Combined Treatment With Conjunctival Rotational Flap And Amniotic Membrane Transplantation For Corneal Perforation In Neurotrophic Keratopathy (Nk).

To describe a case of corneal perforation due to neurotrophic keratopathy which was treated with rotational conjunctival flap associated to amniotic membrane transplantation.

Ophthalmology Department, Hospital El Bierzo, Ponferrada (León), Spain.

We present an 87-year-old man with ophthalmic history of neurotrophic keratitis due to Herpes in his left eye, with poor previous visual acuity. He presented at hospital complaining of pain, tearing and decreased visual acuity in his left eye. The ophthalmic examination revealed a full-thickness corneal perforation, measuring 3 × 3 mm in the temporal mid-periphery of the cornea, positive Seidel test, shallow anterior chamber and protrusion of uveal tissue through the wound. The patient was admitted to the hospital to undergo surgery. The defect was repaired with multilayered amniotic membrane transplantation associated to a rotational conjunctival flap of the inferotemporal conjunctiva, that was performed with local anesthesia. Even though the perforation was not small, the decision of avoiding penetrating keratoplasty was based on the bad prognosis of penetrating keratoplasty in neurotrophic eyes, and also on this patient general health condition that contraindicated general anesthesia. The procedure was successful, accomplishing the sealing of the eye and the recovery of the anterior chamber depth.

Corneal perforation in a cornea with neurotrophic keratopathy is always a therapeutic challenge and corneal surgery in a surface with reduced sensation has a high risk of failure. Commonly available treatment options for ocular perforation are amniotic membrane transplantation, conjunctival flaps and keratoplasty. Despite the availability of all these options, ambiguity remains about management. No case of corneal perforation due to neurotrophic keratopathy treated with dual procedure as the first stage of treatment has been reported in literature. We consider that the conjunctival rotational flap, associated to amniotic membrane transplantation, as it was performed in this case, could be a simple and effective alternative in these cases.