|Year : 1984 | Volume
| Issue : 5 | Page : 385-389
Ulcer cornea and keratoplasty
M Mohan, A Panda, S Chawdhary, AK Gupta
Dr. Rajendra Prasad Centre for Ophthalmic Science.; AIIMS, Ansari Nagar, New Delhi, India
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar, New Delhi-29
Source of Support: None, Conflict of Interest: None
|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
Corneal ulcer is one of the commonest causes of blindness in developing countries., 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. This procedure exerts a beneficial effect by removal of the infective organisms and their toxins and dead necrotic tissues. The type of procedure is decided by nature of infection and the depth of the lesions. 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|| |
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|| |
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|| |
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.
Visual improvement has been shown from 13.3%-48% of cases in literature.,, 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|| |
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|| |
Fine Max., 1960. Trans. Am. Acad Ophthalmol. Otola., 64: 786
Nema H.V., 1965. Proc. of A.I.O.S., Vol. XXII,
Dhanda RP. and Kalever V., 1968. I.C.M.R Scheme
Malik S.R.K_ and Singh G., 1973. Trans. Fourth Asia Pacific Cong. Ophthalmol., P. 213
Taylor D.M., and Stern A.C., 1980. Ophthalmol 87: 892
Singh G. and Gill S., 1980. Ind- J. Ophthalmol, 28: 133
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8]
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