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

Zhong,Jing; Wang,Bowen; Li,Saiqun; Deng,Yuqing; Huang,Haixiang; Chen,Ling; Yuan,Jin

doi:10.3892/etm.2018.5765

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

Authors:
- Jing Zhong
- Bowen Wang
- Saiqun Li
- Yuqing Deng
- Haixiang Huang
- Ling Chen
- Jin Yuan
View Affiliations

Affiliations: State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat‑Sen University, Guangzhou, Guangdong 510060, P.R. China
Published online on: January 17, 2018 https://doi.org/10.3892/etm.2018.5765
Pages: 2711-2718
Copyright: © Zhong et al. This is an open access article distributed under the terms of Creative Commons Attribution License.

Metrics: Total Views: 0 (Spandidos Publications: | PMC Statistics: )

Metrics: Total PDF Downloads: 0 (Spandidos Publications: | PMC Statistics: )

Cited By (CrossRef): 0 citations Loading Articles...

Abstract

Fungal keratitis is a severe and common ocular infectious disease. The present study evaluated the efficiency of full‑thickness conjunctival flap covering surgery with amniotic membrane transplantation (FCCS + AMT) as a transitional surgery for severe fungal keratitis. A total of 17 patients with severe fungal keratitis without corneal perforation underwent FCCS + AMT between January 2010 and December 2015. The pathogenic factors, preoperative diagnosis and postoperative prognosis of FCCS + AMT at 3 months were evaluated. Subsequently, 7 patients received sclerokeratoplasty, and the best‑corrected visual acuity (BCVA) and recurrence ratio were analyzed at 1 month postoperatively. The primary risk factor was agricultural trauma (7 cases), followed by a non‑agricultural object entering the eye (3 cases). Preoperatively, there were 10 cases of fungal keratitis positively identified using confocal microscopy and 9 cases positively identified by corneal scrapings. A total of 3 months following FCCS + AMT, the percentage of cases resulting in preservation of the eyeball was 88.24%, with 15/17 patients demonstrating complete conjunctival re‑epithelization and a smooth conjunctival surface without any complications. A total of 2 (11.76%) patients experienced melting of the conjunctival flap and development of endophthalmitis, and subsequently underwent ocular evisceration surgery. A total of 7 patients underwent sclerokeratoplasty and the mean logarithm of the minimum angle of resolution BCVA at 1 month was significantly improved (0.689±0.121; P<0.001) compared with preoperative values (2.459±0.037) and BCVA values following FCCS + AMT (2.529±0.066). No recurrence was observed in any of the cases during the follow‑up period. Conclusively, FCCS + AMT may be a preferable treatment for severe fungal keratitis of the entire corneal ulcer without perforation, and may save the eyeball and provide a greater opportunity for corneal transplantation.

View Figures

View References

1	Cao J, Yang Y, Yang W, Wu R, Xiao X, Yuan J, Xing Y and Tan X: Prevalence of infectious keratitis in Central China. BMC Ophthalmol. 14:432014. View Article : Google Scholar : PubMed/NCBI
2	Xie L, Zhong W, Shi W and Sun S: Spectrum of fungal keratitis in north China. Ophthalmology. 113:1943–1948. 2006. View Article : Google Scholar : PubMed/NCBI
3	Thomas PA: Fungal infections of the cornea. Eye (Lond). 17:852–862. 2003. View Article : Google Scholar : PubMed/NCBI
4	FlorCruz NV and Evans JR: Medical interventions for fungal keratitis. Cochrane Database Syst Rev. 4:CD0042412015.
5	Prajna NV, Krishnan T, Mascarenhas J, Rajaraman R, Prajna L, Srinivasan M, Raghavan A, Oldenburg CE, Ray KJ, Zegans ME, et al: The mycotic ulcer treatment trial: a randomized trial comparing natamycin vs voriconazole. JAMA Ophthalmol. 131:422–429. 2013. View Article : Google Scholar : PubMed/NCBI
6	Prajna NV, Mascarenhas J, Krishnan T, Reddy PR, Prajna L, Srinivasan M, Vaitilingam CM, Hong KC, Lee SM, McLeod SD, et al: Comparison of natamycin and voriconazole for the treatment of fungal keratitis. Arch Ophthalmol. 128:672–678. 2010. View Article : Google Scholar : PubMed/NCBI
7	Prajna NV, Krishnan T, Mascarenhas J, Srinivasan M, Oldenburg CE, Toutain-Kidd CM, Sy A, McLeod SD, Zegans ME, Acharya NR, et al: Predictors of outcome in fungal keratitis. Eye (Lond). 26:1226–1231. 2012. View Article : Google Scholar : PubMed/NCBI
8	Li LM, Zhao LQ, Qu LH and Li P: Excimer laser phototherapeutic keratectomy for the treatment of clinically presumed fungal keratitis. J Ophthalmol. 2014:9632872014. View Article : Google Scholar : PubMed/NCBI
9	Henry CR, Flynn HW Jr, Miller D, Schefler AC, Forster RK and Alfonso EC: Delayed-onset endophthalmitis associated with corneal suture infections. J Ophthalmic Inflamm Infect. 3:512013. View Article : Google Scholar : PubMed/NCBI
10	Jiaxu Hong, Weiyun Shi, Zuguo Liu, Roberto Pineda, Xinhan Cui, Xinghuai Sun and Jianjiang Xu: Limitations of Keratoplasty in China: A Survey Analysis. PLoS One. 10:e01322682015. View Article : Google Scholar : PubMed/NCBI
11	Shang X and Zhang M: Body and organ donation in Wuhan, China. Lancet. 376:1033–1034. 2010. View Article : Google Scholar : PubMed/NCBI
12	Sharma A, Mohan K, Sharma R and Nirankari VS: Repositioning of pedicle conjunctival flap performed for refractory corneal ulcer. Middle East Afr J Ophthalmol. 21:89–91. 2014. View Article : Google Scholar : PubMed/NCBI
13	Gundersen T: Conjunctival flaps in the treatment of corneal disease with reference to a new technique of application. AMA Arch Ophthalmol. 60:880–888. 1958. View Article : Google Scholar : PubMed/NCBI
14	Gao H, Jia Y, Li S, Wang T, Tan Y and Shi W: Conjunctival flap covering combined with antiviral and steroid therapy for severe herpes simplex virus necrotizing stromal keratitis. Scientific World Journal. 2015:5659642015. View Article : Google Scholar : PubMed/NCBI
15	Yang X, Zhou Q and Du S: Conjunctival flap covering in the treatment of corneal blood staining. Can J Ophthalmol. 46:442–443. 2011. View Article : Google Scholar : PubMed/NCBI
16	Ding J, Chen T, Hou Z, Qin Y, Hao L and Li D: Cosmetic shell fitting over a sensitive cornea in mild phthisis bulbi using total conjunctival flap. Aesthetic Plast Surg. 37:398–401. 2013. View Article : Google Scholar : PubMed/NCBI
17	Yazici B: Use of conjunctiva-Muller muscle pedicle flap in surgical treatment of necrotizing scleritis. Ophthal Plast Reconstr Surg. 24:19–23. 2008. View Article : Google Scholar : PubMed/NCBI
18	Sun GH, Li SX, Gao H, Zhang WB, Zhang MA and Shi WY: Clinical observation of removal of the necrotic corneal tissue combined with conjunctival flap covering surgery under the guidance of the AS-OCT in treatment of fungal keratitis. Int J Ophthalmol. 5:88–91. 2012.PubMed/NCBI
19	Erie JC, McLaren JW and Patel SV: Confocal microscopy in ophthalmology. Am J Ophthalmol. 148:639–646. 2009. View Article : Google Scholar : PubMed/NCBI
20	Cruciani F, Cuozzo G, Di Pillo S and Cavallaro M: Predisposing factors, clinical and microbiological aspects of bacterial keratitis: A clinical study. Clin Ter. 160:207–210. 2009.PubMed/NCBI
21	Kim JC and Tseng SC: Transplantation of preserved human amniotic membrane for surface reconstruction in severely damaged rabbit corneas. Cornea. 14:473–484. 1995. View Article : Google Scholar : PubMed/NCBI
22	Gopinathan U, Garg P, Fernandes M, Sharma S, Athmanathan S and Rao GN: The epidemiological features and laboratory results of fungal keratitis: A 10-year review at a referral eye care center in South India. Cornea. 21:555–559. 2002. View Article : Google Scholar : PubMed/NCBI
23	Baum J, Chaturvedi N, Netland PA and Dreyer EB: Assessment of intraocular pressure by palpation. Am J Ophthalmol. 119:650–651. 1995. View Article : Google Scholar : PubMed/NCBI
24	The ischemic optic neuropathy decompression trial (IONDT), . design and methods. Control Clin Trials. 19:276–296. 1998.PubMed/NCBI
25	Arbelaez JG, Feng MT, Pena TJ, Price MO and Price FW Jr: A year of cornea in review: 2013. Asia Pac J Ophthalmol (Phila). 4:40–50. 2015. View Article : Google Scholar : PubMed/NCBI
26	Avunduk AM, Beuerman RW, Varnell ED and Kaufman HE: Confocal microscopy of Aspergillus fumigatus keratitis. Br J Ophthalmol. 87:409–410. 2003. View Article : Google Scholar : PubMed/NCBI
27	Eguchi H, Toibana T, Hotta F, Miyamoto T, Mitamura Y and Yaguchi T: Severe fungal sclerokeratitis caused by Metarhizium anisopliae: A case report and literature review. Mycoses. 58:88–92. 2015. View Article : Google Scholar : PubMed/NCBI
28	Anane S, Ben Ayed N, Malek I, Chebbi A, Lejri S, Bouguila H, Kaouech E, Belhadj S, Kallel K, Ayed S and Chaker E: Keratomycosis in the area of Tunis: epidemiological data, diagnostic and therapeutic modalities. Ann Biol Clin (Paris). 68:441–447. 2010.(In French). PubMed/NCBI
29	Yao YF, Zhang YM, Zhou P, Zhang B, Qiu WY and Tseng SC: Therapeutic penetrating keratoplasty in severe fungal keratitis using cryopreserved donor corneas. Br J Ophthalmol. 87:543–547. 2003. View Article : Google Scholar : PubMed/NCBI
30	Golchet G, Carr J and Harris MG: Why don't we have enough cornea donors? A literature review and survey. Optometry. 71:318–328. 2000.PubMed/NCBI
31	Ozbek Z, Burakgazi AZ and Rapuano CJ: Rapid healing of vernal shield ulcer after surgical debridement: A case report. Cornea. 25:472–473. 2006. View Article : Google Scholar : PubMed/NCBI
32	Liu J, Sheha H, Fu Y, Liang L and Tseng SC: Update on amniotic membrane transplantation. Expert Rev Ophthalmol. 5:645–661. 2010. View Article : Google Scholar : PubMed/NCBI
33	Abdulhalim BE, Wagih MM, Gad AA, Boghdadi G and Nagy RR: Amniotic membrane graft to conjunctival flap in treatment of non-viral resistant infectious keratitis: a randomised clinical study. Br J Ophthalmol. 99:59–63. 2015. View Article : Google Scholar : PubMed/NCBI
34	Alino AM, Perry HD, Kanellopoulos AJ, Donnenfeld ED and Rahn EK: Conjunctival flaps. Ophthalmology. 105:1120–1123. 1998. View Article : Google Scholar : PubMed/NCBI
35	Khodadoust A and Quinter AP: Microsurgical approach to the conjunctival flap. Arch Ophthalmol. 121:1189–1193. 2003. View Article : Google Scholar : PubMed/NCBI
36	Zhou Q, Long X and Zhu X: Improved conjunctival transplantation for corneal ulcer. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 35:814–818. 2010.PubMed/NCBI