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Conjunctival Flap


The conjunctival flap procedure covers an unstable or painful corneal surface with a hinged flap
of more durable conjunctiva. Conjunctival flap surgery is performed less frequently now than in
the past because of broadened indications for penetrating keratoplasty (PK) (see Chapters 10
and 15), more effective antimicrobial agents, availability of bandage contact lenses, and
improved management of corneal inflammatory diseases. Nevertheless, this procedure
remains an effective method for managing inflammatory and structural corneal disorders when
restoration of vision is not an immediate concern. It should not be used for active microbial
keratitis or corneal perforation, because residual infectious organisms may proliferate under a
flap if an ulcer is not sterilized first. Any corneal perforation must first be sealed, or it will
continue to leak under the flap. The procedure is not meant to provide tectonic support to a very
thin cornea. The principal indications for this procedure are

chronic sterile epithelial and stromal ulcerations (stromal herpes simplex virus
keratitis, chemical and thermal burns, keratoconjunctivitis sicca, postinfectious
ulcers, neurotrophic keratopathy)
closed but unstable corneal wounds

painful bullous keratopathy in a patient who is not a good candidate

for PK a phthisical eye being prepared for a prosthetic shell

A reduced view of the anterior chamber and the creation of a potential barrier against drug
penetration are among the disadvantages of conjunctival flap surgery. However, a successful
conjunctival graft, free of buttonholes, will thin out and enable functional vision.

Surgical technique

A complete (Gundersen) flap (Fig 14-3) is highly successful if attention is paid to several
fundamental principles:

complete removal of the corneal epithelium and debridement of necrotic

tissue reinforcement of thin areas with corneal or scleral tissue

creation of a mobile, thin conjunctival flap that contains minimal Tenon

capsule absence of any conjunctival buttonholes
absence of any traction on the flap at its margins that may lead to flap retraction
Figure 14-3 Surgical steps for the Gundersen conjunctival flap. A, Removal of the corneal epithelium using cellulose sponges. B,
A 360 peritomy with relaxing incisions, placement of superior limbal traction suture, superior forniceal incision, and dissection of
a thin flap. C, Positioning of flap. D, Suturing of flap into position with multiple interrupted sutures.
(Reproduced by permission from Mannis MJ. Conjunctival flaps. Int Ophthalmol Clin. 1988;28(2):165168.)

Retrobulbar, peribulbar, or general anesthesia may be used. The corneal epithelium and all
necrotic tissue are removed, and the eye is retracted inferiorly with an intracorneal traction suture (6-0
silk) at the superior limbus. Elevation of the flap with subconjunctival injection of lidocaine 1%2%
with epinephrine enhances anesthesia, facilitates dissection, and reduces bleeding. The
needle for this injection should not pierce the conjunctiva in the area to be used for the flap.

The dissection may start from either the limbus or the superior fornix. Dissection of
conjunctiva from underlying Tenon fascia must be performed carefully under direct visualization
to prevent conjunctival perforation, especially in eyes with previous conjunctival surgery. Once
the flap has been dissected, a 360 peritomy is performed with relaxing incisions, followed by
scraping of all remaining limbal and corneal epithelium. Additional undermining of the flap
allows it to cover the entire cornea and to rest there without traction. Any residual tension may
foster later retraction of the flap. After the flap is positioned over the prepared cornea, it is
sutured to the sclera just posterior to the limbus superiorly and inferiorly with 8-0 polyglycolic
acid suture or 10-0 nylon suture, depending on surgeon preference.

A partial, or bridge, flap may be used for temporary coverage of a peripheral

Partial conjunctival flap
wound or area of ulceration. Retraction is common despite adequate relaxation of the base. The
flap should be well undermined to relieve tension and decrease the chance of retraction. The flaps
are fixated to the cornea with nonabsorbable suture (9-0 or 10-0 nylon).

Bipedicle flapThis partial, or bucket handle, flap can be used for small central or paracentral corneal
lesions that do not require complete corneal coverage. It can be useful in a cornea with inferior
exposure. The advantage is that the view of the anterior chamber and the remaining uninvolved
cornea is not obstructed. The flap is fashioned similar to the Gundersen flap but with only enough
dissection required to cover the lesion, plus a small margin (the width of the flap should be 1.31.5
times the width of the lesion). Subconjunctival anesthesia is administered, and the epithelium beneath
the site of the flap is removed. After marking the bulbar conjunctiva with methylene blue, the surgeon
can create the flap and move it into position for suturing with interrupted nylon suture.

Advancement flap Peripheral limbal or paralimbal corneal lesions can be covered with a simple
advancement conjunctival flap. A limbal incision is created with relaxing components, and the
conjunctiva is simply advanced onto the cornea to cover the defect. Scleral patch grafts and onlay
grafts may also be used in conjunction with this technique. The disadvantage of this type of flap is
a tendency to retract with time.

Single-pedicle flapAlso known as a racquet flap, a single-pedicle flap can be used for peripheral
corneal lesions that are not large enough to require a total flap. Although a single-pedicle flap is
more difficult to dissect than an advancement flap, it is less likely to retract.


Retraction of the flap is the most common complication, occurring in approximately 10% of
cases. Other complications include hemorrhage beneath the flap and epithelial cysts. In some
cases, inclusion cysts enlarge to the point of requiring excision or marsupialization. Ptosis,
usually due to levator dehiscence, may also occur postoperatively. Unsatisfactory cosmetic
appearance can be improved with a painted contact lens. Progressive corneal disease under
the flap is a concern with infectious and autoimmune conditions.

Considerations in removal of the flap

If PK is to be performed in an eye with a conjunctival flap, the flap may be removed as a separate
procedure or at the time of PK. Simple removal of the flap (without keratoplasty) is usually
unsatisfactory in restoring vision, as the underlying cornea is almost always scarred and/or thinned.
Because the conjunctival flap procedure tends to destroy or displace most limbal stem cells, a limbal
autograft or allograft after removal of the flap may be necessary to provide a permanent source
of normal epithelium before an optical corneal transplant.
Management of Descemetocele, Corneal Perforation, and Corneal Edema

Bandage contact lens

Applying a thin, continuous-wear soft contact lens as a therapeutic bandage can protect loosely
adherent remaining or regenerating epithelium from the windshield wiper action of the blinking
eyelids. Use of bandage contact lenses has significantly improved and simplified the management of
recurrent erosions and persistent epithelial defects. Continuous bandaging can reduce stromal
leukocyte infiltration and promote the regeneration of basement membrane and restoration of tight
epithelialstromal adhesion without compromising the patients vision and comfort.

The choice of a soft contact lens for patients with severe dry eye can be difficult. In general, patients
with dry eye run a high risk of infection with soft contact lenses; punctal occlusion can facilitate lens
retention and comfort. High-water-content lenses usually are not appropriate because rapid water
evaporation further compounds the hypertonicity-induced surface damage in dry eyes. Low-water-content
lenses with high oxygen transmissibility (eg, HEMA-silicone polymer) would be the most appropriate
choice in this setting. Lenses should be replaced every 24 weeks or as deposits accumulate on the lens.
Frequent lubrication, prophylaxis with antibiotics, and close follow-up are crucial, especially in patients
with decreased corneal sensitivity or dry eye. The use of an acrylic scleral lens may circumvent
the problems encountered with a hydrogel lens.

Even though a hydrogel lens can actually cause corneal hypoxia and increase corneal edema,
continuous wear of this type of lens can provide symptomatic relief of painful bullous or filamentary
keratopathy. Mild corneal edema can often be managed with hypertonic saline solution and judicious
use of topical corticosteroids, if indicated. Long-term use of a bandage contact lens can lead to corneal
pannus and compromise the success of future PK for vision rehabilitation. Tarsorrhaphy should be
considered for patients who have contact lens complications or a high risk of infection.

Cyanoacrylate adhesive

Tissue adhesives, particularly n-butyl cyanoacrylate, have been used widely as an adjunct in
the management of corneal ulceration and perforation. Early application of tissue adhesives in
the management of stromal melting has greatly reduced the need for urgent surgical
interventions such as therapeutic keratoplasty or conjunctival flap. Although cyanoacrylate
tissue adhesives are not approved by the US FDA for use on the eye, they have been employed
extensively over the past 3 decades to seal perforations or near perforations.

Some perforations are small and seal spontaneously before any ophthalmic examination, with no
intraocular damage, prolapse, or adherence. These cases may require only treatment with systemic
and/or topical antibiotic therapy, along with close observation. If a corneal wound is leaking but the
chamber remains formed, leakage can be reduced or stopped with pharmacologic suppression of
aqueous production (topical ocular hypotensive agent or systemic carbonic anhydrase inhibitors),
patching, and/or a bandage contact lens. Generally, if these measures fail to seal the wound in 3 days,
closure with cyanoacrylate glue or sutures is recommended. Perforations greater than 12 mm are
usually not amenable to tissue adhesive and require a corneal patch graft.
Cyanoacrylate tissue adhesive applied to thinned or ulcerated corneal tissue may prevent
further thinning and support the stroma through the period of vascularization and repair. The
adhesive plug is also thought to retard the entry of inflammatory cells and epithelium into the
area, thus decreasing the rate of corneal melting. After the lesion has been sealed, new stromal
tissue may be laid down, and accompanying corneal vascularization may help ensure the
integrity of the area by providing nutrients and antiproteases.

Surgical techniqueTissue adhesive can usually be applied on an outpatient basis using topical
anesthetics. However, if adherent or prolapsed uvea in the leakage site or a flat chamber is
encountered, the procedure should be performed in the operating room using air and/or
viscoelastic substances to re-form the anterior chamber. The adhesive is applied under slit-lamp or
microscopic observation with a topical anesthetic (eg, proparacaine hydrochloride 0.5%). An eyelid
speculum is useful. Before the adhesive is applied, any necrotic tissue and corneal epithelium
should be removed from the involved area and a 2-mm surrounding zone. The area is then dried
with a cellulose sponge, and a small drop of the fluid adhesive is applied with a 30-gauge needle or
a 27-gauge anterior chamber cannula. The glue polymerizes completely within 2060 seconds and
usually adheres well to the deepithelialized surface. A drop of viscoelastic solution speeds
polymerization of the glue and makes its surface smoother.

The glue does not polymerize on plastic, so a simple way to handle it is to spread a small amount on a
surface such as the inside of the sterile plastic wrapping of any medical product cut to a size slightly larger
than the perforation. It should then be applied to the surface of the cornea in as thin a layer as possible
using the plastic handle of a cellulose sponge or the wooden stick of a cotton-tipped applicator. The
adhesive plug has a rough surface and can be irritating, so a bandage contact lens is used to protect the
upper tarsal conjunctiva and to prevent the plug from being dislodged by eyelid blinking. The
use of fibrin sealant, also called fibrin glue, in corneal diseases is currently under investigation.
An alternative to applying cyanoacrylate for a near perforation, not actual perforation, is to
use multiple layers of amniotic membrane that has been cut to the shape of the defect, placing
a patch into the defect where the near perforation is located. This patch may be held in place
with a larger amniotic membrane patch, nylon sutures, and a bandage contact lens, or by
means of fibrin sealant. With time, scar tissue will reinforce the deficient area and may mitigate
against the need for a corneal transplant.

Kim HK, Park HS. Fibrin glueassisted augmented amniotic membrane transplantation for the treatment of large
noninfectious corneal perforations. Cornea. 2009;28(2):170176.

Shaw C, Islam MN, Chakroborty S, et al. Tissue adhesive in ophthalmology. J Indian Med Assoc. 2010;108(7):460461.

Reconstructive lamellar and patch grafts

See Chapter 15 for discussion and illustration of PK and lamellar keratoplasty.

Corneal Tattoo

Indications and options

Corneal tattooing has been used for centuries to improve the cosmetic appearance of a blind
eye with an unsightly leukoma. It has also been used occasionally in seeing eyes to reduce the
glare from scars and to eliminate monocular diplopia in patients with large iridectomies,
traumatic loss of iris, and congenital iris colobomas.
Different techniques have been used to create the tattoo. One involves applying a platinum ion solution
to the cornea. When this solution is reacted with a second agent, a dark black precipitate is formed in the
cornea, producing a dark deposit that can simulate a pupil. A second technique involves utilizing the
standard methods used in skin tattooing: applying to the cornea a paste of colored pigment, either india ink
or a metal oxide, and then using a hypodermic needle or angled blade to drive the pigment into the corneal
stroma in the area that needs coverage. Multiple superficial punctures are made until enough pigment has
been applied; multiple pigment colors can be used to give a more natural appearance. However, the
method is time-consuming and often needs to be repeated if the pigment uptake is inadequate or the
pigment migrates. Femtosecond-assisted anterior lamellar corneal staining-tattooing in the cosmetic
treatment of leukocoria is under investigation.

Kim JH, Lee D, Hahn TW, Choi SK. New surgical strategy for corneal tattooing using a femtosecond laser. Cornea.

Rocher N, Hirst L, Renard G, Doat M, Bourges JL, Mancel E. Corneal tattooing: a series of 14 case studies. J Fr
Ophtalmol. 2008;31(10):968974.


Tarsorrhaphy is the surgical fusion of the upper and lower eyelid margins. It is one of the safest and
most effective procedures for healing difficult-to-treat corneal lesions. Tarsorrhaphy is most commonly
performed to protect the cornea from exposure caused by inadequate eyelid coverage, as may occur
in thyroid eye disease or facial nerve (cranial nerve VII) dysfunctions such as Bell palsy. It can also be
used to aid in the healing of indolent corneal ulceration sometimes seen with tear-film deficiency,
herpes simplex or zoster, stem cell dysfunction, or trigeminal nerve (cranial nerve V) dysfunction
(neurotrophic lesions). Tarsorrhaphies may be temporary (Fig 14-4) or permanent (Fig
14-5). They may be total or partial, depending on whether all or only a portion of the palpebral
fissure is occluded. Tarsorrhaphies are also classified as lateral, medial, or central, according to
the position in the palpebral fissure. BCSC Section 7, Orbit, Eyelids, and Lacrimal System,
discusses eyelid anatomy and surgical procedures in detail. Note that the cosmetic effect of a
lateral tarsorrhaphy is significant, and patients are often unhappy with the appearance afterward.

Figure 14-4 Temporary tarsorrhaphy. A, A thin strip of eyelid margin is shaved over the gray line. B, One or two mattress sutures
(double-armed 4-0 silk) are passed through the upper and lower eyelids to secure the tarsorrhaphy. Sutures are threaded
through bolsters (#40 silicone band) and tied. Each suture end should be placed through skin of the upper eyelid approximately 5
mm above the lash line, traverse the upper tarsal plate, exit through raw surface of the upper eyelid margin, enter through raw
surface of the lower lid margin, traverse the lower tarsal plate, and exit through skin of the lower eyelid

approximately 5 mm from the lash line. (Reproduced with permission from Hersh PS. Ophthalmic Surgical Procedures. 2nd ed. New York: Thieme
Medical Publishers; 2009:253.)

Figure 14-5 Permanent tarsorrhaphy. A, A vertical intermarginal incision (between tarsus and orbicularis muscle) is made
through the gray line of the upper and lower eyelids (using a #11 blade); care should be taken not to incise into the tarsal plate. B,
View of the tarsus of the upper and lower eyelids. C, A double-armed mattress suture (6-0 polyglycolic acid) is then passed
through the lower and upper tarsal plates, with the sutures 45 mm from each other and 3 mm from the edge in a lamellar fashion.
The suture should not be placed through the full thickness of the tarsal plate, because doing so could abrade the cornea. D, The
suture is tied. E, A double-armed mattress suture (4-0 silk) is brought through the back of the lower eyelid and passed through the
upper lid skin, with each suture end threaded through bolsters. F, The suture is tied, with care taken to
ensure proper positioning of the lashes. (Courtesy of Francisco Irochima, MD, and Denise de Freitas, MD.)
Postoperative care

Antibiotic ointment is usually applied to the wound twice a day for

the first 5 days after the procedure. If anterior lamellar sutures are
used over a pledget, ointment is applied until the sutures are
removed 2 weeks later. Ointment containing corticosteroids should
be avoided, because corticosteroids may interfere with rapid

A temporary tarsorrhaphy can be released under local anesthesia.

A muscle hook is placed under the tissue, and a blade is used to incise
the tarsorrhaphy adhesion parallel to the upper and lower eyelid
margins. Iris scissors can also be used to cut along the margin. If the
status of the corneal exposure is uncertain, the tarsorrhaphy can be
opened in stages, a few millimeters at a time. If the tarsorrhaphy has
been performed properly, eyelid margin deformity will be minimal.

Alternatives to tarsorrhaphy

Injection of onabotulinumtoxinA into the levator palpebrae muscle, to

paralyze its function, can cause pharmacologic ptosis and provide a
temporary protective effect. Applying cyanoacrylate tissue adhesive
(discussed earlier in this chapter) to the eyelid margins may also provide
temporary closure of the eyelids. Plastic eyelid splints may be placed on the
upper eyelid to cause complete closure. If kept dry, these splints may last
for a week or more. Tape may also be used for this purpose, but tape rarely
lasts for more than 24 hours. As a temporary measure, moisture chambers
may be used to protect the ocular surface. These are available
commercially or may be constructed with plastic wrap.