Full-thickness conjunctival flap covering surgery combined with amniotic membrane transplantation for severe fungal keratitis

Modified tectonic corneoscleral graft technique for treating devastating corneoscleral infections

BACKGROUND

This study aims to evaluate the clinical outcomes and efficacy of a modified tectonic corneoscleral graft (TCG) in patients suffering from devastating corneoscleral infections.

METHODS

Thirty-eight eyes from 38 patients who underwent the modified TCG were included in this study. The outcomes measured were recurrence rates, best-corrected visual acuity (BCVA), ocular surface stability, postoperative complications, and graft survival.

RESULTS

Among the 38 patients, 23 had fungal infections, 9 had bacterial infections and 6 had Pythium insidiosum infections. At the final follow-up, with an average duration of 25.1 ± 8.6 months, the rate of monocular blindness decreased from 100 to 58%. Significant improvements in LogMAR BCVA were observed from preoperative to postoperative measurements (P < 0.001). Thirty-two eyes (84.2%) maintained a stable ocular surface. The survival rate of ocular surface stability was 84.2%±5.9% at one year and 57.7%±9.7% at three years post-surgery. Twenty eyes (52.6%) retained a clear graft, with a survival rate for graft clarity was 81.6%±6.3% at one year and 36.0%±10.8% at three years post-surgery. The incidence of immune rejection was 36.8%. Corneal epithelial defects were observed in ten patients, and choroidal detachment occurred in four patients. No cases of elevated intraocular pressure were detected.

CONCLUSIONS

The modified TCG is effective in eradicating infections, preserving the eyeball, and maintaining useful vision in cases of devastating corneoscleral infections. Regular use of tacrolimus, timely administration of glucocorticoids, and good patient compliance can help mitigate postoperative challenges.

Real-life experience on the effectiveness of conjunctival flap and amniotic membrane graft in the treatment of refractory fungal corneal ulcer

PURPOSE

To evaluate and compare the results of the conjunctival flap (CF) and cryopreserved amniotic membrane graft (AMG) in the management of fungal corneal ulcers either with complications or non-responsive to medical treatment.

STUDY DESIGN

A retrospective observational study.

METHODS

Medical records of 30 patients with culture-positive fungal corneal ulcer treated with either CF or AMG (15 eyes in each group) in real world settings were retrieved for analysis. After the surgical procedure, patients were followed up on days 1, 7, 14, 21, 30, 60, 90, 120, and 180 to explore the outcomes of the operations along with complications.

RESULTS

Infecting fungi were of genus Fusarium (n = 11), Aspergillus (n = 10), Mucor (n = 4) and Penicillium (n = 10). The most common indication was resistant ulcer with perforation. After the procedure, epithelization was completed in 11(73.33%) patients in the CF, and 13 patients in the (86.67%) AMG group. Visual acuity improvement was significantly better in the latter group (CF: 1 [6.67%] vs. AMG: 7 [46.67%], p = 0.023). Flap failure occurred in 4 patients (26.67%) from the CF and 2 (13.33%) from the AMG group. No significant differences were found between the two groups regarding success rate (p = 0.651), epithelialization time (p = 0.691), healing of corneal ulcer (p = 0.651), and postoperative stability (p = 0.651) of the flaps.

CONCLUSIONS

CF and AMG are both effective for the management of refractory fungal corneal ulcers. However, AMG appears to improve visual acuity better than CF.

Management of Filamentous Fungal Keratitis: A Pragmatic Approach

Filamentous fungal infections of the cornea known as filamentous fungal keratitis (FK) are challenging to treat. Topical natamycin 5% is usually first-line treatment following the results of several landmark clinical trials. However, even when treated intensively, infections may progress to corneal perforation. Current topical antifungals are not always effective and are often unavailable. Alternatives topical therapies to natamycin include voriconazole, chlorhexidine, amphotericin B and econazole. Surgical therapy, typically in the form of therapeutic penetrating keratoplasty, may be required for severe cases or following corneal perforation. Alternative treatment strategies such as intrastromal or intracameral injections of antifungals may be used. However, there is often no clear treatment strategy and the evidence to guide therapy is often lacking. This review describes the different treatment options and their evidence and provides a pragmatic approach to the management of fungal keratitis, particularly for clinicians working in tropical, low-resource settings where fungal keratitis is most prevalent.

Adjunctive Green Thermal Laser Photocoagulation for Treatment of Resistant Infectious Keratitis

Purpose

To investigate the safety and efficacy of green thermal laser as an adjunctive therapy for the treatment of resistant infectious keratitis (IK) in the Delta region of Egypt.

Methods

A retrospective case series of 150 patients, within a 4 year duration, with resistant IK, who failed to respond to specific medical treatment alone for 7 days, were included. They all received green thermal laser photocoagulation treatment to the cornea as an adjunctive to medical treatment.

Results

Forty-eight women and 102 men were included in this study with a mean age of 46.2 ± 7.7 years. Common risk factors associated with IK included trauma by material of plant origin and contact lens wear. The mean duration of healing was 2.87 ± 0.7 weeks. A single session of green thermal laser application was adequate in 138 IK cases (92%), while 12 cases (8%) required an additional session a week later. Supplementary amniotic membrane transplantation (AMT) was required in 26 cases (17.3%). Two patients (1.3%) required tectonic keratoplasty for corneal perforation. The final corrected distance visual acuity (CDVA) was counting fingers (CF) or better in 78 patients (52%). No decrease of CDVA was reported throughout the study.

Conclusion

Green thermal laser is a safe and effective adjunctive therapy for the treatment of resistant infectious keratitis.

Update on the management of fungal keratitis

PURPOSE

The aim of this article is to introduce the recent advance on the studies of fungal keratitis published over past 5 years.

METHODS

We performed literature review of articles published on PubMed, Google Scholar, CNKI and Web of Science relevant to the diagnosis, pathogenesis and novel treatment of fungal keratitis.

RESULTS

Excessive inflammation can lead to stromal damage and corneal opacification, hence the research on immune mechanism provides many potential therapeutic targets for fungal keratitis. Many researchers discussed the importance of earlier definitive diagnosis and were trying to find rapid and accurate diagnostic methods of pathogens. Develop new drug delivery systems and new routes of administration with better corneal penetration, prolonged ocular residence time, and better mucoadhesive properties is also one of the research hotspots. Additionally, many novel therapeutic agents and methods have been gradually applied in clinical ophthalmology.

CONCLUSION

The diagnosis and treatment of fungal keratitis are still a challenge for ophthalmologist, and many researches provide new methods to conquer these problems.

Corneal transplantation and eye banking practices during COVID-19-related lockdown period in India from a network of tertiary eye care centers

Purpose:

The purpose of this study was to discuss the guidelines and modification of practices with respect to corneal transplantation and eye banking during the COVID-19 pandemic lockdown period and beyond, at a network of tertiary care centers in India.

Methods:

Descriptive study of the challenges faced in eye banking during the lockdown, and practices adopted to overcome the critical aspects in the clinical care of patients who presented with emergency corneal diseases requiring keratoplasty.

Results:

Complete lockdown orders from the Indian government, as a strategy to control the Coronavirus pandemic, resulted in drastic reduction of all types of elective corneal transplants and eye banking activities from March 24, 2020 to May 31, 2020. The sudden cessation of eye banking resulted in an acute demand and supply imbalance of fresh donor corneas for transplants during this time. Our network of eye banks addressed this issue by adopting glycerol preservation of donor corneas, which were subsequently utilized for tectonic penetrating keratoplasty. The donor cornea retrieval was resumed in a strategized manner 3 weeks prior to the date of exit of the lockdown, with modified guidelines on donor suitability, screening, retrieval, processing, and harvesting from various sources. A triage of keratoplasty priority was formulated to tide over the post lockdown shortage of corneas. We performed 31 therapeutic keratoplasties during the nationwide lockdown among our network of tertiary eye care centers.

Conclusion:

The study highlights the approach and strategies to manage and tide over an unprecedented crisis situation faced by corneal surgeons in general and, specifically, the eye banking community.

Conjunctival flap surgery in the management of ocular surface disease (Review)

Literature regarding conjunctival flap surgery was reviewed to describe and discuss the rationale for this type of procedure. The conjunctival flap is an acknowledged surgery for the treatment of various corneal diseases with a chronically compromised ocular surface, such as severe dry eye, neurotrophic or neuroparalytic disease, or bullous keratopathy. The purpose of this surgery is to restore the integrity of the corneal surface and thus to prevent gradual corneal ulceration and secondary infection, as well as to ameliorate pain, reduce the need for frequent medications, improve cosmetic appearance, and offer an alternative to invasive surgery or enucleation. Since the introduction of more effective methods of treating severe ocular surface diseases, conjunctival flap surgery has rarely been the primary modality of treatment and has usually followed a range of medical and surgical treatments. The availability of improved ocular lubricants, more effective antimicrobials, bandage contact lenses, tissue adhesives, and other corneal and conjunctival surgical interventions, has reduced the need for conjunctival flaps. However, conjunctival flaps remain extremely useful in selected cases and deserve a place in the ophthalmologist's repertoire for the management of ocular surface disease.

Use of autologous fascia lata graft to repair a complex corneal ulcer in a mare

Background

Application of an autogenous fascia lata graft in the treatment of keratomalacia in the horse has not been reported. The present case describes the use of an autologous fascia lata graft to surgically treat a complicated corneal ulcer in a horse.

Case presentation

A 12-year-old Arabian mare was admitted to Sharjah Equine Hospital with a history of right eye ulcerative keratitis of unknown duration. Following a week of aggressive medical treatment, the condition deteriorated and a keratectomy and pedicle conjunctival graft were performed. A week later, the conjunctival graft partially dehisced and the ulcer continued to degrade.

In attempting to preserve the integrity of the globe a second grafting procedure was performed when a segment of fascia lata harvested from the ipsilateral hind leg was grafted onto the corneal lesion.

Response to surgery was positive and the mare was discharged from the hospital on Day 31 post diagnosis (17 days after the second surgery) with a comfortable eye.

Follow-up12 months later revealed a comfortable but only partially visual eye due to corneal scarring.

Conclusion

Although the graft actually failed from the point of view of tissue integration, fascia lata appears to be a readily available, effective and affordable autografting material and we believe this technique has potential for short term physical and structural support of severe malacic or other complex corneal ulcers.