Conjunctival Flaps
Martin Filipec
The creation of conjunctival flaps is a surgical procedure used in the management of corneal surface diseases when other medical or surgical therapy is not successful or available. Conjunctiva is used to cover part or all of the corneal surface to heal and stabilize the corneal surface. Conjunctival flaps as a therapeutic modality were first described at the end of 19th century (1,2), but the procedure did not gain widespread popularity until the second half of the 20th century, when Gundersen, at the Massachusetts Eye and Ear Infirmary in Boston, described the technique of fashioning a very thin conjunctival flap (3). The major innovation of Gundersen was to use conjunctiva split from Tenon’s capsule, thereby decreasing the common tendency for flap retraction often seen with earlier, thicker flaps.
Although the mechanism of a conjunctival flap’s effect on corneal healing is not fully understood, several possible explanations exist. The flap does not promote epithelial cell proliferation, but it does enhance healing by the apposition of vascularized conjunctival substantia propria to the corneal surface (4). Conjunctiva contains not only blood but lymphatic vessels. Bringing them into close contact with the diseased cornea may provide a source of cells and growth factors helpful in the process of infection resolution and corneal wound healing. The corneal surface is protected from the deleterious action of enzymes such as collagenases, metalloproteinases, and other proteases responsible for corneal melting after conjunctival flap surgery. Mechanical protection may also promote corneal wound healing.
With the enlargement of our armamentarium in the conservative medical treatment of infectious and immune-mediated diseases and dry-eye conditions, and with improved (corneal grafting, glue, contact lenses, amniotic membrane) and new (limbal stem cell transplantation) strategies for surgical treatment, the role of the conjunctival flap in the care of patients with ocular surface disease has decreased. But conjunctival flaps are still very useful, and probably are underused today in the management of corneal diseases (4, 5, 6). Just as every cornea specialist must know how to perform a tarsorrhaphy expertly, so too should he or she know how to perform a conjunctival flap.
The use of a conjunctival flap at the right time may solve an otherwise difficult problem and may prevent disastrous consequences related to the loss of globe integrity from corneal perforation and loss of the eye from endophthalmitis. It can also improve the overall quality of the patient’s life through pain control and a decreased frequency of medication and visits to the ophthalmologist’s office (6).
INDICATIONS
Conjunctival flaps are the last resort in the treatment of resistant infectious corneal diseases, eye surface diseases threatening the loss of corneal integrity, painful corneal disorders, and injuries (Table 54-1). Conjunctival flaps can be used when other means of treatment are not successful, available, or indicated. However, the decision to perform a conjunctival flap should be made early enough to preserve the integrity of the cornea. Conjunctival flaps are not appropriate for the care of corneal perforations. They might be used in this indication only in situations in which other, more appropriate methods of treatment are not available. A conjunctival flap may serve as a temporary measure to treat inflammation and stabilize the cornea before other surgery (e.g., penetrating keratoplasty) is undertaken. Flaps may also be used as a permanent measure when visual rehabilitation of the eye is not contemplated in the near future, or the probability of improving the underlying pathologic process through other techniques is low.
Therapeutic Indications
In the management of infectious keratitis, when medical therapy is failing and the situation is not under control in the long term, the use of a conjunctival flap is an option. Successful use of conjunctival flaps was reported in the treatment of infectious keratitis caused by many types of pathogens (7). From the technical point of view, it is important to
perform concomitant keratectomy to remove as much necrotic and infected corneal tissue as possible.
perform concomitant keratectomy to remove as much necrotic and infected corneal tissue as possible.
TABLE 54-1. INDICATIONS FOR CONJUNCTIVAL FLAP SURGERY | ||||||||||||||||||||||||||||||||||||||||||
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Conjunctival flaps usually do not have a role in the management of bacterial keratitis. However, the successful use of a conjunctival flap in the therapy of bacterial keratitis has been reported in seven patients (8), and in Pseudomonas keratitis, success was reported in three of four patients (9).
The most common indication for the use of a conjunctival flap in the treatment of infectious diseases is in herpetic keratitis. Metaherpetic and stromal keratitis are the most common indications for a conjunctival flap (3,5,6,8,10,11).
Good results of a partial conjunctival flap associated with keratectomy were reported in the management of peripheral fungal keratitis when medical therapy failed (12).
Tectonic Indications
Conjunctival flaps are used as an eye-saving procedure in cases of primary corneal melting or recurrent melting when medical and surgical treatment such as amniotic membrane transplantation, patch grafting, or penetrating keratoplasty failed. A conjunctival flap may be used in association with lamellar or perforating keratoplasty.
A lack of corneal sensitivity and decreased lacrimation is typical in neurotrophic ulcerations. This condition can be very difficult to manage, and a conjunctival flap may help to maintain corneal integrity and is more cosmetically acceptable than tarsorrhaphy (15). Metaherpetic keratitis is sometimes difficult to manage, and a conjunctival flap may be a good solution. Also, in children with the rare Riley-Day syndrome, a conjunctival flap may be used.
Conjunctival flaps were used in the past quite often to cover leaking corneal wounds after perforating injury, but their success rate in permanently restoring corneal integrity is not more than 30% (16). Flaps are no longer used for this indication because refined microsurgical technique gives better results. Conjunctival flaps can be used in cases of descemetocele or corneal perforation when other therapy is unavailable (17).
In peripheral ulcerative keratitis of autoimmune origin, conjunctival resection at the place of inflammation is indicated together with appropriate systemic immunosuppressive therapy (18). A conjunctival flap may be considered in cases of central and paracentral ulcerations in rheumatoid arthritis.
Palliative Indications
A conjunctival flap may be used to relieve pain.
The most common corneal disease associated with pain in which a conjunctival flap can be useful is bullous keratopathy due to Fuchs’ dystrophy or related to cataract surgery (5,8,10). The flap is indicated only in cases in which other procedures, such as contact lens fitting, penetrating keratoplasty, endothelial replacement, anterior stromal puncture, or amniotic membrane transplantation, are not available, successful, or indicated.
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