Transplantation of the autologous submandibular gland in patients with severe keratoconjunctivitis sicca - 2 years' experience

Introduction: The conservative treatment of the most severe cases of keratoconjunctivitis sicca (KCS) can be sometimes frustrating. Especially with an underlying autoimmunologic disorder, even the application of artificial tears as often as every 5 min may not prevent further damage to the ocular surface. A microvascular transplantation of the autologous submandibular gland (SG) can be performed by a maxillo-facial surgeon as an alternative approach for those cases. We report 2 years of ophthalmological experience with the results of this procedure. Material and methods: To date 27 operations have been performed in 23 patients. The SG was moved from its natural site into the temporal fossa. The secretory duct was implanted into the conjunctival fornix and the gland's vessels connected to the temporal artery and vein. A complete ophthalmological examination has been performed in 25 eyes of 21 patients up to 1 year and in 11 eyes of 9 patients 2 years after surgery. Results: Three months and 1 year postoperatively 19 of 25, and 2 years postoperatively 8 of 11 transplants remained vital. The baseline secretion increased in patients with a vital transplant from an average of 1.6 +/- 1.3 mm before the operation to 16.2 +/- 11.3 mm after 3 months and 20.6 +/- 10.6 mm after 1 year. Ten of 19 vital grafts were reduced 1 year after transplantation in a minor second procedure to control an increasing epiphora. Subsequently baseline secretion was reduced to 13.6 +/- 8.2 mm 2 years after transplantation. Patients with a vital graft reported in 84 % of cases (16 of 19) at 3 months, and 79 % at 1 year (15 of 19) and Z years (7 of 8), a strong relief of dry eye symptoms. In 58 % (3 months), 79 % (1 year) and 63 % (Z years) of the eyes with a vital transplant all artificial tear substitution could be stopped. Break-up time increased significantly, resulting in reduced bengal rose staining. Conclusion: The transfer of the autologous SG into the temporal fossa can be used to provide patients with very severe KCS with a continuous, endogenous source of ocular lubrication. Despite surgical denervation the graft maintains a sufficient baseline secretion over a period of years. Subjective symptoms and the application of pharmaceutical lubricating substances are reduced to a large extent. If epiphora occurs, it can be controlled by surgically reducing the transplant. The influence of SG saliva on the ocular surface is the object of ongoing studies.