0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Surgical Technique |

Microsurgical Approach to the Conjunctival Flap FREE

Ali Khodadoust, MD; Ania Porazinski Quinter, MD
[+] Author Affiliations

From the Connecticut Eyecare Center, New Haven. Drs Khodadoust and Quinter have no relevant financial interest in this article.


Arch Ophthalmol. 2003;121(8):1189-1193. doi:10.1001/archopht.121.8.1189.
Text Size: A A A
Published online

Objectives  To describe a microsurgical approach to a selective pedunculated conjunctival flap for the treatment of chronic corneal ulceration with or without corneal perforation, and to present the results of 50 consecutive cases.

Design  Retrospective, noncomparative case series and case reports.

Patients  All patients who had microsurgical conjunctival flap procedures for the treatment of chronic corneal ulcers between 1982 and 1996 at the Connecticut Eyecare Center, New Haven.

Interventions  Partial pedunculated conjunctival flap surgery.

Methods  Review of the initial ocular diagnoses and characteristics as well as retrospective study of the postoperative course.

Main Outcome Measures  Resolution of the corneal ulcer and postoperative stability of the conjunctival flap.

Results  Sixty-two percent of the corneal ulcers treated were nonperforated, and 38% were perforated. The diagnoses included herpes simplex virus (14 patients), bacterial ulcer (11 patients), rheumatoid arthritis (8 patients), aphakic bullous keratopathy (6 patients), graft rejection (4 patients), herpes zoster virus (5 patients), and other (2 patients). Postoperatively, 94% of the conjunctival flaps were stable, and 3% had failed. The procedures were definitive in 64% of cases and temporary in 36%; 61% of patients received a corneal transplant 6 to 24 months postoperatively, and in 38% the flaps were removed 6 to 12 months after the original lesion had healed.

Conclusion  A selective pedunculated conjunctival flap is an effective and practical surgical approach to the treatment of perforated and nonperforated corneal ulcers that have not responded to other types of medical therapy.

Figures in this Article

THE TECHNIQUE of using a conjunctival flap for the treatment of chronic corneal ulceration was described by Gunderson1 in the late 1950s and became a standard surgical procedure. There are some drawbacks to this procedure, however.1,2 During the past 20 years, progress in microsurgical technique, aided by the microscope and fine surgical tools, has enabled us to use a selective pedunculated conjunctival flap secured in place by fine sutures and tailored to cover a desired area of the diseased cornea for the treatment of chronic corneal ulceration with or without corneal perforation. This microsurgical approach to the conjunctival flap provides a convenient alternative to the procedure developed by Gunderson without its drawbacks. The technique may be performed in an outpatient setting, and postoperative recovery is rapid. The purpose of this article is to describe the microsurgical approach to the conjunctival flap, highlight 2 case reports, and present the results of 50 consecutive cases.

The microsurgical conjunctival flap technique may be performed in the minor surgical procedure room under a microscope. After the application of topical anesthetic solution, the eye is prepared with povidone iodine and draped in the usual sterile fashion. An eye speculum is inserted. A sponge(Weck-Cel; Medtronic Ophthalmics, Jacksonville, Fla) or cotton-tipped applicator is used to remove the loose epithelium over the diseased portion of the cornea and for 1 mm surrounding the lesion. A cotton-tipped applicator soaked in a solution of 5% povidone iodine is touched to any nonsterile area of the lesion and allowed to absorb without rinsing. The size and location of the denuded area are evaluated, and a decision is made regarding the most suitable site for obtaining a pedunculated bulbar conjunctival segment for covering the area (Figure 1A). The most suitable segment will typically be the one nearest the corneal lesion and with the best blood supply. Next, 0.5 to 1 mL of 1% to 2% lidocaine hydrochloride with epinephrine (dilution, 1:100 000) is injected subconjunctivally into the desired area. The initial needle puncture is kept away from the site where the conjunctiva is going to cover the diseased cornea. Rolling a cotton-tipped applicator over the inflated conjunctiva helps to spread the lidocaine and reduce the conjunctival stretching from the injection (Figure 1B).

Place holder to copy figure label and caption
Figure 1.

A, Pictorial representation of the site for obtaining, proper positioning, and suturing of the pedunculated conjunctival flap (arrow) to cover the affected corneal area. B, Slitlamp photograph demonstrating preparation of the conjunctival site after injection of anesthetic and debridement of the loose epithelium. C, Slitlamp photograph demonstrating the pedunculated conjunctival flap covering the corneal lesion without any traction. D, Slitlamp photograph of the pedunculated conjunctival flap secured in place with running nylon sutures.

Graphic Jump Location

A peritomy is performed from the 2-o'clock to 3-o'clock positions in the desired quadrant. A crescent-shaped incision peripheral to the peritomy is then made to isolate the appropriate size of the pedunculated conjunctival flap. The flap is undermined, and the incision is extended until the mobilized flap can stay over the corneal defect without traction (Figure 1C). If the conjunctival flap is being prepared for a perforated corneal ulcer, tissue from the Tenon capsule is mobilized along with the conjunctiva. Care is taken to preserve the vascular supply of the flap as much as possible.

The flap is then secured to the cornea using 10-0 monofilament nylon sutures. The suturing technique is one of the most crucial steps and the key to the success of this procedure. The first suture bite is passed through the conjunctival flap near the limbus. The needle is inserted at the edge of the diseased portion of the cornea, passed through the intact cornea, and pulled out just central to the edge of the intact corneal epithelium, being careful not to include any of the epithelium and to avoid infolding of the conjunctiva. The suture is tied snug. The second bite follows the tract of the first suture, pulling it. The initial knot passes into the suture tract, thus minimizing postoperative irritation from exposed knots. Each subsequent bite of the running suture includes 0.5 mm of the central conjunctiva and 0.5 to 1 mm of peripheral corneal tissue. Each bite passes through half the thickness of the cornea, enters about 0.5 mm central to the denuded edge of the corneal epithelium, and comes out just at the edge of the rolled epithelium. The last suture is tightened, tied, and rolled. The knot is buried under the conjunctiva or into the corneal tissue (Figure 1D).

The flap over the cornea should be neither too tight nor too loose. Sutures that are too tight may pull through a tight conjunctival flap, and a loose flap will not heal and may come off during the postoperative period. After completion of the running suture, edges of the corneal epithelium can be rolled over the suture and denuded area. Antibiotic ointment and a cycloplegic drug are administered, and the eye is patched. After 24 hours, the dressing is changed; by that time, there is usually no epithelial defect. The eye is treated with a topical antibiotic until it heals. The sutures may be removed 10 days to 2 weeks postoperatively if they become loose. Otherwise, they can be left in place for weeks or months.

We reviewed the records of all patients who had microsurgical conjunctival flap procedures for the treatment of chronic corneal ulcers between 1982 and 1996. A total of 50 eyes of 50 patients were evaluated (Table 1). Patients were aged 15 to 85 years.

There were 21 male patients and 29 female patients. At the time of the initial diagnosis, 31 (62%) of the corneal ulcers were nonperforated. Nine(29%) of these were infected, and 22 (71%) were sterile (noninfected). The remaining 19 eyes (38%) had perforated ulcers. Eight (42%) of these were infected, and 11 (58%) were noninfected. The diagnoses for patients requiring a microsurgical conjunctival flap included herpes simplex virus (14), bacterial ulcer (11), rheumatoid arthritis (8), aphakic bullous keratopathy (6), graft rejection(4), herpes zoster virus (5), and other (2). The immediate postoperative outcome for 47 patients (97%) was successful, marked by a formed anterior chamber, healed ulcer, and quiet anterior segment of the eye. Three (6%) of the conjunctival flaps failed because of retraction or a nonhealing lesion. Thirty-two (64%) were performed as definitive procedures, 21 (42%) for peripheral ulcers and 11 (22%) on blind eyes. Eighteen (36%) of the conjunctival flap procedures were perfomed as a temporary measure. Eleven (61%) of these eyes received corneal transplants 6 to 24 months postoperatively. In 7 eyes (38%), the conjunctival flap was removed 6 to 12 months postoperatively after the original lesion had healed.

CASE 1

An 18-year-old female contact lens wearer developed redness and a white spot in the nasal corner of her right eye. Forty-eight hours later, the patient developed a large necrotic ulcer caused by Pseudomonas aeruginosa infection that perforated despite intensive topical antibiotic treatment(Figure 2A). Although tissue adhesive was applied, results of the Seidel test were positive for leaks, and the anterior chamber was shallow. She was seen at our office 1 week after her initial visit for a second opinion on a possible corneal transplant. The initial visual acuity was hand motions OD. Using microsurgical technique, a conjunctival flap was mobilized from the upper nasal quadrant and secured onto the area of the perforated cornea. The anterior chamber reformed within half an hour postoperatively. The eye was patched, and the patient was sent home. On postoperative day 1, results of the Seidel test were negative for leaks, and the anterior chamber was deep. The epithelium had healed. The patient was prescribed a topical antibiotic. At 6 weeks postoperatively, the sutures were removed. Her visual acuity was 20/60 OD. Five months after the procedure, the eye remained quiet with a corneal scar on the nasal side (Figure 2B).

Place holder to copy figure label and caption
Figure 2.

A, Slitlamp photograph demonstrating the perforated necrotic ulcer, caused by Pseudomonas aeruginosa infection, covered with glue adhesive. B, Slitlamp photograph showing the cornea 5 months after the pedunculated conjunctival flap procedure.

Graphic Jump Location
CASE 2

A 78-year-old woman with rheumatoid arthritis came to our office 12 hours after developing watery eyes and decreased vision in the right eye. At examination, her visual acuity was 20/100 OD, the anterior chamber was flat, and a perforated sterile ulcer was seen at the 2-o'clock position in the midperiphery (Figure 3A). Using microsurgical technique, a conjunctival flap was secured into place over the perforated cornea. The anterior chamber reformed within half an hour postoperatively. The eye waspatched, and the patient was sent home. At 6 weeks postoperatively, the sutures were removed (Figure 3B). Three months after the procedure, the patient's visual acuity was 20/60 OD, and an immature cataract was seen.

Place holder to copy figure label and caption
Figure 3.

A, Slitlamp photograph of the right eye showing a perforated sterile ulcer in a patient with a history of rheumatoid arthritis. B, Slitlamp photograph showing the eye 6 weeks after the pedunculated conjunctival flap procedure. The sutures were removed.

Graphic Jump Location

In the past century, there have been many surgical approaches to the treatment of destructive corneal conditions.311 Among them was the use of conjunctival flaps, which could restore ocular surface integrity1215 and provide metabolic and mechanical support for corneal healing.12,16,17 Described by Gunderson, 1 the most accepted and popular technique involved making a 360° peritomy, mobilizing tissue from the upper bulbar conjunctiva, removing the corneal epithelium, and securing the flap to the lower limbal conjunctiva. Coverage of the entire cornea with the conjunctiva obstructed any view of the anterior chamber, 1,2 precluded monitoring of corneal disease progression, and made it difficult to determine the presence and progress of secondary glaucoma. In addition, this procedure was challenging in patients with short fornices and had the potential to cause ptosis.1 It also required a more careful and extensive surgical procedure in the operating room. Any buttonholes or traction that could ultimately lead to flap failure had to be avoided. These limitations as well as advancements in modern corneal transplantation techniques and the use of tissue adhesives ultimately favored alternative approaches to treatment.1823 However, corneal transplantation is not always suitable; an inflamed, highly vascularized cornea, for example, carries a high risk of graft rejection. The use of tissue adhesive also has its drawbacks. It may result in a long, protracted course of recovery and has limited use in the setting of prolapsed uveal tissue through a corneal perforation.

The microsurgical technique of using a selective, pedunculated, partial conjunctival flap tailored to cover the desired part of the diseased cornea provides a convenient and logical alternative to the procedure developed by Gunderson1 in instances when only partial protection of the cornea is needed. It is an easily performed, highly effective solution for difficult-to-treat destructive corneal problems. It can be done in an outpatient setting, and postoperative recovery is rapid. Visualization of the anterior segment is not limited with this technique. Progression of corneal disease can be monitored, and intraocular pressure can be measured. It may be used in patients with short fornices, and we have seen no cases of ptosis in this series.

We used a thin conjunctival flap for nonhealing superficial ulceration. For deeper corneal ulcers and perforation, we included the Tenon capsule with the conjunctival peduncle to provide stronger mechanical support for the cornea. In no instance of ulcer perforation did we notice bleb formation at the site of the conjunctival flap. The appeal of our selective pedunculated conjunctival flap technique is in its practicality for being performed as a minor surgical procedure and its versatility in being used as a temporizing measure. For peripheral ulceration or microperforation, this technique is meant as the definitive procedure. However, for central ulceration it can be used to temporize the inflamed eye until the ulcer heals and corneal transplantation can be performed. In this series, 18 (36%) of the flaps were later removed; 11 of these patients received a corneal transplant 6 to 24 months postoperatively once the eye was stable without any inflammation. Temporizing with a selective conjunctival flap has the advantage of reducing the risk of corneal graft rejection. The other 7 conjunctival flaps that were removed stabilized the original lesion and aided in the healing process of the corneal ulcer.

Of the 50 selective pedunculated conjunctival flap procedures performed in this case series, only 3 (6%) failed because of retraction of the flap or because the original lesion had not healed. The key to a successful pedunculated conjunctival flap includes selection of the appropriate site and size, mobilization of the flap without traction, preservation of the flap's blood supply, avoidance of cautery, avoidance of conjunctival or corneal epithelial entrapment, debridement and application of povidone iodine to infected ulcers, securing the flap over the denuded area with running 10-0 monofilament nylon sutures, and avoidance of excessive traction on these sutures. In summary, a selective pedunculated conjunctival flap is an effective and practical surgical approach to the treatment of perforated and nonperforated corneal ulcers that have not responded to other types of medical therapy. This technique deserves a place in the repertoire of ophthalmic surgeons.

Corresponding author and reprints: Ali Khodadoust, MD, Connecticut Eyecare Center, 46 Prince St, Suite 202, New Haven, CT 06519 (e-mail: CTeyecare@aol.com).

Submitted for publication November 6, 2002; final revision received March 21, 2003; accepted March 28, 2003.

Gunderson  T Conjunctival flaps in the treatment of corneal disease with reference to a new technique application. Arch Ophthalmol. 1958;60880- 888
Link to Article
Lin  TWebster  R  JrAbbott  R Repair of corneal lacerations and perforations. Int Ophthalmol Clin. 1988;2869- 75
PubMed Link to Article
Arentsen  JLaibson  PCohen  E Management of corneal descemetoceles and perforations. Ophthalmic Surg. 1985;1629- 33
PubMed
Scholer  H Jahresberichte uber die Virksamkeit der Augen-Klinik, in den Jahren 1874-1880.  Berlin, Germany H Peters1875- 1881
Krebs  C Uber die Heilung perforirender Schleralwunden mit und ohne Bindenhautlappen, nach an Kaninchen ausgefuhrten Experimenten.  Berlin, Germany G Schade1878;
Kuhnt  H Beitrage zur operativen Augenheilkunde.  Jena, Germany G Fisher1883;69- 87
Meyer  E Klinischer und experimenteller Beitrag zur Infection vernarbter Irisvorfalle auf endogenem Vege, Schutz derselben gegen ectogene Infection. Versammlung der Ophthalmologie Ber Ophth Ges Heidel. 1892;22109- 115
Van Lint  A The sliding flap operation in the removal of cataract. Ophthalmoscope. 1912;10563- 568
Beyers  W Conjunctival flaps in ophthalmic surgery. Trans Am Ophthalmol Soc. 1909-1911;12389- 409
Green  J Conjunctivo-plasty in certain corneal affections. Trans Am Ophthalmol Soc. 1927;2539- 47
Haik  G Fornix conjunctival flap as a substitute for the dissected conjunctival flap: a clinical and experimental study. Trans Am Ophthalmol Soc. 1954;52497- 524
Thoft  R Conjunctival transplantation. Arch Ophthalmol. 1977;951425- 1427
PubMed Link to Article
Coster  DAggarwal  RWilliams  K Surgical management of ocular surface disorders using conjunctival and stem cell allografts. Br J Ophthalmol. 1995;79977- 982
PubMed Link to Article
Danjo  SFriend  JThoft  R Conjunctival epithelium in healing of corneal epithelial wounds. Invest Ophthalmol Vis Sci. 1987;281445- 1449
PubMed
Kenyon  KScheffer  CTseng  G Limbal autograft transplantation for ocular surface disorders. Ophthalmology. 1989;96709- 723
PubMed Link to Article
Monks  TBusin  M Modifizierte Technik zur autologen Bindehauttransplantation nach Hornhautveratzung. Klin Monatsbl Augenheilkd. 1994;204121- 125
PubMed Link to Article
Reim  MTeping  C Surgical procedures in the treatment of most severe eye burns: revival of the artificial epithelium. Acta Ophthalmol Suppl. 1989;19247- 54
PubMed
Saini  JSharma  AGrewal  S Chronic corneal perforations. Ophthalmic Surg. 1992;23399- 402
PubMed
Hirst  LSmiddy  WStark  W Corneal perforations: changing methods of treatment, 1960-1980. Ophthalmology. 1982;89630- 635
PubMed Link to Article
Portnoy  SInsler  MKaufman  H Surgical management of corneal ulceration and perforation. Surv Ophthalmol. 1989;3447- 58
PubMed Link to Article
Weiss  JWilliams  CLindstrom  R  et al.  The use of tissue adhesive in corneal perforations. Ophthalmology. 1983;90610- 615
PubMed Link to Article
Hirst  LWDe Juan  E  Jr Sodium hyaluronate and tissue adhesive in treating corneal perforations. Ophthalmology. 1982;891250- 1253
PubMed Link to Article
Sharma  AKaur  RKumar  S  et al.  Fibrin glue versus N-butyl-2-cyanoacrylate in corneal perforations. Ophthalmology. 2003;110291- 298
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

A, Pictorial representation of the site for obtaining, proper positioning, and suturing of the pedunculated conjunctival flap (arrow) to cover the affected corneal area. B, Slitlamp photograph demonstrating preparation of the conjunctival site after injection of anesthetic and debridement of the loose epithelium. C, Slitlamp photograph demonstrating the pedunculated conjunctival flap covering the corneal lesion without any traction. D, Slitlamp photograph of the pedunculated conjunctival flap secured in place with running nylon sutures.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A, Slitlamp photograph demonstrating the perforated necrotic ulcer, caused by Pseudomonas aeruginosa infection, covered with glue adhesive. B, Slitlamp photograph showing the cornea 5 months after the pedunculated conjunctival flap procedure.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A, Slitlamp photograph of the right eye showing a perforated sterile ulcer in a patient with a history of rheumatoid arthritis. B, Slitlamp photograph showing the eye 6 weeks after the pedunculated conjunctival flap procedure. The sutures were removed.

Graphic Jump Location

References

Gunderson  T Conjunctival flaps in the treatment of corneal disease with reference to a new technique application. Arch Ophthalmol. 1958;60880- 888
Link to Article
Lin  TWebster  R  JrAbbott  R Repair of corneal lacerations and perforations. Int Ophthalmol Clin. 1988;2869- 75
PubMed Link to Article
Arentsen  JLaibson  PCohen  E Management of corneal descemetoceles and perforations. Ophthalmic Surg. 1985;1629- 33
PubMed
Scholer  H Jahresberichte uber die Virksamkeit der Augen-Klinik, in den Jahren 1874-1880.  Berlin, Germany H Peters1875- 1881
Krebs  C Uber die Heilung perforirender Schleralwunden mit und ohne Bindenhautlappen, nach an Kaninchen ausgefuhrten Experimenten.  Berlin, Germany G Schade1878;
Kuhnt  H Beitrage zur operativen Augenheilkunde.  Jena, Germany G Fisher1883;69- 87
Meyer  E Klinischer und experimenteller Beitrag zur Infection vernarbter Irisvorfalle auf endogenem Vege, Schutz derselben gegen ectogene Infection. Versammlung der Ophthalmologie Ber Ophth Ges Heidel. 1892;22109- 115
Van Lint  A The sliding flap operation in the removal of cataract. Ophthalmoscope. 1912;10563- 568
Beyers  W Conjunctival flaps in ophthalmic surgery. Trans Am Ophthalmol Soc. 1909-1911;12389- 409
Green  J Conjunctivo-plasty in certain corneal affections. Trans Am Ophthalmol Soc. 1927;2539- 47
Haik  G Fornix conjunctival flap as a substitute for the dissected conjunctival flap: a clinical and experimental study. Trans Am Ophthalmol Soc. 1954;52497- 524
Thoft  R Conjunctival transplantation. Arch Ophthalmol. 1977;951425- 1427
PubMed Link to Article
Coster  DAggarwal  RWilliams  K Surgical management of ocular surface disorders using conjunctival and stem cell allografts. Br J Ophthalmol. 1995;79977- 982
PubMed Link to Article
Danjo  SFriend  JThoft  R Conjunctival epithelium in healing of corneal epithelial wounds. Invest Ophthalmol Vis Sci. 1987;281445- 1449
PubMed
Kenyon  KScheffer  CTseng  G Limbal autograft transplantation for ocular surface disorders. Ophthalmology. 1989;96709- 723
PubMed Link to Article
Monks  TBusin  M Modifizierte Technik zur autologen Bindehauttransplantation nach Hornhautveratzung. Klin Monatsbl Augenheilkd. 1994;204121- 125
PubMed Link to Article
Reim  MTeping  C Surgical procedures in the treatment of most severe eye burns: revival of the artificial epithelium. Acta Ophthalmol Suppl. 1989;19247- 54
PubMed
Saini  JSharma  AGrewal  S Chronic corneal perforations. Ophthalmic Surg. 1992;23399- 402
PubMed
Hirst  LSmiddy  WStark  W Corneal perforations: changing methods of treatment, 1960-1980. Ophthalmology. 1982;89630- 635
PubMed Link to Article
Portnoy  SInsler  MKaufman  H Surgical management of corneal ulceration and perforation. Surv Ophthalmol. 1989;3447- 58
PubMed Link to Article
Weiss  JWilliams  CLindstrom  R  et al.  The use of tissue adhesive in corneal perforations. Ophthalmology. 1983;90610- 615
PubMed Link to Article
Hirst  LWDe Juan  E  Jr Sodium hyaluronate and tissue adhesive in treating corneal perforations. Ophthalmology. 1982;891250- 1253
PubMed Link to Article
Sharma  AKaur  RKumar  S  et al.  Fibrin glue versus N-butyl-2-cyanoacrylate in corneal perforations. Ophthalmology. 2003;110291- 298
PubMed Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 3

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles