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Update on Surgical Management of Corneal Ulceration and Perforation

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Update on Surgical Management of Corneal Ulceration and Perforation Romanian Journal of Ophthalmology, Volume 63, Issue 2, April-June 2019. pp:166-173 GENERAL ARTICLE Update on surgical management of corneal ulceration and perforation Stamate Alina-Cristina* **, Tătaru Călin Petru* ***, Zemba Mihail* **** *Department of Ophthalmology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania **Arena Med Clinic, Bucharest, Romania ***Clinical Hospital of Ophthalmologic Emergencies, Bucharest, Romania ****Department of Ophthalmology, “Dr. Carol Davila” Central Military Emergency University Hospital, Bucharest, Romania Correspondence to: Stamate Alina-Cristina, MD, Arena Med Clinic, Bucharest, 68 Basarabia Boulevard, Ap. 1, District 2, Bucharest, Romania, Mobile phone: +40737 027 067, E-mail: [email protected] Accepted: May 28th, 2019 Abstract Corneal ulcerations are a medical emergency, and in recalcitrant cases, leading to perforation, a surgical ophthalmological emergency. The urgency of the treatment is dictated by the necessity of preventing complications that can lead to serious ocular morbidities. Medical treatment represents the first therapeutic approach and is a defining step in the further management of a patient with corneal ulceration. Multiple surgical strategies are available, but the option depends on the etiology and parameters of the ulceration: size, depth, and location. Keywords: corneal ulceration, corneal perforation, tissue adhesives, cross-linking, amniotic membrane, conjunctival flap, keratoplasty Introduction reepithelialization by using preservative-free lubricants, to prevent or eradicate an infection, Corneal ulcerations are a medical through adequate antimicrobial, antiviral or emergency, and in recalcitrant cases, leading to antifungal therapy, or to reduce inflammation, perforation, a surgical ophthalmological tailored for each specific etiology. emergency. The urgency of the treatment is Medical treatment is crucial in the initial dictated by the necessity of preventing management, and if the corneal ulceration is complications that can lead to serious ocular persistent and unresponsive to medical morbidities. treatment, adequate surgical intervention is Medical treatment represents the first required. The combination of both types of therapeutic approach and is a defining step in treatment ensures a successful outcome. the further management of a patient with Multiple surgical strategies are available, corneal ulceration. but the option depends on the etiology and The main pathologic mechanism of a parameters of the ulceration: size, depth, and corneal ulceration, irrespective of the underlying location. etiology, is a breakdown of the corneal The prevalence of corneal perforations has epithelium. decreased over the last decades due to Starting from this premise, the goal of the improvements in medical management and medical treatment is to promote refinement in the microsurgical technique, 166 Romanian Society of Ophthalmology © 2019 doi:10.22336/rjo.2019.25 Romanian Journal of Ophthalmology 2019; 63(2): 166-173 leading to a better prognosis for corneal 5. Promoting epithelial healing ulceration and a reduction in complications Maintenance of the tear film is important associated with this disorder. for epithelial healing, and this can the ensured through two mechanisms, by increasing the Medical management ocular surface moisture with preservative-free lubricants and by delaying evaporation with An accurate diagnosis and prompt medical punctal or intracanalicular plugs or with thermal treatment increase the chances for a successful cautery of the puncta. surgical outcome. The main principles of the In addition, topical cyclosporine A can be medical management are the following: beneficial in cases of dry eye. Moreover, in cases 1. proper antimicrobials to prevent or with persistent epithelial defects, autologous eradicate an infection: topical and/or systemic serum drops can be applied. antibiotics (e.g. fourth-generation In cases of small corneal perforations or fluoroquinolones), antivirals, and antifungals. self-sealed corneal perforations and progressive Cycloplegia can also be added to minimize corneal melting, hydrophilic contact lenses or inflammation and synechiae and to improve simple patching can be used to promote patient comfort. epithelial healing and reduce patient discomfort 2. Aqueous suppressants to promote [1]. wound healing and reduce pressure that can encourage extrusion of intraocular contents. Surgical management 3. Anti-collagenases Even though clear clinical benefit has not 1. Corneal gluing been evidenced, topical and systemic collagenase Tissue adhesives are effective in the closure inhibitors have been used as an adjunctive of impending corneal perforations or small therapy, such as topical acetylcysteine, oral corneal perforation of up to 3 mm in diameter. doxycycline to inhibit collagenase and vitamin C There are two types of tissue adhesives: to facilitate collagen synthesis. synthetic (cyanoacrylate derivatives) and Additional enzyme inhibitors to target biologic (fibrin glue). Cyanoacrylate derivatives metalloproteinases that contribute to corneal are non-biodegradable and can induce corneal destruction are currently under investigation. inflammation and neovascularization, foreign 4. Anti-inflammatory therapy body sensation and tissue necrosis. Meanwhile, Inflammation plays an important role in the fibrin glue is biocompatible and biodegradable, pathogenesis of a corneal ulceration, so steroids and it induces minimal adverse reactions and no can be beneficial, especially when used with tissue necrosis. Fibrin glue provides faster caution. healing, but it requires a longer time for adhesive In bacterial infection, topical steroid should plug formation [2]. be commenced after the organism and Corneal gluing may be a definitive sensitivities are known and after 2-5 days of treatment in cases of peripheral perforations or appropriate antibiotic treatment. a temporary one in central perforations pending In viral infection (e.g. herpes simplex a corneal transplantation; this measure ensures keratitis), it is best that corticosteroids are that healing can occur with adequate medical avoided. If, however, they are used, the smallest therapy and allows surgery to be more selective dose should be used together with an antiviral or performed under more optimal conditions agent. once the inflammation is reduced and the Systemic immunosuppressants may be structure of the globe restored [3]. helpful in unresponsive and severe corneal inflammatory disease. Surgical technique Tissue adhesives are applied directly or by 167 Romanian Society of Ophthalmology © 2019 Romanian Journal of Ophthalmology 2019; 63(2): 166-173 using the patch technique. The procedure takes resistance to antimicrobial agents. The infection place in an operating theatre and it starts with itself and afferent inflammatory reaction can the preparation of the site of the perforation. Any lead to corneal ulceration, melting, and mucus and necrotic tissues are carefully perforation [4]. Therefore, current research is removed from the area of the perforation, and so aimed at finding novel treatment options beyond is the surrounding 1-2 mm of epithelium. After antimicrobial therapy, particularly for the debridement, the cornea should be as dry as treatment of resistant forms. possible; otherwise, the glue will not stick. If the anterior chamber is flat or if there is a prolapse Cross-linking (CXL) has shown an of the iris, a paracentesis is performed, and air or antimicrobial effect against a variety of common viscoelastic is injected in the anterior chamber, pathogens in vitro. However, clinical evidence to avoid incarceration of the iris or other tissues. that cross-linking can be efficient in the During direct application, the cyanoacrylate treatment of microbial keratitis and in halting glue is injected at the site of perforation using a the progression of corneal melting is limited. 1-mL syringe. The polymerization process occurs To distinguish between the CXL used in the in several minutes and afterwards the site of treatment of keratoconus and that used in perforation is checked for leaks. If the infectious keratitis, the term photo-activated perforation is completely sealed, a bandage chromophore (PACK-CXL) was introduced at the contact lens is applied. ninth cross-linking congress in Dublin, Ireland, in During the patch technique, a plastic disc is 2013. prepared from a sterile plastic surgical drape by PACK-CXL has at least two mechanisms of using a 3- or 4-mm dermatological punch. The action. First, it increases stromal resistance to sterile plastic disc with a small amount of glue on proteolysis by enzymes involved in the it is placed on the dry cornea and centered over inflammatory reaction [4] and second, the the perforation site. If there is no leak and the apoptosis induced affects not only the disc is adequately placed over the cornea, a keratocytes, but also the pathogens, which bandage contact lens is applied [3]. further decreases the infectious process [5]. The postoperative treatment includes In a study by Said and collaborators, the topical antibiotics and aqueous suppressants. results indicated that PACK-CXL might be an The glue should stay in place as long as possible effective adjuvant in the treatment of severe and a careful monitoring is needed because of infectious keratitis associated with corneal the risk of dislodgement and re-perforation [1]. melting [5]. In another study by Bamdad and In the same manner, the two components
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