Conjunctival Flaps for Corneal Disease
Shahzad Mian
Alan Sugar
The popularity of conjunctival flaps for treatment of corneal disease has diminished with the increasing success of medical therapy for corneal infections, the improvement in ocular lubrication systems, the use of bandage contact lenses for corneal surface diseases, the use of tissue adhesives for threatened perforations, the use of amniotic membrane grafts, and the improved techniques for corneal, conjunctival, and lid surgery. Nonetheless, conjunctival flaps are useful in occasional cases and should be a part of the operative repertoire of most anterior segment surgeons. Conjunctival grafting for corneal disease has a long history, especially for treatment of corneal trauma prior to the availability of modern suturing techniques. Initial procedures used full-thickness conjunctiva, including Tenon’s capsule; however, this resulted in early failure and short duration of coverage of the cornea.1 Current use of conjunctival flaps is primarily based on the technique described by Gundersen in 1958, along with more recent variations.2
INDICATIONS
In general, the indications for conjunctival flap procedures are treatment of corneal infections resistant to medical therapy, control of resistant surface corneal disease, control of corneal pain, and structural support. Only rarely is the use of a conjunctival flap the best choice for primary treatment. A few large series of cases are reported in the literature, and it is likely that indications have changed over time. The use of conjunctival flaps for primary treatment of corneal lacerations, a frequent indication in the past, is now almost never indicated when modern microsurgical treatment is available.3
Gundersen and Pearlson presented a series of 177 cases in 1969.4 Sixty (34%) had herpes simplex keratitis, 44 (25%) had bullous keratopathy, and 11 (6%) suffered trauma. Paton and Milauskas presented 122 cases in 1970: 36 (30%) with herpetic keratitis, 33 (27%) with bullous keratopathy, 23 (19%) with nonherpetic ulcers, 12 (10%) with descemetocele, and seven (6%) with alkali burns.5 Insler and Pechous reported 33 cases 17 years later.6 Eight (25%) had herpes simplex, seven (22%) had bacterial ulcers, and three (9%) had herpes zoster. The most recent series confirm a predominance of herpes simplex keratitis as an indication for conjunctival flaps.7 Alino and colleagues presented 48 patients in 1998 with total conjunctival flaps and 13 with partial conjunctival flaps. In this series, 12 (20%) had nonherpetic corneal ulcers, nine (15%) had herpes simplex keratitis, nine (15%) had bullous keratopathy, and seven (11%) had herpes zoster keratitis.8 Khoudadoust and Quinter reported 50 cases of conjunctival flaps in 2003 with 14 (28%) secondary to herpes simplex keratitis, 11 (22%) secondary to bacterial ulcers, and eight (16%) secondary to rheumatoid arthritis related corneal melt.9 The cases series for indications for conjunctival flaps are summarized in Table 1.
Table 33-1. Conjunctival flap case series: indications | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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INFECTIONS
The development and refinement of effective antimicrobial agents over the last 50 years has greatly improved the treatment of corneal infections. However, resistant corneal ulcers rarely may need to be treated with a conjunctival flap. The flap brings in blood supply that promotes healing by increasing corneal access to humoral and cellular immune mechanisms. Exposure, drying, and neurotrophic factors in delayed healing may be moderated as well. In all cases of necrotic ulcers treated with conjuctival flaps it is mandatory that appropriate drug therapy be tried first, and that remaining areas of necrosis be debrided, often with lamellar keratectomy. However, penetrating keratoplasty may have limited benefit because of the degree of inflammation and vascularization of the cornea resulting in high risk for graft rejection. Therefore, a conjunctival flap may allow stabilization of the infection and persistent inflammation in preparation for corneal grafting and visual rehabilitation.
Conjunctival flaps have been used to halt progression of a refractory pseudomonas corneal abscess.10 This is a useful technique in eyes with poor visual potential and a delayed healing rate after both infectious and sterile corneal ulcers. A conjunctival flap was used to treat such keratitis occurring in the region of the corneal incisions in a patient after radial keratotomy.11 Flaps have been promoted for treatment of fungal keratitis resistant to medical treatment.12 This approach may reflect the limited success of topical ophthalmic antifungals. Fungal keratitis, as any infection, can still progress beneath the conjunctival flap in some cases, and the flap itself may limit drug penetration postoperatively. Treatment of advanced acanthamoeba keratitis with deep lamellar keratectomy and conjunctival flap to control the infection and help relieve pain also has been reported.13
The use of flaps to treat herpes simplex keratitis has remained helpful despite the availability of antivirals.4,5,6,7 Persistent epithelial disease may rarely benefit from treatment with a flap. More often, chronic or painful herpetic stromal ulceration and keratouveitis requiring frequent examinations and medical therapy benefit from a conjunctival flap. Brown and colleagues found a marked decrease in the need for medications and office visits in such patients.7 They noted no recurrence of active viral keratitis, although perforation beneath the flap for herpetic keratitis may occur. However, Lesher and colleagues reported recurrence of herpetic stromal keratitis after a conjunctival flap.14
BULLOUS KERATOPATHY
Conjunctival flaps were more widely used for treatment of bullous keratopathy when the success rate of penetrating keratoplasty was poor.15,16 Now, conjunctival flaps are used only to treat the pain of bullous keratopathy in eyes in which a soft contact lens or anterior stromal puncture has failed and the patient refuses penetrating keratoplasty or has poor visual potential.17 Cautery of Bowman’s membrane has also been used in these patients, either alone or combined with a conjunctival flap.18 Flaps may be total for diffuse bullous keratopathy or partial for peripheral localized edema.15,16
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