Objectives: To describe the 3-month outcomes of conjunctival flap in managing severe Microbial Keratitis (MK).
Design: This was a prospective cohort study.
Setting: Patients were enrolled at two major eye hospitals in Mbarara, a major city in the Southwestern sub-region
of Uganda, over a one year period.
Subjects: Individuals of any age that met the case definition of severe microbial keratitis, in which perforation
occurred acutely or was impending.
Interventions: A complete Gunderson conjunctival flap was done in all suitable patients. Demographics, health
access, clinical, and microbiological data were recorded.
Main outcome measures: Statistical significance testing was done to assess predictors of evisceration at the
3-month follow-up time point.
Results: Among 57 patients (57 affected eyes), median age was 44 years (IQR 38, 60) and 47.4% were women.
Trauma was associated with 35.1% of cases. Median time to presentation was 23 days (IQR 12, 34). Etiology was
80.7% purely fungal pathogens, 10.5% mixed bacterial/fungal, and 8.8% undetermined. Mean infiltrate and epithelial
defect sizes were 7.2mm (SD 2.3) and 6.0mm (SD 2.5), respectively. Presenting visual acuity was <3/60 in
78% of eyes. At 3-months, 19 eyes (34.5%, 95%CI 23.5-48.2) had improved best-corrected visual acuity, though 9
eyes required evisceration (15.8%, 95%CI 8.3-28.0). There were no clinically or statistically significant predictors
for evisceration at 3 months.
Conclusions: Conjunctival flap is a reasonable rescue procedure, especially if therapeutic penetrating keratoplasty
is an eventually feasible option. However, there are considerable risks of vision loss or lack of improvement
and eventual need for evisceration.
Ung L, Bispo PJ, Shanbhag SS, Gilmore MS,
Chodosh J. The persistent dilemma of microbial
keratitis: global burden, diagnosis, and antimicrobial
resistance. Surv Ophthalmol. 2019; 64(3):255-271.
Whitcher JP, Srinivasan M, Upadhyay MP. Corneal
blindness: a global perspective. Bull World Health
Entekume G, Patel J, Sivasubramaniam S, et al.
Prevalence, causes, and risk factors for functional low
vision in Nigeria: results from the national survey of
blindness and visual impairment. Invest Ophthalmol
Vis Sci. 2011;52:6714-19.
Flaxman SR, Bourne RRA, Resnikoff S, et al. Global
causes of blindness and distance vision impairment
-2020: a systematic review and meta-analysis.
Lancet Glob Health. 2017;5:e1221-e1234.
Poole TR, Hunter DL, Maliwa EM, Ramsay AR.
Aetiology of microbial keratitis in northern Tanzania.
Br J Ophthalmol. 2002;86:941-942.
Burton MJ, Pithuwa J, Okello E, et al. Microbial
keratitis in East Africa: why are the outcomes so
poor? Ophthalmic Epidemiol. 2011;18:158-163.
Chidambaram JD, Venkatesh Prajna N, Srikanthi P, et
al. Epidemiology, risk factors, and clinical outcomes in
severe microbial keratitis in South India. Ophthalmic
Gain P, Jullienne R, He Z, et al. Global survey of
corneal transplantation and eye banking. JAMA
Mannis MJ. Conjunctival flaps. Int Ophthalmol Clin.
Khor WB, Prajna VN, Garg P, et al. The Asia cornea
society infectious keratitis study: A prospective
multicenter study of infectious keratitis in Asia. Am J
Zemba M, Stamate AC, Tataru CP, Branisteanu DC,
Balta F. Conjunctival flap surgery in the management
of ocular surface disease (Review). Exp Ther Med.
Lim LS, How AC, Ang LP, Tan DT. Gundersen flaps
in the management of ocular surface disease in an
Asian population. Cornea. 2009;28:747-751.
Arunga S, Kintoki GM, Mwesigye J, et al.
Epidemiology of microbial keratitis in Uganda:
a cohort study. Ophthalmic Epidemiol. 2020;
Prajna NV, Krishnan T, Mascarenhas J, et al. The
mycotic ulcer treatment trial: a randomized trial
comparing natamycin vs voriconazole. JAMA
Leck AK, Thomas PA, Hagan M, et al. Aetiology
of suppurative corneal ulcers in Ghana and south
India, and epidemiology of fungal keratitis. Br J
Gundersen T. Conjunctival flaps in the treatment
of corneal disease with reference to a new
technique of application. AMA Arch Ophthalmol.
Arunga S, Asiimwe A, Apio Olet E, et al. Traditional
eye medicine use in microbial keratitis in Uganda:
a mixed methods study. Wellcome Open Res.
Oladigbolu K, Rafindadi A, Abah E, Samaila E.
Corneal ulcers in a tertiary hospital in Northern
Nigeria. Ann Afr Med. 2013;12:165-170.
Abdulhalim BE, Wagih MM, Gad AA, Boghdadi
G, Nagy RR. Amniotic membrane graft to
conjunctival flap in treatment of non-viral resistant
infectious keratitis: a randomised clinical study. Br J
Sun GH, Li SX, Gao H, Zhang WB, Zhang MA, Shi
WY. Clinical observation of removal of the necrotic
corneal tissue combined with conjunctival flap
covering surgery under the guidance of the AS-OCT
in treatment of fungal keratitis. Int J Ophthalmol.
Zhou Q, Long X, Zhu X. Improved conjunctival
transplantation for corneal ulcer. Zhong Nan Da Xue
Xue Bao Yi Xue Ban. 2010;35:814-818.
Nizeyimana H, Zhou DD, Liu XF, et al. Clinical
efficacy of conjunctival flap surgery in the treatment
of refractory fungal keratitis. Exp Ther Med.
Raj A, Bahadur H, Dhasmana R. Outcome of
therapeutic penetrating keratoplasty in advanced
infectious keratitis. J Curr Ophthalmol.
Titiyal JS, Negi S, Anand A, Tandon R, Sharma N,
Vajpayee RB. Risk factors for perforation in microbial
corneal ulcers in north India. Br J Ophthalmol.
Kibret T, Bitew A. Fungal keratitis in patients
with corneal ulcer attending Minilik II Memorial
Hospital, Addis Ababa, Ethiopia. BMC Ophthalmol.
Prajna NV, Srinivasan M, Lalitha P, et al. Differences
in clinical outcomes in keratitis due to fungus and
bacteria. JAMA Ophthalmol. 2013;131:1088-89.
Gopinathan U, Sharma S, Garg P, Rao GN. Review of
epidemiological features, microbiological diagnosis
and treatment outcome of microbial keratitis:
experience of over a decade. Indian J Ophthalmol.
Courtright P, Lewallen S, Kanjaloti S, Divala DJ.
Traditional eye medicine use among patients with
corneal disease in rural Malawi. Br J Ophthalmol.