Prompt treatment essential
Old and established treatments best for corneal ulcers
Corneal ulcers require prompt treatment to avoid further complications and long-established techniques still provide the best options for ophthalmic surgeons today, the 37th Congress of the ESCRS in Paris, France, was told by a leading expert in the area.
Marc Muraine MD, PhD, France, discussed the various surgical approaches for treating corneal ulcers, giving practical advice and outlining his personal experiences, during a dedicated session on non-healing corneal ulcers at the Congress.
“As we know, corneal ulcers require prompt treatment as there is a high risk of perforation and, in addition, the corneal ulcer could result in sight-threatening complications due to neovascularisation and infection risk.
“So when dealing with a severe nonhealing corneal ulcer that has perforated the strategy is to cover it as soon as possible. Using glue is the easiest technique, as it doesn’t involve going to the operating room, amniotic membrane transplantation is the most popular technique, and conjunctival flap is the most efficient technique,” he said.
Sometimes it will be necessary to perform tectonic grafts, and sometimes to combine them with a conjunctival flap and tarsoraphia for more difficult ulcers, Dr Muraine added. “Of course you will have to maintain medical treatment, and do not forget about using contact lenses, especially scleral lens.”
Dr Muraine then went on to describe the various surgical approaches for those attending the session. He noted that glue is most suitable in perforations of <1mm, adding that fibrin glue is more expensive than cyanoacrylate glue. Describing the use of amniotic membrane transplantation, Dr Muraine said it is the “gold standard in the management of deep corneal ulcers”, and in treating corneal pre-perforation or perforation <2mm. Most often, amniotic membrane transplantation has to be performed using a multilayer technique, he explained. Dr Muraine then briefly described tectonic keratoplasty saying it is a useful new trepanation technique for penetrating keratoplasty in cases of large corneal perforation.
To compare the success rates of the various procedures, Dr Muraine quoted a 2006 study he contributed to of 56 eyes treated for a non-traumatic corneal perforation between 1997 and 2004. Mean patient age was 69 years (range, 16-95 years) and the mean follow-up was 20.5 months (range, 6-96 months).
The diseases associated with the corneal perforations in the 56 eyes were neurotrophic ulcers in 51% of cases, peripheral ulcerative keratitis (PUK) in 21%, infectious keratitis in 15% and dry eye in the remaining 13% of cases.
As a first procedure, cyanoacrylate glue was used in 24% of cases (50% anatomic success), multilayer amniotic membrane transplantation in 39% of cases (100% anatomic success), conjunctival flap in 10%, and tectonic keratoplasty in 27% of cases.
Dr Muraine also discussed the latest technique, corneal neurotisation, ‘a novel solution to neurotrophic keratopathy’. He described the direct approach involving re-innervation of the anaesthetic cornea using the contralateral supraorbital and supratrochlear branches, but said it is currently suitable for very few patients.
Speaking to EuroTimes Dr Muraine summarised his thoughts on treating corneal ulcers: “The surgical techniques to deal with corneal ulcers are well known, and are long established and are very good. They include the glue, amniotic membrane, and conjunctival flap and tectonic graft so you have to choose the best option for each specific case. The new technique, neurotisation, is for very few patients so maybe in the future [it will be used more].”