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Year : 2004  |  Volume : 52  |  Issue : 4  |  Page : 341-2

Penetrating keratoplasty after a total conjunctival flap.

Correspondence Address:
Nikhil S Gokhale

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Source of Support: None, Conflict of Interest: None

PMID: 15693335

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How to cite this article:
Gokhale NS. Penetrating keratoplasty after a total conjunctival flap. Indian J Ophthalmol 2004;52:341

How to cite this URL:
Gokhale NS. Penetrating keratoplasty after a total conjunctival flap. Indian J Ophthalmol [serial online] 2004 [cited 2020 Jun 3];52:341. Available from: http://www.ijo.in/text.asp?2004/52/4/341/14552

Dear Editor,

A total conjunctival flap is one of the modalities of treatment of bullous keratopathy.[1] The surgery involves debridement of the entire corneal epithelium and then raising a thin conjunctival flap which is sutured over the cornea. The surgery is thus likely to cause limbal deficiency and induce vascularisation of the cornea. Both these factors are likely to lower the success of a penetrating graft if required later.

A 75-year-old patient presented with a history of a total conjunctival flap done in his right eye 6 years ago for pseudophakic bullous keratopathy. The left eye had been blind for the past 6 months following post cataract surgery endophthalmitis. His right cornea was scarred, the surface was covered with conjunctiva and showed 3600sub superficial and deep vascularisation [Figure - 1]a. The anterior chamber was deep, pupil was round and there was a posterior chamber lens. The digital pressure was normal. The vision was hand movements close to face and accurate projection. A 'B' scan ultrasound showed a normal posterior segment. The left eye was atrophic with no perception of light. The corneal limbus appeared intact in the left eye.

The patient was advised surface reconstruction followed by penetrating keratoplasty as a two-stage procedure in the right eye. In the first stage a superficial dissection was done in the right eye to remove the conjunctival epithelium over the cornea and up to 4 mm from the limbus. Two limbal grafts, each about six clock hours were harvested from the left eye and sutured at the limbus in the right eye. A bandage contact lens was placed at the end of surgery. Postoperatively the patient was put on preservative-free lubricants and cortico steroid antibiotic drops for 6 weeks. The corneal surface epithelised fully in a week and the bandage contact lens was removed after 2 weeks. The donor areas healed well. At the end of three months the corneal surface was covered by corneal epithelium with no superficial vessels and a significant regression of the deep vessels as well. The patient underwent a successful penetrating keratoplasty after six months of the surface reconstruction. His best corrected vision was 6/36 at six months' followup [Figure - 1]b.

A total conjunctival flap wherein the entire corneal epithelium is scraped off during surgery will induce a total limbal deficiency. For a corneal graft to be successful the limbal deficiency would need to be corrected before the graft is done. Flap removal followed by keratoplasty is usually recommended.[2] One stage keratoplasty without flap removal, however has also been shown to be successful.[3] A total conjunctival flap for bullous keratopathy should be done only in eyes with no visual potential. Leaving the limbal epithelium intact during a total flap may be a better option. Alternatives such as an anterior stromal puncture or bandage contact lens would be more preferable in eyes with visual potential, even if the patient refuses a keratoplasty.

  References Top

Gundersen T. Surgical treatment of bullous keratopathy. Arch Ophthalmol 1960;64:260-67.  Back to cited text no. 1
Paton D. The prevention and management of the complications of penetrating keratoplasty. XXI Concilium Ophthalmologicusm. Mexico, 1970. Amsterdam: Excerpta Medica , 1971: 740-45.  Back to cited text no. 2
Geria RC, Zarate J, Geria MA. Penetrating keratoplasty in eyes treated with conjunctival flaps. Cornea 2001;20:345-49.  Back to cited text no. 3


  [Figure - 1]

This article has been cited by
1 The value of conjunctival flaps in the management of refractory corneal ulcer
Shi, W.-Y., Li, S.-X.
Chinese Journal of Ophthalmology. 2007; 43(4): 293-296


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