Treatment of symptomatic bullous keratopathy with poor visual prognosis using a modified Gundersen conjunctival flap and amniotic membrane

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Treatment of symptomatic bullous keratopathy with
poor visual prognosis using a modified Gundersen
conjunctival flap and amniotic membrane

• Jose L. Güell MD
• Merce Morral MD
• Oscar Gris MD
• Instituto Microcirugia Ocular
• Barcelona, Spain
• The authors have no financial interest in the
  subject matter of this poster

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Purpose

• To describe the use of a modified Gundersen
  conjunctival flap combined with amniotic membrane
  (AM) graft implantation to treat symptomatic
  bullous keratopathy (BK) in 5 eyes of 5 patients
  with poor visual prognosis.

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Methods Surgical technique (video file attached)
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1. 360º conjunctival peritomy 2mm from the limbus
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Methods Surgical technique
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2. Deepithelialization of the decompensated
cornea preserving, if healthy, the limbal
conjunctiva where the stem cell niches are located
3. Graft of AM sutured epithelial side up using a
running 10-0 nylon suture at the periphery of the
cornea with the knot buried in the corneal
stroma. Attach the edges of the AM and the
border of the peritomized conjunctiva using
single 9/0 vycril sutures. The conjunctival
border should lie over the AM. The AM graft
covers the whole decompensated cornea and
provides a basement membrane for conjunctival
cells to grow on. Epithelialization occurs over
the AM, which remains trapped until reabsortion
is completed (Observe the section figure).
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Methods

• Bandage contact lens
• Topical steroids and antibiotics qid for three
  weeks, and tapered until complete reabsortion of
  the AM.
• Outcome measures
• Resolution of the pain
• Presence of ocular surface inflammation
• Reinterventions

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Results

• 5/5 (100) eyes - Immediate resolution of the
  pain and minimal postoperative inflammation.
• 5/5 (100) eyes - Epithelialization occurred over
  the AM.
• 1/5 (20) eye - The AM was reabsorbed before
  complete conjunctival epithelialization.
  Conjunctival reepithelialization over the central
  cornea was delayed.
• No reinterventions required.
• All the eyes asymptomatic for at least 16 months.
  

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Case report
Recurrent epithelial defects in a patient with
post penetrating keratoplasty BK. Modified
Gundersen conjunctival flap with amniotic
membrane grafting was performed.
Twelve months postoperatively, conjunctival
vascular epithelium covers the cornea completely,
providing sustained relief of the symptoms
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Conclusion

• The combination of a modified Gundersen
  conjunctival flap and a graft of amniotic
  membrane provided sustained relief of symptomatic
  bullous keratopathy
• It is essential to implant the AM as a graft. The
  AM as a patch has only a temporary effect on
  relieving the pain
• With this technique, conjunctival manipulation
  and anatomical distortion are significantly
  reduced
• The conjunctiva is not pulled over the cornea
  Therefore, the fundus of the conjunctival sac
  is not shortened
• The conjunctival peritomy is circular and the
  conjunctiva is not pulled Therefore, there is
  no distortion of the interpalpebral bulbar
  conjunctiva