| BackgroundFungal Keratitis is a suppurative, ulcerative and sight-threatening infection of the cornea that sometimes leads to severe damage of the eye and blindness if not diagnosed and treated effectively on time. Currently available topical antifungal drugs have limitations such as poor penetration into the eye, limited spectrum of activity and surface toxicity. Thus, ophthalmologists resort to surgical intervention when medical treatment has failed. The best choice of treatment for refractory corneal ulcers is keratoplasty. Unfortunately the shortage of corneal donations in China has made Conjunctival Flap surgery an alternative and most commonly used treatment for refractory Fungal Keratitis. Selective, pedunculated, partial flap is one of the most widely used techniques.The main goals of such surgery are to control the infection and maintain the integrity of the globe. As a matter of fact, Conjuctival Flap acts as a biological patch having tropic, protective and analgesic effect. This microsurgical technique is about using a selective, partial, pedunculated(tongue-shaped), conjunctival flap to cover only the diseased part of the cornea instead of covering the entire cornea.ObjectiveThe main objective of our study is to describe the use of a selective,pedunculated(tongue-shaped), partial Conjunctival Flap for treatment of refractory Fungal Keratitis with or without perforation, to examine its effectiveness and to present some cases with detailed medical information regarding diagnosis, surgical treatment and treatment outcome.DesignWe did a non-comparative, retrospective study of case series.Materials and methodsWe did a non-comparative, retrospective study of cases recruited from Department I of Ophthalmology at the First Hospital of Jilin University in Changchun city, China. We analyzed all the cases that had undergone conjunctival flap surgery for treatment of corneal diseases from April 2014 to October 2015 and we found 31 cases in total. Then, we selected only those diagnosed with fungal keratitis for our study.Only 16 were diagnosed with fungal keratitis. We also chose some cases of them to present in detail.Since sometimes clinical features and laboratory results of scraped contents from the corneal ulcers were not always conclusive, the golden standard diagnosis of fungal keratitis was essentially confirmed based on IVCM findings. Conjunctival flap was performed on the ulcerated cornea in order to control the infection and preserve the eyeball if medical treatment has failed. In all our patients, the surgeon was using a selective pedunculated(tongue- shaped) flap to cover only the ulcerated part of cornea instead of covering the whole cornea. This method provides an alternative method to Gunderson’s flaps to avoid complications associated to his technique. We always choose the segment nearest to the corneal lesion and with best blood supply. After the conjunctival segment is set on the diseased area of the cornea, it is then secured by interrupted sutures using 10-0 monofilament nylon.Statistical analysis was evaluated using Chi-Square test, Mann-Whitney, simple and multiple logistic regression analyses wherever suitable with p< 0.05 considered significant. SPSS 18.0 software was used for the statistical analyses.ResultsA total of 16 patients were diagnosed with Fungal Keratitis and Conjunctival Flap surgery was performed on them. Among the 16 patients, there are 11 Males, 5females. We found out that numerically there were more male patients(68.8%) than female patients(31.2%) but statistically, no statistic difference in distribution of Fungal Keratitis between males and females( Mann-Whitney value=14.5, p=0.141).The age distribution is as follows: 1 case’s age is under 40, 5 cases between 41-60, 8cases between 61-80, and 2 cases over 80. The age group 61-80 was found to have the largest number of patients with a percentage of 50.1. Our results also revealed that there is no statistically significant difference in the distribution of our study patients by age, sex and age groups: P-values= 0.141, 0.134 and 0.058, respectively. Among our study patients, 4 presented with Fungal Keratitis associated with perforation before surgery. Thirteen(11) had Conjunctival Flap combined with corneal ulcer debridement only and 3 had Conjunctival flap combined with both corneal ulcer debridement and anterior chamber lavage among them one had eyeball removal. 0ut of our 16 cases, 3 had post-operation complications-one patient had corneal perforation resorting to corneal transplant, another had uncontrolled spreading of purulent exudates(hypopion) beyond the anterior chamber that led to eyeball removal as final resort 10 days after Conjunctival flap, and the other had hypopion in anterior chamber resolved by anterior chamber lavage and another conjunctival flap. The other13 patients recovered well.We also carried out both simple and multiple logistic regression analyses to ascertain factors that influence the possible occurrence of complications and our results showed that age, sex, diagnosis, operation time and combined surgeries are not statistically associated with the possibility of complications(all P-values > 0.05).ConclusionAlthough keratoplasty is one of the best choices of treatment of fungal keratitis with or without perforation whenever medical treatment had failed, conjunctival Flap surgery has proven to be a very useful alternative treatment in case corneal transplant is not feasible immediately. This is the case in china where there is lack of cornea donations. In this study, the outcome was good in all the patients except for one patient whose severity of the infection required eyeball removal. The surgeries performed on our study participants helped to control the infection or to preserve the eyeball for possible future corneal transplant. |
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