Complete rupture or avulsion of an extraocular muscle after orbital trauma is rare, and intraoperative identification of the retracted muscle stump may be difficult when the surgical field is distorted by hemorrhage and edema. Trypan blue 0.1% is a vital dye that stains muscle sheaths and tendons without staining sclera or muscle fibers, and has been described in strabismus reoperations and lost-muscle recovery. Its use during acute exploratory surgery for orbital trauma has not, to our knowledge, been reported.

A 72-year-old male patient presented with early orbital implant exposure and lower eyelid symblepharon after evisceration surgery performed at an outside center after severe ocular penetrating trauma. A single-stage reconstruction was performed. After release of the lower eyelid symblepharon and exposure of the remaining scleral tissue, previous closure with 6-0 polypropylene sutures and the absence of well-defined scleral flaps were noted. The nonabsorbable sutures were removed, 2 scleral flaps were fashioned, and the same 20-mm silicone orbital implant was reinserted because no clinical signs of active socket infection were observed intraoperatively. The scleral flaps were closed with 6-0 polyglactin sutures, followed by Tenon's capsule and conjunctival closure. The inferior fornix was reconstructed using an oral mucosal graft harvested from the lower lip, with transcutaneous fixation sutures, external bolster support, and scleral conformer placement. At 8 weeks, the graft was well integrated, the implant remained stable, and successful ocular prosthesis fitting was achieved. To the best of our knowledge, this combined single-stage approach has not previously been described in the indexed literature.

Kelly and Wendel reported the first successful intervention for idiopathic full-thickness macular holes in 1991. Since then, pars plana vitrectomy and internal limiting membrane peeling have become the standard treatment approach, with >90% hole closure rates. However, the results were not satisfactory in cases of complicated macular holes, including large, recurrent, refractory, and myopic macular holes. To date, several surgical approaches, including the inverted internal limiting membrane flap technique, autologous retinal transplantation, the human amniotic membrane plug, and the autologous Tenon's capsule plug, have been described by various authors to improve the anatomical and functional outcomes of challenging cases. Although these techniques have significantly increased hole closure rates, each technique has its own strengths and weaknesses. Currently, there is no consensus among vitreoretinal surgeons on a single ideal technique for treating challenging macular holes. In this review, the inventors of each innovative surgical technique will discuss the indications, pros and cons, complications, and anticipated future applications.

The anatomy of the conjunctiva should be considered when reconstructing and replacing the conjunctiva. Please see StatPearls' companion reference, "Anatomy, Head and Neck, Eye Conjunctiva," for further information. The human conjunctiva is an epithelial layer composed of nonkeratinized stratified squamous epithelium and stratified columnar epithelium. The conjunctiva has goblet cells (see Image. Anatomy and Physiology of Mucous Membrane Graft). The conjunctiva is a complex structure that contains lymphatic channels, blood vessels, fibrous tissue, melanocytes, T- and B-cell lymphocytes, accessory lacrimal glands, and Langerhans cells. Glands of Krause are found within the deep fibrous layer of the conjunctiva, and the goblet cells, which are greatest in the fornices, secrete mucin. The conjunctiva contributes to the protection of the eye with the production of mucus and tears. The conjunctiva also provides mechanical protection for the eye and facilitates the free movement of the globe and eyelids. The conjunctiva lines the tarsus (or palpebral conjunctiva), where it lines the eyelid margin of the tarsus and the Tenon capsule. The flexibility of the fornical conjunctiva is important in the free movement of the globe and the eyelids. Loss or scarring of the conjunctiva from injury or disease can result in eyelid malposition, restriction of ocular movement with double vision, and dryness. When replacing the injured conjunctiva, materials such as amniotic membrane, hard palate grafts, nasal septal mucosa, autogenous conjunctiva, and tarsus with conjunctiva have been used. Ideally, clinicians should use a like-for-like replacement approach. Unfortunately, except for small defects, autogenous conjunctiva is limited by availability. Oral mucosal grafts are used in 2 forms: Oral mucous membrane grafting. Minor salivary gland grafting for the treatment of severe dryness. The oral mucosa shares biological properties with the conjunctiva, provides an easily accessible, universally available donor site, is technically easy to harvest, is low-cost, allows repeat harvesting, and is associated with few complications. Oral mucosa also serves as an autograft, avoiding the risks of allogeneic grafts. In 1912, Denig first described the use of the mucous membrane graft in lime burns. Subsequently, Weeks used mucous membrane grafts to correct trichiasis and symblepharon. Notably, the membrane does not contain goblet cells, which are present in the conjunctiva. Consequently, the membrane does not help treat dry eye disease unless it is transplanted with minor salivary glands. Moreover, in patients with concurrent limbal stem cell deficiency of more than 3 to 4 clock hours, a limbal stem cell transplant should be performed concurrently. The oral mucosa is rich in elastin, making it resistant to shearing and compression and highly vascular, facilitating graft uptake. The oral mucosa is histocompatible and exhibits minimal contraction at the transplant site. Indications for the use of mucous membrane grafts in ophthalmology include the following: After the removal of pterygia. Repair of contracted anophthalmic sockets. Globe surface and fornix reconstruction after tumor resection. Deformities of the eyelids (cicatricial entropion, keratinization of the eyelid margin after chemical burns, or Stevens-Johnson syndrome). Repair of erosions over glaucoma drainage devices. Repair over the scleral buckle exposure. Support of keratoprosthesis associated with corneal melt. Formation of the lining during conjunctivodacryocystorhinostomy or dacryocystorhinostomy . In addition to its structural role, mucous membrane grafting has gained prominence as a functional reconstructive modality for complex ocular surface disorders in which the restoration of a stable epithelial environment is essential (see Image. Clinical Indications for Ocular Mucous Membrane Grafting). The success of these grafts is closely linked to the vascularity of the recipient bed, control of underlying inflammation, and meticulous surgical technique. Preoperative optimization, including treatment of active cicatrizing disease, lubrication, and control of adnexal abnormalities, plays a crucial role in improving graft survival and long-term outcomes. Recent advances have also emphasized the role of mucous membrane grafts as an adjunct rather than a standalone procedure in many cases. In severe cicatricial conditions, particularly those associated with immune-mediated pathology, integrating systemic immunosuppression with staged reconstruction strategies has been shown to improve anatomical and functional outcomes. Furthermore, the concept of surface rehabilitation now extends beyond mere defect coverage to include restoration of fornix depth, preservation of ocular motility, and prevention of recurrent symblepharon. From a histological perspective, although mucosal grafts lack goblet cells, they demonstrate rapid epithelialization and adaptation to the ocular surface microenvironment. Over time, partial phenotypic modification has been observed, thereby improving surface lubrication. The inherent elasticity and resistance to keratinization make the oral mucosa particularly suitable for dynamic areas such as the fornices and eyelid margin. The role of mucous membrane grafting has also expanded in the era of keratoprosthesis and ocular surface prosthetic devices, where it provides durable tectonic support and reduces the risk of extrusion. In socket reconstruction, especially in contracted sockets, mucous membrane grafting helps restore volume and fornical architecture, thereby improving prosthesis retention and cosmesis. Despite its advantages, careful patient selection remains essential. Factors such as severe dry eye without salivary gland support, uncontrolled inflammation, and poor lid-globe apposition may compromise outcomes. Therefore, a tailored, interdisciplinary approach involving cornea specialists, oculoplastic surgeons, and ocular surface experts is critical to achieving optimal results.

This study evaluates the clinical outcomes of adjunctive amniotic membrane transplantation (AMT) in the surgical management of fat adherence syndrome (FAS), a rare but challenging cause of restrictive strabismus following inferior oblique surgery. This retrospective clinical series included patients diagnosed with FAS between 2016 and 2022 who presented with hypotropia, supraduction limitation, and a positive forced duction test after prior inferior oblique surgery. All patients underwent meticulous adhesiolysis, conjunctival recession, and, when indicated, inferior rectus recession, with adjunctive AMT. Surgical success was predefined as postoperative deviation ≤10 prism diopters, improved supraduction without mechanical restriction, and resolution of abnormal head posture. Seven patients (mean age: 17.7 years) met the inclusion criteria. Intraoperatively, dense adhesions involving the inferior rectus muscle, Tenon capsule, and prolapsed fat were identified and successfully released in all cases. Postoperatively, all patients demonstrated improvement in both alignment and motility, and 6 of 7 met the predefined surgical success criterion of ≤10 prism diopters. Diplopia and abnormal head posture resolved in affected patients. No cases of anterior segment ischemia, recurrent restriction, or other complications were observed during 6 to 36 months of follow-up. Adjunctive AMT may help improve postoperative healing and reduce recurrent fibrosis in patients undergoing surgery for FAS. In this retrospective series, favorable functional and cosmetic outcomes were observed following combined surgical management with AMT. Larger prospective controlled studies are required to further clarify its therapeutic contribution.

Direct chemical reprogramming provides a potentially scalable approach for generating retinal lineage-associated cells without genetic manipulation. In this study, human Tenon's capsule fibroblasts were converted into retinal progenitor-like cells using a defined small-molecule cocktail. Retinal lineage-associated features were evaluated by immunofluorescence staining, quantitative reverse-transcription PCR, Western blot analysis, and bulk RNA sequencing, showing upregulation of neural and retinal markers, including VSX2, and transcriptomic remodeling consistent with transcriptional features associated with neuronal differentiation programs. Functional responsiveness was assessed by glutamate-evoked intracellular calcium imaging, revealing glutamate-responsive intracellular calcium dynamics in induced cells but not in parental fibroblasts. For in vivo assessment, induced cells were delivered via intravitreal transplantation in Wistar rats and subretinal transplantation in Long-Evans rats. One month after transplantation, structural and functional evaluations using optical coherence tomography, electroretinography, and histological analyses showed localized alterations in retinal structure at the subretinal injection site, while no significant differences were observed in scotopic ERG responses under the present experimental conditions. In contrast, fibroblast transplantation showed more prominent structural alterations under similar conditions. Human nuclei-positive signals were detectable in a subset of eyes, exhibiting focal and heterogeneous distribution within retinal regions at the one-month endpoint. Collectively, these suggest the induction of retinal lineage-associated molecular and functional features, with short-term functional tolerability observed in vivo under the present experimental conditions.