Partial visual rehabilitation 5 and 6years after aGundersen total conjunctival flap procedure

Abstract

We present the results of penetrating keratoplasty (PKP) after previous treatment with atotal conjunctival flap in two patients. Patient1, a66-year-old with ahistory of bilateral cement chemical burn in 1986 and external right-sided limbokeratoplasty in 2008 was treated externally with atotal conjunctival flap in the right eye in 2014 due to apersistent corneal ulcer with imminent perforation. Best-corrected visual acuity (BCVA) in the right eye was light sensation, intraocular pressure on palpation was within normal range. Clinically, total conjunctival flap was present. Patient2 was treated externally in May 2015 due to acanthamoeba keratitis in the left eye with adeep anterior lamellar keratoplasty (DALK). Are-DALK was also performed externally in the same month. Athird DALK was performed externally in August 2015 due to apersistent corneal ulcer, followed by atotal conjunctival flap 2weeks later. BCVA of the left eye was light sensation and intraocular pressure on palpation was within the normal range. Patient1 was treated with removal of the conjunctival flap in the right eye and penetrating central re-keratoplasty (hand-held Barron trephine; graft diameter 8.5/8.75 mm). Simultaneously, lens extraction and intraocular lens implantation were performed (as atriple procedure). Additionally, amniotic membrane transplantation (AMT) as patch and atemporal lateral tarsorrhaphy were performed. BCVA 6months postoperatively was 0.1. The graft was clear, without any signs of rejection. Patient2 was treated on the left eye with removal of the conjunctival flap and apenetrating central keratoplasty (hand-held Barron trephine; graft diameter 7.0/7.5 mm). An AMT as patch and atemporal lateral tarsorrhaphy were simultaneously performed. Cataract surgery was performed 3months postoperatively and BCVA of the right eye was 0.1 thereafter. The graft was clear, without any signs of rejection. The conjunctival flap is atreatment of last resort of the (almost) penetrated corneal ulcer, which is to be used only when akeratoplasty is technically impossible. Provided the eye structure and retinal function are preserved, partial visual rehabilitation can possibly be achieved through aPKP after excision of the conjunctival flap, even years after corneal blindness.