Giant Fornix Syndrome Repair

The giant fornix syndrome is an uncommon, but often missed diagnosis in a patient with chronic ocular discharge.  I believe that it is a diagnosis of exclusion.  It is important to rule out other causes of chronic ocular discharge such as chronic bacterial conjunctivitis and nasolacrimal duct obstruction.  Conservative treatment consists of irrigating the fornices with betadine and treatment with topical antibiotics.  However, due to the deep reservoir in the fornices, these conservative treatments are often temporizing.  I believe that resection of the redundant conjunctiva in the fornices is ultimately the treatment for these cases.  I will perform a canthotomy with an upper and lower cantholysis so that I have wide exposure of the fornices.

This is Richard Allen at oculosurg.com.  This video demonstrates resection of redundant conjunctiva in the upper and lower fornices, with shallowing of the fornices in a patient diagnosed with giant fornix syndrome.  The extensive mucoid discharge is noted and the deep upper and lower fornices are demonstrated.  A lateral canthotomy is performed with the 15 blade and upper and lower cantholyses are performed with the needle tip cautery.  This allows adequate visualization of the fornices.  Exposure is always very important in surgery.  A 4-0 silk suture is placed through the lower eyelid at the level of the tarsus to provide traction during the case.   A subconjunctival injection of local anesthetic with epinephrine is given in the area of the redundant conjunctiva.  Calipers are placed on approximately 8 mm and a marking is made 8 mm inferior to the lower lid margin.  A similar marking is made along the bulbar conjunctiva from the limbus.  Resection of the redundant conjunctiva between these marking will result in a fornix depth of approximately 8 mm.  Westcott scissors are then used to resect the redundant conjunctiva.  This is performed along the length of the fornix.  Hemostasis is then attained with the needle tip cautery. 

Attention is then directed to the upper eyelid where the procedure is performed similarly.  The eyelid is everted and the area of the redundant conjunctiva is infiltrated with 1% lidocaine with epinephrine.  The area of the lacrimal gland ductules laterally are identified and will be avoided.  Markings on the conjunctiva 8 mm superior to the limbus and 8 mm from the eyelid margin are made.  This is tapered laterally to avoid the lacrimal gland ductules.  Westcott scissors are then used to excise the marked redundant conjunctiva.  The conjunctival specimens are sent to the pathologist.  The area is then irrigated with ophthalmic betadine.  I essentially scrub the areas with betadine.  The edges of the conjunctiva are then sutured together with interrupted, buried 7-0 Vicryl sutures.  The lateral upper and lower canthoyses are then repaired with a 4-0 Vicryl suture that engages the periosteum of the lateral orbital rim, followed by the lateral lower tarsus, followed by the lateral upper tarsus, and finally engaging the periosteum of the lateral orbital rim again.  The suture is tied and the repair is inspected.  The lateral canthotomy is repaired and the shallowing of the fornices is demonstrated.