Choice of Surgical Therapy For

Perforating Corneal Ulcer :

Keratoplasty or Periosteal Graft

HAVRIZA VITRESIA, MD

Infection Immunology Division, Ophthamology

Department Of Medical Faculty Andalas University,
Dr M Djamil Hospital, Padang, West Sumatera

Presented in The 1st Indonesian Congress on Controversion in

Ophthalmology, Nov 24-25th, 2016, Padang West Sumatera
MICROBIAL CORNEAL ULCER

• Infection of the cornea

• Cause ; Microbial organism ; bacteria, fungal,
virus, acanthamoeba
• clinical features ; corneal defect, inflamed
eye, suppuration, ulceration
• severe condition ; corneal thinnig,
descematocele, perforation
MANAGEMENT
 Early Diagnosis
 Thorough undestranding of pathogenesis
 Potent antimicrobials ; topical and systemic drug

 if good response ;
continue treatment -- healing -- scar formation
 if condition worsens ;
- virulent and resistant microorganisms
- delayed diagnosis and treatment

 uncontrolled infection
 progress to corneal perforation,
endophthalmitis
SURGICAL TREATMENT OF
PERFORATION CORNEAL ULCER

Small / Moderate Perforation

 Corneal Gluing
 Amnion Membran Graft
 Conjunctival Flap
 Patch Graft

Large Perforation (central)

 Keratoplasty
 Periosteal / Fascia Lata Graft
Management
Management of Perforating Corneal Ulcer
Keratoplasty
Keratoplasty
 replace the disease cornea (scar, infection,
perforation with corneal donor

Purpose ;
 Optical (to overcome better visual acuity)
 Therapeutic (eliminate microorganism and necrotic
tissue )
 Tectonic (maintain integrity of the eyeball)
 Cosmetic (better appearance)
Therapeutic Penetrating Keratoplasty

Indications ;
 perforating corneal ulcer
 extensive infection
 uncontrolled microbial
infections

Purpose ;
 elimination or removing the
infectious tissue
 maintains the structure and
function of the globe
Advantage

Excision of the infectious process by debulking

infectious inoculum
- the organisms in the cornea decreases
and the host defense becomes active
maintain the integrity of the globe
provide visual rehabilitation in some cases
help in diagnosis of the infective pathology
 Therapeutic Penetrating Keratoplasty

Preoperative
 Systemic and topical antimicrobial
 IOP Control
 Regardless etiology, topical AB should be
given (broad spectrum, non toxic, good
penetration)

Operative
 excised all infected and necrotic tissue
 tissue should be removed
 smaller graft has a better prognosis than
large graft
 use interupted sutures
 Therapeutic Penetrating Keratoplasty

Post operative
 Regardless etiology, topical AB should be given (broad
spectrum, non toxic, good penetration)
Complication
 Recurrence of infection
 Secondary Glaucoma
 Haemorrhage / hyphema
 Graft Failure
 REINFECTED GRAFT

• Host Corneal Excision

• Microorganism Virulence
• Medical treatment is not optimal
• Steroid topical and systemic use

REPEAT KERATOPLASTY
PERIOSTEAL / FASCIA LATA GRAFT
Large Corneal Perforation ;

 no Corneal Donor or
 can not dokeratoplasty

other Choice ;
Periosteal or Fascia Lata Graft
Periosteal Graft

Periosteum Tissue
• Cover bone surface from articulate cartilage muscle
• consist of cambium and dense fibrous layer
• carries dense blood vessel (cambium layer
• it works very goo for infected corneal ulcer
• faster infection and inflammation

severe bacterial ulcer post periosteal graft

Fascia Lata Graft

• Fascia (connective tissue) is a fibrous and avascular

layer
• fascia lata encloses the muscles of upper leg (thigh)
from illiac crest (gluteal) to the tibia
• several muscles in upper leg have fibrous attachment
to this fascia band
• it's narrow and thicker at the distal part, wider and
thinner at the proximal

severe fungal ulcer post fascia lata graft

 Advantages / Disadvantages

Keratoplasty Periosteal/Fascia lata

graft
 cosmetic ; good  cosmetic ; poor
 can replace with  can replace with
optical keratoplsty keratoplasty
 post surgical  post surgical ; faster
complication ; often healing
- reinfection,  complication ; rarely
- secondary glaucoma
THANK YOU