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ORIGINAL ARTICLE
Year : 1984  |  Volume : 32  |  Issue : 5  |  Page : 385-389

Ulcer cornea and keratoplasty


Dr. Rajendra Prasad Centre for Ophthalmic Science.; AIIMS, Ansari Nagar, New Delhi, India

Correspondence Address:
M Mohan
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi-29
India
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Source of Support: None, Conflict of Interest: None


PMID: 6400100

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How to cite this article:
Mohan M, Panda A, Chawdhary S, Gupta A K. Ulcer cornea and keratoplasty. Indian J Ophthalmol 1984;32:385-9

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Mohan M, Panda A, Chawdhary S, Gupta A K. Ulcer cornea and keratoplasty. Indian J Ophthalmol [serial online] 1984 [cited 2021 Sep 26];32:385-9. Available from: https://www.ijo.in/text.asp?1984/32/5/385/27518



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Corneal ulcer is one of the commonest causes of blindness in developing countries.[1],[2] The medical management of fulminating cases showing perforation or impending per­foration is poor and ultimately leads to loss of eye. The therapeutic corneal transplantation gradually became popular as an eye saving procedure.[3] This procedure exerts a beneficial effect by removal of the infective organisms and their toxins and dead necrotic tissues.[2] The type of procedure is decided by nature of infection and the depth of the lesions.[4] It is important to try all possible measures of medical management before surgery.

The present study is aimed at critically analysing the results of therapeutic kerato­plasty in a large series.


  Material and methods Top


259 patients with various types of ulcera­tive ker atitis, operated during the last 3th years were reviewed.. Majority of the cases had per­foration (110 cases) or had impending per­foration [Figure - 1],-102 cases). Only a few chroinc cases (47) with superficial ulcers which failed to respond to medical therapy and other con­ventional treatment are included. The ulcers were classified into different grades.

Scrapping from ulcer margin and bed were performed. Laboratory investigations included Gram's stain, KOH preparation and culture sensitivity, As a last resort the therapeutic keratoplasty was performed and the corneal buttons were subjected to mic­robiological study and histopathological study. During post operative period the cases were followed up with special reference to epithelial healing, suture infiltration or abscess formation and development of secon­dary glaucoma. Post operatively steroids were withheld in all the cases as long as the buttons were not declared as negative for fungus.


  Observations Top


The age and sex of the patients are as shown in [Figure - 2]. The duration of the episodes prior to the surgical intervention is high­lighted in [Table - 1]. The sizes of the grafts are analysed in [Table - 2]. The results of smear examination - and culture from the ulcer scrapping are as shown in [Table - 3]. The fin­dings are again compared with that of the obtained corneal buttons. In 13% of cases more than one isolate is found. The most com­mon pathogens of the bacterial group was Staphylococcus and that of fungal was Asperigillus. The correlation of the organisms and fate of the graft is evident from [Table - 4]. Similarly the clarity is also compared with each other according to ulcers grading. [Table - 5] & [Figure - 3][Figure - 4][Figure - 5][Figure - 6]. The post operative com­plications are evident from [Table - 6]. The pre-operative and post operative visual status are highlighted in [Table - 7]. Success rate is com­pared with various authors [Table - 8].


  Discussion Top


Corneal ulcer is a serious disease which calls for immediate appropriate and intensive treatment Inspite of the increased sophistication of treatment for this, there are few reports on the relation of surgical results in relation to causative organisms, the grade of the clinical ulcer, the type of the surgery, the size of the graft and the various combined procedures.

Gram's staining and study of KOH pre­paration, culture and sensitivity of the corneal scrapping, not only guides one regarding the specific treatment but also saves from unnecessary prolonged use of antibiotics. New strains of penicillinase producing Staphylococcus aureus and albus are emerg­ing and are resistant to all the medical therapy. These are posing a . great challaage, However, in a large number of our patients the organisms are sensitive to cloxacillin, Lack of isolations of any organisms from the culture definetely shows a better graft pro­gnosis, since the infection may have already come under control by the medical therapy. At this moment it is felt to classify the initial ulcers to various gradings. It is observed that the results are excellent in grade II & III ulcers. In more than half the cases of grade IV ulcers the results are good. Cases belonging to group V are unfavourable.

It isalso seen in this study that where the surgery is performed in cases of impending perforation or recent perforation the results are better than waiting for a medical trial and then operating. It is also in agreement with Taylor and Stern.[5]

Visual improvement has been shown from 13.3%-48% of cases in literature.[4],[6],[8] In the pre­sent study the overall visual improvement is seen in 35% of cases. The poor quality of donor material, choice of patients .and the high rate of postoperative glaucoma and rein­fection of the graft maybe the cause attributed to the inadequate visual recovery in these cases.

The size.of the graft is an important factor for the final outcome of the graft. Larger graft size has a bad prognosis because of the chan­ces of having immunological graft reactions with vascularisation, development of peripheral anterior synaechiae and secon­dary glaucoma. The secondary glaucoma can be controlled by the combined procedure like keratoplasty and trabeculectomy and post operative anti-glaucoma therapy.

The other important points to be remem­bered are applications of interrupted sutures, non-interference with lens, use of larger size of donor button in comparison to host button and early tarsorrhaphy at the recognition of graft ectaesiae.


  Summary and conclusion Top


After conducting a study on 259 neglected cases of corneal ulcers where therapeutic penetrating keratoplasty was carried out the following conclusions are drawn.

(1) Therapeutic corneal grafts are to be taken up only after investigative and thera­peutic measures had been attempted and should be performed in desparate cases only.

(2) 98.2% of cases eyes were saved anato­mically and 35.0% cases gained from optical angle. 1.8% eyes were lost inspite of the surgi­cal intervention.

(3) Better understanding and improve­ments in medical treatment by antibiotics and antifungal agents is required.

 
  References Top

1.
Fine Max., 1960. Trans. Am. Acad Ophthalmol. Otola., 64: 786  Back to cited text no. 1
    
2.
Nema H.V., 1965. Proc. of A.I.O.S., Vol. XXII,  Back to cited text no. 2
    
3.
Dhanda RP. and Kalever V., 1968. I.C.M.R Scheme  Back to cited text no. 3
    
4.
Malik S.R.K_ and Singh G., 1973. Trans. Fourth Asia Pacific Cong. Ophthalmol., P. 213  Back to cited text no. 4
    
5.
Taylor D.M., and Stern A.C., 1980. Ophthalmol 87: 892  Back to cited text no. 5
    
6.
Singh G. and Gill S., 1980. Ind- J. Ophthalmol, 28: 133  Back to cited text no. 6
    
7.
Mukherjee G., Mohan M. and Saini J.S.,1980. Ind. J. Ophthalmol 28: 2  Back to cited text no. 7
    
8.
Sander N., 1970. Amer. J. Ophthalmol, 70: 24.  Back to cited text no. 8
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8]


This article has been cited by
1 Urgent penetrating keratoplasty in perforated infectious corneal ulcers | [Kératoplastie transfixante à chaud dans les ulcères cornéens infectieux perforés]
Boujemaa, C., Souissi, K., Daghfous, F., Marrakchi, S., Jeddi, A., Ayed, S.
Journal Francais dæOphtalmologie. 2005; 28(3): 267-272
[Pubmed]
2 Therapeutic sclerokeratoplasty versus therapeutic penetrating keratoplasty in refractory corneal ulcers
Panda, A., Sharma, N., Angra, S.K., Singh, R.
Australian and New Zealand Journal of Ophthalmology. 1999; 27(1): 15-19
[Pubmed]



 

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