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

IntroductionCorneal 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

• Last follow up –• Ulcer haeled• Integrity of globe

maintained• Visual acuity

20/40(aided)

18 year maleH/o Foreign body falling into eye 1 month backAt presentation-corneal infiltrates in peripheral cornea with hypopyonMicrobiology-negativeTreated with antibioticsInfiltrates decreased but marked cornal thinning resulted.LCSBCPF was done

Results

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.

• 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