Surgical Treatment of 32 Cases of Long-term Atopic Keratoconjunctivitis Using the Amniotic Membrane

J Yang; F-h Yang; C-H Peng; D Erol; S H Tsang; X-r Li


Eye. 2013;27(11):1254-1262. 

In This Article


Table 1 displays each patient's clinical information. Thirty-seven subjects took part in the study. Twenty of these were misdiagnosed before their first visit to our hospital (Figure 1). Period of misdiagnosis varied between 30 days and 3 years.

Figure 1.

Misdiagnoses by condition and number of cases.

As some of our patients had been misdiagnosed for long periods, corneal scarring, corneal opacity, and vascularization of the cornea were commonly observed. Some patients exhibited severe central, marginal or shield ulcers, or even corneal perforation. All patients displayed a variety of atopic conditions with various degrees of severity: allergic rhinitis, eczema, and asthma (Table 2).

All patients were followed up for 21.7±3.8 months. The time required for the AM to be reabsorbed varied from 1 week to 1 month. Generally, the inner layer remained attached until the ulcer and perforation healed. Because of irregular astigmatism and residual scarring in different parts of cornea, the best-corrected visual acuity was uneven in different groups (Table 3). In the surgical groups, two patients experienced the recurrence of AKC, manifesting as itching, foreign-body sensation, decreases in vision, and signs of formation of new shield ulcers at the edges of the transplanted AM, but these were controlled by the topical medications 0.1% olopatadine and 0.05% cyclosporine A eye drops twice a day without a need for further surgery. As all surgical cases healed in 24.4±13 days, and vision had improved stably by the time of long-term follow-up visits, all surgeries were classed as both primary and secondary successes. Mean best-corrected visual acuity improved from 0.6±0.2 to 0.198±0.16 logarithm of the minimum angle of resolution (P<0.001, t=5.8034).

The recovery time of the control group was 52±16 days, much longer than that of the surgery group. In one case, new corneal lesions appeared on the original area of corneal lesions 3 months into treatment (Figure 2, control case). Mean best-corrected visual acuity improved from 0.74±0.15 to 0.54±0.29 logarithm of the minimum angle of resolution (P≤0.05, t=4.298). The vision improvement has significant difference for surgical treatment vs medical. (Mann–Whitney U-test, U=119, P=0.044, one tailed).

Figure 2.

Control case and surgical case examples. Control case a: severe corneal swelling is present in the central area and corneal epithelial defects are apparent, with peripheral superficial vascular invasion. Control case b: vascular invasion and swelling are both reduced after 3 months of medical treatment, but a new 2-cm ulceration area (arrow) appears again on the original epithelial defect area. Surgical cases: case 1 underwent AMC surgery; case 2 underwent AMT Surgery; case 3 underwent combined AMC and AMF surgery; and case 4 underwent combined GCT, AMIF, and AMC surgeries.

Surgical Case Examples

Case 1 A 58-year-old farmer with a history of 2 years of bilateral eye redness, itching, and swelling, and with decreased vision in the left eye, was referred for evaluation. On initial examination, best-corrected visual acuity was 20/40 OD and 20/200 OS. External examination revealed eczema of each eyelid with thickened lid margins. Slit-lamp examination revealed punctate epithelial inflammation on the temporal side of the right eye. There was a 2-mm white area of inflammation with notable new vascular invasion on the superior area of the left eye and extensive epithelial erosions (Figure 2, case 1a). After multiple AKC medications were administered over 3 weeks, 20/20 visual acuity in the right eye was attained, but a central superficial ulcer of about 4 mm appeared on the left eye (Figure 2, case 1b). We classed this case with group 2 and performed an AMC surgery on the ulcer in the left eye (Figure 2, case 1c). Corneal inflammation was controlled at 3-week follow-up. Vision (20/60) and corneal epithelialization were found on examination 18 months after the surgery (Figure 2, case 1d).

Case 2 A 43-year-old man had suffered from photophobia and tearing in both eyes for a period of 1 year. Over the 2 months before his visit to the hospital, this had been accompanied by decreased vision in the left eye. Before enrolling in the study, he had previously been misdiagnosed with viral keratitis and was treated with antiviral eye drops for more than 1 month. After 1 month of treatment with the antiviral medication, hyperemia of the conjunctiva developed in both eyes. The cornea of the left eye was swollen, with a corneal flake ulcer evident in the upside of the left eye (Figure 2, case 2a), in addition to intensive neovascularization in the vicinity of the ulcer. His total serum IgE level was 5000 IU/ml. After a definite diagnosis was made, the patient was treated and kept under medication for 1 week. The conjunctival inflammation was greatly reduced, but the corneal lesion remained unchanged. In addition, he had developed a resistant corneal ulcer in the upside of the left eye. His best-corrected visual acuity was 20/25 in the right eye and 20/200 in the left eye. Because of refractory corneal involvement, he underwent surgery with an AMT in the left eye (group 1) (Figure 2, case 2b).

Twenty days after the procedure, AM grafts showed excellent maintenance. However, 40 days after the surgery, neovascularization was evident around the corneal lesion and under the membrane (Figure 2, case 2c). New shield ulcers formed again on the edge of original ulcer at 50 days after treatment (Figure 2, case 2d). Giving a recent history, the patient revealed that he had reduced the medicine shortly after the surgery; following this, doses of topical medication were administered again, and, after 2 weeks, corneal swelling was reduced. The patient continued taking the medication at its prescribed dose for 5 months, until the cornea was clear and all vascularization had disappeared (Figure 2, case 2e). The best-corrected vision of the patient was restored to 20/40 after 10 months (Figure 2, case 2f). No reoccurrence was reported at 2-year follow-up.

Case 3 A 28-year-old man complained of 2 years of photophobia and itching in his right eye. Prior diagnosis was dry eye. The patient appeared in the emergency room with red eye and ocular pain in the right eye, reporting that vision had decreased dramatically in the past 20 days. Slit-lamp examination showed a marginal corneal perforation of 1 mm in diameter at the 1230 clock position, with the iris bulging (Figure 2, cases 3a and b). The patient had no history of trauma. A combined AMF with AMC surgery (group 3) was performed (Figure 2, cases 3c and d). The perforation healed in 30 days. At 2-year follow-up, his vision had improved to 20/25 from the initial 20/60 (Figure 2, cases 3e and f).

Case 4 A 15-year-old female student was hospitalized for 2 weeks in another hospital because of photophobia and tearing that had both persisted for more than 1 year. Vision in the left eye decreased suddenly one day while the patient was washing her face. Diagnosis showed corneal degeneration in both eyes, with a central corneal perforation of the left eye. Conjunctival flap surgery had already been performed on the patient, but the corneal lesion did not improve after the treatment. At this time, the patient was referred to our hospital. Vision measured 20/20 OD and hand motion OS. Slit-lamp examination revealed lid swelling and redness in the bulbar and palpebral conjunctivas of both eyes. Cornea epithelial defects spanned a 3-mm area of inflammation with a superficial vascular invasion on the left eye. The conjunctival flap was detached, covering the center of the cornea of the left eye, with a 3-mm central perforation and extensive neovascularization in the perforation area. The anterior chamber had disappeared (Figure 2, cases 4a and b). Laboratory tests showed a high level of IgE (6120 IU/ml) in the patient's serum. Local anesthesia was administered, and the flap was removed with a spatula. We then treated this case as a member of group 4, with combined surgeries: glycerol-preserved corneal transplant (GCT), amniotic membrane inlay filling (AMIF), and AFC (Figure 2, cases 4c and d). The anterior chamber had re-formed 1 week after surgery. At 35 days, the corneal perforation was substantially healed. Visual acuity in the right eye had improved to 20/60 at 24-month follow-up (Figure 2, cases 4e and f). Visual acuity had not completely recovered because of irregular astigmatism and residual scarring. No reoccurrence was reported at the 2-year follow-up.