Transcript Treatment of symptomatic bullous keratopathy with poor

Treatment of symptomatic bullous keratopathy
with poor visual prognosis using a
modified Gundersen conjunctival flap and
amniotic membrane
Jose L. Güell MD
Merce Morral MD
Oscar Gris MD
Instituto Microcirugia Ocular
Barcelona, Spain
The authors have no financial interest in the subject matter of this poster
Purpose
• To describe the use of a modified Gundersen
conjunctival flap combined with amniotic membrane
(AM) graft implantation to treat symptomatic bullous
keratopathy (BK) in 5 eyes of 5 patients with poor visual
prognosis.
Methods: Surgical technique (video file attached)
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1. 360º conjunctival peritomy 2mm from the limbus
Methods: Surgical technique
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2. Deepithelialization of the decompensated cornea
preserving, if healthy, the limbal conjunctiva where the stem
cell niches are located
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3. Graft of AM sutured epithelial side up using a running 100 nylon suture at the periphery of the cornea with the knot
buried in the corneal stroma.
Attach the edges of the AM and the border of the
peritomized conjunctiva using single 9/0 vycril sutures. The
conjunctival border should lie over the AM.
The AM graft covers the whole decompensated cornea and
provides a basement membrane for conjunctival cells to
grow on. Epithelialization occurs over the AM, which
remains trapped until reabsortion is completed (Observe the
section figure).
Methods:
• Bandage contact lens
• Topical steroids and antibiotics qid for three weeks, and
tapered until complete reabsortion of the AM.
• Outcome measures:
• Resolution of the pain
• Presence of ocular surface inflammation
• Reinterventions
Results
• 5/5 (100%) eyes - Immediate resolution of the pain and
minimal postoperative inflammation.
• 5/5 (100%) eyes - Epithelialization occurred over the AM.
• 1/5 (20%) eye - The AM was reabsorbed before
complete conjunctival epithelialization. Conjunctival
reepithelialization over the central cornea was delayed.
• No reinterventions required.
• All the eyes asymptomatic for at least 16 months.
Case report
Recurrent epithelial defects in a patient with post penetrating keratoplasty BK.
Modified Gundersen conjunctival flap with amniotic membrane grafting was performed.
Twelve months postoperatively, conjunctival vascular epithelium covers the
cornea completely, providing sustained relief of the symptoms
Conclusion
• The combination of a modified Gundersen conjunctival flap and a
graft of amniotic membrane provided sustained relief of symptomatic
bullous keratopathy
• It is essential to implant the AM as a graft. The AM as a patch has
only a temporary effect on relieving the pain
• With this technique, conjunctival manipulation and anatomical
distortion are significantly reduced:
– The conjunctiva is not pulled over the cornea –Therefore, the
fundus of the conjunctival sac is not shortened
– The conjunctival peritomy is circular and the conjunctiva is not
pulled – Therefore, there is no distortion of the interpalpebral
bulbar conjunctiva