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Yale University Postgraduate Program
SOCIETY PROCEEDINGS EDITED
B Y
DON^
YALE UNIVERSITY P O S T G R A D U A T E PROGRAM January 13, 1961 DR.
R. M. F A S A N E L L A ,
C O N J U N C T I V A L
F L A P S
I N
presiding
C O R N E A L
DISEASES
DR. TRYGVE G U N D E R S E N , Boston, gave a brief history of the development of conjunctival flaps, citing their usefulness in lacerating wounds, ulcers and in trachoma. Although their mode of action is still not fully understood, the dramatic beneficial effect which often follows is thought to be due to several causes. The tears are excluded from the ulcer and corneal edema is reduced. The pain and epiphora reflex is interrupted. Nutrition to the ulcer is probably enhanced. A relatively anaerobic atmosphere surrounds an herpetic infection which may inhibit or stop proliferation of the virus. A peritomy is in fact done. The history of peritomy was traced back to Antonio Scarpa (1801).
Personal experiences with the use of conjunctival flaps were illustrated by serial colored slides of a dozen patients. These included a series of herpetic infections, illustrating the various phases of herpetic keratitis. Included in these were stromal herpes with and without ulceration, fascicular keratitis following herpes and the neuroparalytic phase of herpes corneae. Several cases showed hypopyon which was interpreted as an indication of herpetic iridocyclitis rather than secondary infection. The use of complete conjunctival covering over blind, painful eyes was demonstrated. Frequently this is best combined with lamellar keratectomy. Traumatic relapsing keratitis which defies any other form of treatment has been successfully treated by a semipermanent conjunctival covering. T w o patients were shown whose most obstinate disease subsided after the cornea was covered for three to six months. Another patient was shown whose
D
J.
LYLE,
M.D.
uniocular filamentary keratitis had incapacitated him for two and one-half years. H i s cornea was completely covered with conjunctiva and, after three months, the pupillary space was uncovered to give him comfortable binocular vision. The use of complete conjunctival flaps alone or combined with peripheral lamellar keratectomy was then described—as used for bullous keratopathy. This seems to be a useful procedure for selected cases where all other forms of treatment have failed. Surgical techniques of these operations were then illustrated, and discussed in detail. A differentiation was made between the method of applying a thin complete permanent or semipermanent conjunctival covering from the upper bulbar conjunctiva and the method of applying a partial covering full-thickness flap from the adjacent conjunctiva. Discussion. D R . F A S A N E L L A : Each case is different. In herpetic lesions a lamellar graft may end up as a penetrating keratoplasty and a penetrating graft may end up as a failure because of one suture in poor tissue. When would you use a lamellar keratoplasty and when a flap? DR. GUNDERSEN: The amount of corneal necrosis is often the deciding factor. A flap is more conservative and can be used as preparation for a lamellar graft. Frequently, however, the decision is difficult to make. If the central cornea is relatively clear and free from much infiltration it is better to do a flap. D R . F A S A N E L L A : When can the lids be sutured rather than use a flap ? DR. GUNDERSEN: I haven't seen many tarsorrhaphies used in herpes corneae. Sometimes tarsorrhaphy is used in neuroparalytic keratitis but in my experience a total thin conjunctival flap seems much better. One point is important to bring out. I don't think herpes virus thrives under a conjunctival
1150
SOCIETY
PROCEEDINGS
flap. I've never seen dendritic keratitis under D R . F A S A N E L L A : I've done these and have a conjunctival flap. gotten good results. I've seen grafts taken D R . R A Y M O N D : D O you use toxoid in refrom below rather than from above. Would lapsing erosion of the cornea ? you comment on this ? D R . G U N D E R S E N : I've used histamine deD R . G U N D E R S E N : Y O U get more conjuncsensitization in relapsing erosion with some tiva from above. good results. D R . L O V E K I N : I S the cornea still irregular DR. TROUBALOS: Is trauma or diet in- under the flap after you remove it ? volved in herpes ? D R . G U N D E R S E N : Sometimes, when there is either much loss of substance or increased D R . G U N D E R S E N : There is no relation as far as I know. Eighty percent of us have had substance, such as hyaline. Time tends to herpes simplex and are carriers. smooth out the cornea. D R . T A Y L O R : Have you ever cured bulD R . T A Y L O R : When you know herpes is present in the stroma, well localized and lous keratopathy with this? quiet, can you do penetrating keratoplasty ? D R . G U N D E R S E N : None get perfect vision after this, although I have had a few very D R . G U N D E R S E N : When it is quiet, y e s ; but in the active stage my results have been good results. I've never seen any cases get poor, especially penetrating keratoplasties. better by leaving them alone. At least this DR. ROSENTHAL: W e have seen cases gives comfort. where fungus followed herpes. In one case you showed, was it checked for fungus? January 27, 1961 D R . G U N D E R S E N : Yes, she did not have a PAROTID DUCT TRANSFER FOR TOTAL fungus infection. XEROPHTHALMIA D R . T A Y L O R : I saw Dr. DeVoe's article in which he described keratoplasty in the acute D R . R O B E R T C H A S E : The procedure of stage. parotid duct transfer for total xerophthalmia has been described by Russian and Chinese D R . G U N D E R S E N : I feel that a conjunctival investigators during the last decade. The first flap is more conservative. report of a successful parotid duct transfer D R . R A Y M O N D : In preoperative preparafor xerophthalmia was that of Filatov, in tion, do you do cultures for bacteria? 1950. In 1955, Lao in a review of the ChiD R . G U N D E R S E N : W e have full-time bacnese literature reported 12 cases of parotid teriologists at the hospital but don't do rouduct transfer and noted that Filatov, et al., tine cultures. W e do check for fungi in sushad reported 80 cases in which the procepicious cases. dure had been done. In none of these reports D R . K A P L A N : How do you do this in limwas there a description of the late follow-up bal degenerative disease? results after parotid duct transfer. StramD R . G U N D E R S E N : I prefer a lamellar type pelli reported on a case of transfer of Stengraft in this type of case. sen's duct to the conjunctival sac in xerophD R . T A Y L O R : When you do a bridge flap and expose Tenon's, do you ever get granula- thalmia with a 10-year follow-up and with a good result. tion ? The procedure first appeared in the AmerDR. GUNDERSEN: If conjunctiva is dissected off Tenon's cleanly and carefully, ican literature when Bennett and Bailey published their papers in 1957. These investigranulation never occurs. gators worked out the technique on dogs and D R . C O R C O R A N : D O you have any experience with the thin mucous membrane graft human cadavers before reporting their case from mouth as Dr. Castroviejo does with his of successful treatment of total xerophthalmia by transplantation of the parotid duct in shaver ? 1957. Ashley, et al., reported three cases of D R . G U N D E R S E N : N O experience.
B Y
DON^
YALE UNIVERSITY P O S T G R A D U A T E PROGRAM January 13, 1961 DR.
R. M. F A S A N E L L A ,
C O N J U N C T I V A L
F L A P S
I N
presiding
C O R N E A L
DISEASES
DR. TRYGVE G U N D E R S E N , Boston, gave a brief history of the development of conjunctival flaps, citing their usefulness in lacerating wounds, ulcers and in trachoma. Although their mode of action is still not fully understood, the dramatic beneficial effect which often follows is thought to be due to several causes. The tears are excluded from the ulcer and corneal edema is reduced. The pain and epiphora reflex is interrupted. Nutrition to the ulcer is probably enhanced. A relatively anaerobic atmosphere surrounds an herpetic infection which may inhibit or stop proliferation of the virus. A peritomy is in fact done. The history of peritomy was traced back to Antonio Scarpa (1801).
Personal experiences with the use of conjunctival flaps were illustrated by serial colored slides of a dozen patients. These included a series of herpetic infections, illustrating the various phases of herpetic keratitis. Included in these were stromal herpes with and without ulceration, fascicular keratitis following herpes and the neuroparalytic phase of herpes corneae. Several cases showed hypopyon which was interpreted as an indication of herpetic iridocyclitis rather than secondary infection. The use of complete conjunctival covering over blind, painful eyes was demonstrated. Frequently this is best combined with lamellar keratectomy. Traumatic relapsing keratitis which defies any other form of treatment has been successfully treated by a semipermanent conjunctival covering. T w o patients were shown whose most obstinate disease subsided after the cornea was covered for three to six months. Another patient was shown whose
D
J.
LYLE,
M.D.
uniocular filamentary keratitis had incapacitated him for two and one-half years. H i s cornea was completely covered with conjunctiva and, after three months, the pupillary space was uncovered to give him comfortable binocular vision. The use of complete conjunctival flaps alone or combined with peripheral lamellar keratectomy was then described—as used for bullous keratopathy. This seems to be a useful procedure for selected cases where all other forms of treatment have failed. Surgical techniques of these operations were then illustrated, and discussed in detail. A differentiation was made between the method of applying a thin complete permanent or semipermanent conjunctival covering from the upper bulbar conjunctiva and the method of applying a partial covering full-thickness flap from the adjacent conjunctiva. Discussion. D R . F A S A N E L L A : Each case is different. In herpetic lesions a lamellar graft may end up as a penetrating keratoplasty and a penetrating graft may end up as a failure because of one suture in poor tissue. When would you use a lamellar keratoplasty and when a flap? DR. GUNDERSEN: The amount of corneal necrosis is often the deciding factor. A flap is more conservative and can be used as preparation for a lamellar graft. Frequently, however, the decision is difficult to make. If the central cornea is relatively clear and free from much infiltration it is better to do a flap. D R . F A S A N E L L A : When can the lids be sutured rather than use a flap ? DR. GUNDERSEN: I haven't seen many tarsorrhaphies used in herpes corneae. Sometimes tarsorrhaphy is used in neuroparalytic keratitis but in my experience a total thin conjunctival flap seems much better. One point is important to bring out. I don't think herpes virus thrives under a conjunctival
1150
SOCIETY
PROCEEDINGS
flap. I've never seen dendritic keratitis under D R . F A S A N E L L A : I've done these and have a conjunctival flap. gotten good results. I've seen grafts taken D R . R A Y M O N D : D O you use toxoid in refrom below rather than from above. Would lapsing erosion of the cornea ? you comment on this ? D R . G U N D E R S E N : I've used histamine deD R . G U N D E R S E N : Y O U get more conjuncsensitization in relapsing erosion with some tiva from above. good results. D R . L O V E K I N : I S the cornea still irregular DR. TROUBALOS: Is trauma or diet in- under the flap after you remove it ? volved in herpes ? D R . G U N D E R S E N : Sometimes, when there is either much loss of substance or increased D R . G U N D E R S E N : There is no relation as far as I know. Eighty percent of us have had substance, such as hyaline. Time tends to herpes simplex and are carriers. smooth out the cornea. D R . T A Y L O R : Have you ever cured bulD R . T A Y L O R : When you know herpes is present in the stroma, well localized and lous keratopathy with this? quiet, can you do penetrating keratoplasty ? D R . G U N D E R S E N : None get perfect vision after this, although I have had a few very D R . G U N D E R S E N : When it is quiet, y e s ; but in the active stage my results have been good results. I've never seen any cases get poor, especially penetrating keratoplasties. better by leaving them alone. At least this DR. ROSENTHAL: W e have seen cases gives comfort. where fungus followed herpes. In one case you showed, was it checked for fungus? January 27, 1961 D R . G U N D E R S E N : Yes, she did not have a PAROTID DUCT TRANSFER FOR TOTAL fungus infection. XEROPHTHALMIA D R . T A Y L O R : I saw Dr. DeVoe's article in which he described keratoplasty in the acute D R . R O B E R T C H A S E : The procedure of stage. parotid duct transfer for total xerophthalmia has been described by Russian and Chinese D R . G U N D E R S E N : I feel that a conjunctival investigators during the last decade. The first flap is more conservative. report of a successful parotid duct transfer D R . R A Y M O N D : In preoperative preparafor xerophthalmia was that of Filatov, in tion, do you do cultures for bacteria? 1950. In 1955, Lao in a review of the ChiD R . G U N D E R S E N : W e have full-time bacnese literature reported 12 cases of parotid teriologists at the hospital but don't do rouduct transfer and noted that Filatov, et al., tine cultures. W e do check for fungi in sushad reported 80 cases in which the procepicious cases. dure had been done. In none of these reports D R . K A P L A N : How do you do this in limwas there a description of the late follow-up bal degenerative disease? results after parotid duct transfer. StramD R . G U N D E R S E N : I prefer a lamellar type pelli reported on a case of transfer of Stengraft in this type of case. sen's duct to the conjunctival sac in xerophD R . T A Y L O R : When you do a bridge flap and expose Tenon's, do you ever get granula- thalmia with a 10-year follow-up and with a good result. tion ? The procedure first appeared in the AmerDR. GUNDERSEN: If conjunctiva is dissected off Tenon's cleanly and carefully, ican literature when Bennett and Bailey published their papers in 1957. These investigranulation never occurs. gators worked out the technique on dogs and D R . C O R C O R A N : D O you have any experience with the thin mucous membrane graft human cadavers before reporting their case from mouth as Dr. Castroviejo does with his of successful treatment of total xerophthalmia by transplantation of the parotid duct in shaver ? 1957. Ashley, et al., reported three cases of D R . G U N D E R S E N : N O experience.