of cicatrizing ocular surface disorders is extremely challenging. Recent advances in ocular surface reconstruction techniques have dramatically changed the indication and strategy of surgical treatment. The application of intraoperative MMC and AMT are especially effective for reducing recurrent fibrosis and chronic inflammation. The introduction of new techniques based on regenerative medicine may potentially bring a future shift in paradigm. However, severe tear volume deficiency resulting from cicatrization has yet to be overcome. Since a minimum of tear secretion is essential for the survival of surface epithelia, every case should be considered carefully to decide whether the indication and time are right for surgical intervention. Appropriate medical management and surgery are required to improve the prognosis in the long term.