Limbal Conjunctiva Sparing Conjunctival Pedicle Flap in the Management of Corneal Ulceration Arun K Jain, MD, Pankaj Gupta, MS Cornea, Cataract & Refractive Surgery Services Advanced Eye Centre, PGIMER, Chandigarh, India Authors have no financial interest in the subject matter of this paper

Introduction Corneal thinning, ulceration, descematocele formation and perforation can occur following variety of conditions afflicting the cornea. These conditions could be infectious keratitis or noninfectious immune keratitis. Various conditions include : recalcitrant bacterial keratitis, herpes simplex keratitis, herpes zoster corneal involvement, rheumatoid arthritis, acne rosacea, aphakik or pseudophakik bullous keratopathy, graft rejection, post trauma corneal ulceration and melting and host of other conditions. Medical treatment includes treating underlying disease, dry eye management, topical & systemic antibiotics & immunosuppressive agents, oral doxycycline and other supportive therapies Surgical options are tarsorrhaphy, fibrin or cyanoacrylate glue, bandage contact lens, amniotic membrane transplantation, conjunctival flap, patch graft, lameller kertoplasty, penetrating kertoplasty, limbal stem cell transplantation In such situations of corneal thinning or perforation, maintenance of ocular globe integrity is of paramount importance

Purpose of the Study To study the results of limbal conjunctiva sparing bulbar conjunctival pedicle flap [ LCSBCPF] in the management of corneal ulceration with or without corneal perforation Design: Prospective, non-comparative, interventional case series. Main outcome measures: Resolution of the corneal ulcer and postoperative stability of the conjunctival flap and restoration of anatomical integrity of the globe

Methods Twelve patients with corneal ulceration with perforation or impending corneal perforation [ corneal foreign body induced keratitis and perforation [2], post chemical burn [2],, post keratoplasty graft ulceration [1], post corneal trauma [1], chronic noninfectious ulcerative keratitis [3], neurotrophic keratitis [1], recalcitrant bacterial keratitis [1] and herpes simplex keratitis [1] under went LCSBCPF. Method of LCSBCPF [Movie] Surgery was performed under surgical microscope and under topical anesthesia Eye is prepared with poviodin iodine and draped in a sterile manner An eye speculum is inserted Loose epithelium surrounding the pathological area is removed and the size and location of the denuded cornea to be covered with flap is assessed

Methods Suitable site for obtaining the LCSBCPF is selected 0.5 to 1 ml of 2% lidocaine with adrenaline [1: 100,000 dilution] injected subconjunctivally in the desired area of bulbar conjunctiva Conjunctival flap of desired size is fashioned taking care that at least 1.5mm to 2 mm width of limbal conjunctiva was left undisturbed, so that limbal stem cells were not included in the pedicle flap If the flap is prepared for extreme corneal thinning or perforation, tissue from the Tenon capsule dissected along with conjunctiva. Graft is then secured to the cornea with 10-O monofilament nylon suture Antibiotic drops and cyloplegic drops are administered and eye is patched overnight. Post operatively eye is treted with topical antibiotics, tear substitute, and other supportive therapy Sutures can be removed after 2weeeks to 3 weeks Movie

Last follow up – Ulcer haeled Integrity of globe maintained Visual acuity 20/40(aided) 18 year male H/o Foreign body falling into eye 1 month back At presentation-corneal infiltrates in peripheral cornea with hypopyon Microbiology-negative Treated with antibiotics Infiltrates decreased but marked cornal thinning resulted. LCSBCPF was done Results

LCSBCPF with Tenon dissection in a case of severe chemical burns with persistent epithelial defect and corneal thinning

47 year male Presented after 1 month of ocular injury VA 20/400 S/L exam-FB in cornea with surrounding infiltrates FB removed and topical antibiotics started Descemetocele formation after 2 weeks Undergoes LCSBCPF after unsuccessful attempts of glue application Last follow up-Thinning well sealed, globe integrity maintained, Visual acuity 20/25

Case of post trauma corneal melt. LCSBCPF was done. At later date phacosrgery and IOL implantation was done.

7 year male H/o foreign body falling into eye Presents with intracorneal foreign body & Infectious Keratitis FB removed along with cyanoacrylate glue application and bandage contact lens Glue applied twice, but failed LCSBCPF was done Integrity of globe restored Final visual acuity 20/20

Results Out of twelve patients 5 had corneal perforation. Eleven patients had stable pedicle grafts. In one patient graft retracted on fifth postoperative day and it was sutured again. Corneal ulcer healed in all patients. Globe integrity was preserved in all patients. None of the patients manifested localized limbal stem cell deficiency /conjunctivalization of cornea pertaining to the limbal area from where LCSBCPF was dissected Non of the patients developed glaucoma None of the patient required patch graft or penetrating keratoplasty

Conclusions Conjunctival pedicle flap is an appropriate procedure to manage corneal perforations and impending corneal perforations where donor material is not available and transplantation of such tissue is not suitable. The technique is performed easily, and can aid in the healing of areas of thinning that threaten perforation by providing a vascular pedicle. Limbal sparing flap in addition helps prevent conjunctivalization of cornea and therefore gives good anatomic as well as visual outcome