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Therapeutic Approach in Fungal Keratitis
Published in Mahendra Rai, Marcelo Luís Occhiutto, Mycotic Keratitis, 2019
Victoria Díaz-Tome, María Teresa-Rodríguez Ares, Rubén Varela-Fernández, Rosario Touriño-Peralba, Miguel González-Barcia, Laura Martínez-Pérez, María Jesús Lamas, Francisco J. Otero-Espinar, Anxo Fernández-Ferreiro
Conjunctival flap involves conjunctiva’s release near the lesion in order to cover the ulcer afterwards. This procedure may be used in peripheral ulcers which do not respond to pharmacological treatment or in severe keratitis with a corneal-perforation high risk when corneal transplant is not available.
Glaucoma drainage implants and vitreoretinal surgery
Published in A Peyman MD Gholam, A Meffert MD Stephen, D Conway MD FACS Mandi, Chiasson Trisha, Vitreoretinal Surgical Techniques, 2019
Herbert P Fechter III, Richard K Parrish II
If glaucoma cannot be controlled after scleral buckling surgery or vitrectomy, either as a result of secondary angle closure or a primary open-angle mechanism, a drainage implant or possibly a trabeculectomy is indicated. The conjunctival insertion site is often recessed posterior to its original location due to the prior limbal peritomy. Limbal scarring can make dissection of the conjunctival flap technically difficult. In eyes with extensive conjunctival scarring, we prefer a drainage implant to a fornix-based or limbus-based trabeculectomy. The amount of conjunctival fibrosis determines whether a limbus-based trabeculectomy is possible.
Filtration Surgery
Published in Neil T. Choplin, Carlo E. Traverso, Atlas of Glaucoma, 2014
Mina B. Pantcheva, Leonard K. Seibold, Malik Y. Kahook
There are a variety of techniques to close the conjunctival flap. The crucial objective in this step is to achieve a smooth, watertight closure. If a limbal-based conjunctival flap has been created, a two-layer running closure with 8-0 Vicryl on a vascular needle is recommended. The Tenon’s capsule is closed with several large running and locking bites. The final bite through Tenon’s capsule is passed through the conjunctiva in a locked fashion. The remaining closure is between the conjunctival edges using small nonlocking bites. The suture is then tied on a loop of itself and cut. If a fornix-based conjunctival flap has been created, the conjunctiva should then be stretched anteriorly with the goal of suturing both Tenon’s capsule and the conjunctiva back into their original position at the limbus. For short limbal incisions, the closure can be as simple as suturing either end of the peritomy with two wing sutures. The first wing suture is anchored to the episclera by advancing the needle just anterior and lateral to the peritomy edge (Figure 16.17). The suture is placed through the conjunctival edge at a location to reapproximate the cut edge firmly against the limbus. A small running or purse string-type suture may be required to close any gapping of conjunctiva beyond the wing suture (Figure 16.18). This can be tied to the original knot at the limbus to advance the conjunctiva over the knot, covering it. The second wing suture is then placed similarly to anchor the conjunctiva to the episclera on the opposite end of the peritomy. We prefer 8-0 Vicryl suture on a tapered, BV needle for our anchoring wing sutures. The traction suture should be loosened during closure to facilitate approximation of conjunctival tissue to its desired location. The anterior chamber is then reformed to produce a filtration bleb and the conjunctival closure is checked for leakage with a Weck-Cel sponge (Figure 16.19). Fluorescein may be applied to detect the presence of any small leaks.
A Review of Ocular Graft-versus-Host Disease: Pathophysiology, Clinical Presentation and Management
Published in Ocular Immunology and Inflammation, 2021
Jimena Tatiana Carreno-Galeano, Thomas H. Dohlman, Stella Kim, Jia Yin, Reza Dana
In oGVHD patients with severe corneal pathology such as PEDs, corneal ulceration and corneal perforation, several surgical procedures have been reported. Amniotic membrane transplantation is one such procedure and involves suturing or gluing a sheet of processed amniotic membrane to the ocular surface, or placement of a Prokera® device, which consists of amniotic membrane suspended within a plastic ring.105 Amniotic membrane acts as a scaffold for corneal epithelial cells and contains multiple anti-inflammatory and trophic factors which suppress inflammation and foster epithelial and stromal healing. The membrane dissolves over the course of 1–2 weeks and may need to be replaced in some cases. A temporary or permanent tarsorrhaphy may also be of benefit as it protects the ocular surface to facilitate healing and reduces any component of exposure.106–108 Penetrating keratoplasty has been reported in patients with oGVHD but has a poor prognosis in patients with active inflammation and a vascularized recipient bed.109 Allogeneic limbal stem cell transplantation (LSCT) has also been reported in patients with oGVHD but these patients again have a high risk of rejection requiring long-term immunosuppression. In one report investigators were able to mitigate the risk of rejection by transplanting limbal epithelial cells derived from the same HSCT donor.110 In patients with severe ocular surface disease, significant thinning and/or recalcitrant pain, a Gundersen conjunctival flap may also be considered as an end-stage or emergent procedure.
Corneal crosslinking for the treatment of infectious keratitis: a review
Published in Expert Review of Ophthalmology, 2021
Sepehr Feizi, Farid Karimian, Hamed Esfandiari
Two randomized studies evaluated the efficacy of PACK-CXL in bacterial keratitis. A prospective, randomized trial allocated eyes with moderate bacterial keratitis to standard antibiotic therapy (n = 16) or adjunctive CXL (n = 16) [77]. Moderate bacterial keratitis was defined as ulcers with 2 to 6 mm in size, involvement of the anterior two-thirds of the stroma, and 4+ anterior chamber reactions [77]. PACK-CXL was performed before the commencement of any antibiotics [77]. The authors reported that the duration of treatment was significantly reduced in the CXL group. Amniotic membrane transplantation was performed in one eye in each group. Conjunctival flap was required in one patient in the control group for the management of persistent sterile epithelial defects that were unresponsive to conventional therapy [77]. None of the eyes developed corneal perforation [77].
Conjunctival Flap with Biodegradable Collagen Matrix Implantation for the Treatment of Scleromalacia after Periocular Surgery
Published in Ocular Immunology and Inflammation, 2019
Kyung Eun Han, Sangchul Yoon, Roo Min Jun, Tae-im Kim, Eung Kweon Kim, Kyoung Yul Seo
Conjunctival flap surgery has the following advantages: continuous supply of blood to the ischemic sclera, ease of flap creation, and no need for additional surgery or graft material. We have reported the surgical outcomes of conjunctival flap surgery in patients who suffered from complications after previous cosmetic wide conjunctivectomy or pterygium excision surgery.5,6 Through the observations of untreated calcified scleromalacia, we suggested that calcified plaque should be removed, and continuous vascular supply from the conjunctival flap is important to prevent further progression of scleromalacia. Conjunctival flap surgery showed good postoperative cosmetic results in eyes with relatively small and shallow excavation of sclera6; however, the visible bluish choroidal tissue underneath the semilucent conjunctival flap has been a cosmetic shortage in some patients with deep and large scleral defects.