Transcript Amniotic Membrane Transplantation in Peripheral Ulcerative

Limbal Conjunctiva Sparing Conjunctival
Pedicle Flap in the Management of
Corneal Ulceration
Arun K Jain, MD, Pankaj Gupta , MS
Cornea, Cataract & Refractive Surgery Services
Advanced Eye Centre, PGIMER, Chandigarh,
India
Authors have no financial interest in the subject matter of this paper
Introduction
Corneal thinning, ulceration, descematocele formation and perforation
can occur following variety of conditions afflicting the cornea. These
conditions could be infectious keratitis or noninfectious immune
keratitis . Various conditions include : recalcitrant bacterial keratitis,
herpes simplex keratitis, herpes zoster corneal involvement,
rheumatoid arthritis, acne rosacea, aphakik or pseudophakik bullous
keratopathy, graft rejection, post trauma corneal ulceration and melting
and host of other conditions.
Medical treatment includes treating underlying disease, dry eye
management, topical & systemic antibiotics & immunosuppressive
agents, oral doxycycline and other supportive therapies
Surgical options are tarsorrhaphy, fibrin or cyanoacrylate glue, bandage
contact lens , amniotic membrane transplantation, conjunctival flap,
patch graft, lameller kertoplasty, penetrating kertoplasty, limbal stem
cell transplantation
In such situations of corneal thinning or perforation , maintenance of
ocular globe integrity is of paramount importance
Purpose of the Study
• To study the results of limbal conjunctiva sparing bulbar
conjunctival pedicle flap [ LCSBCPF] in the management
of corneal ulceration with or without corneal perforation
• Design: Prospective, non-comparative, interventional case
series .
• Main outcome measures: Resolution of the corneal ulcer
and postoperative stability of the conjunctival flap and
restoration of anatomical integrity of the globe
Methods
Twelve patients with corneal ulceration with perforation or impending
corneal perforation [ corneal foreign body induced keratitis and
perforation [2], post chemical burn [2], , post keratoplasty graft
ulceration [1], post corneal trauma [1], chronic noninfectious
ulcerative keratitis [3], neurotrophic keratitis [1], recalcitrant bacterial
keratitis [1] and herpes simplex keratitis [1] under went LCSBCPF .
Method of LCSBCPF [Movie]
Surgery was performed under surgical microscope and under topical
anesthesia
Eye is prepared with poviodin iodine and draped in a sterile manner
An eye speculum is inserted
Loose epithelium surrounding the pathological area is removed and the
size and location of the denuded cornea to be covered with flap is
assessed
Methods
• Suitable site for obtaining the LCSBCPF is selected
• 0.5 to 1 ml of 2% lidocaine with adrenaline [1: 100,000 dilution]
injected subconjunctivally in the desired area of bulbar conjunctiva
• Conjunctival flap of desired size is fashioned taking care that at least
1.5mm to 2 mm width of limbal conjunctiva was left undisturbed, so
that limbal stem cells were not included in the pedicle flap
• If the flap is prepared for extreme corneal thinning or perforation,
tissue from the Tenon capsule dissected along with conjunctiva.
• Graft is then secured to the cornea with 10-O monofilament nylon
suture
• Antibiotic drops and cyloplegic drops are administered and eye is
patched overnight.
• Post operatively eye is treted with topical antibiotics , tear substitute,
and other supportive therapy
• Sutures can be removed after 2weeeks to 3 weeks
• Movie
18 year male
H/o Foreign body falling
into eye 1 month back
At presentation-corneal
infiltrates in peripheral
cornea with hypopyon
Microbiology-negative
Treated with antibiotics
Infiltrates decreased but
marked cornal thinning
resulted.
LCSBCPF was done
Results
•
•
•
•
Last follow up –
Ulcer haeled
Integrity of globe
maintained
Visual acuity
20/40(aided)
LCSBCPF with Tenon dissection in a case of severe chemical
burns with persistent epithelial defect and corneal thinning
47 year male
Presented after 1 month of ocular
injury
VA 20/400
S/L exam-FB in cornea with
surrounding infiltrates
FB removed and topical antibiotics
started
Descemetocele formation after 2 weeks
Undergoes LCSBCPF after unsuccessful
attempts of glue application
Last follow up-Thinning well sealed,
globe integrity maintained, Visual acuity
20/25
Case of post trauma corneal melt. LCSBCPF was done. At
later date phacosrgery and IOL implantation was done.
•
•
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•
7 year male
H/o foreign body falling into
eye
Presents with intracorneal
foreign body & Infectious
Keratitis
FB removed along with
cyanoacrylate glue application
and bandage contact lens
Glue applied twice , but failed
LCSBCPF was done
•
Integrity of globe restored
•
Final visual acuity 20/20
•
•
Results
• Out of twelve patients 5 had corneal perforation.
• Eleven patients had stable pedicle grafts. In one patient graft retracted
on fifth postoperative day and it was sutured again.
• Corneal ulcer healed in all patients.
• Globe integrity was preserved in all patients.
• None of the patients manifested localized limbal stem cell deficiency
/conjunctivalization of cornea pertaining to the limbal area from
where LCSBCPF was dissected
• Non of the patients developed glaucoma
• None of the patient required patch graft or penetrating keratoplasty
Conclusions
• Conjunctival pedicle flap is an appropriate procedure to
manage corneal perforations and impending corneal
perforations where donor material is not available and
transplantation of such tissue is not suitable.
• The technique is performed easily, and can aid in the
healing of areas of thinning that threaten perforation by
providing a vascular pedicle.
• Limbal sparing flap in addition helps prevent
conjunctivalization of cornea and therefore gives good
anatomic as well as visual outcome