During a cornea-focused session, Sonal Tuli, MD, discussed the surgical management of infectious keratitis, going through options for these patients and why you need a surgical intervention.
Sometimes you need a temporary fix to get people stabilized, she said, and you can do medical or surgical treatment. You also may need surgical management if there’s a lot of inflammation that won’t let the eye heal or if the infection is out of control.
She shared several principles for management, with three modalities: maintain structural integrity temporarily to allow the underlying tissue to heal; scaffold with tissues that reduce inflammation/infection or enhance healing; and replace infected tissue by corneal grafting.
Dr. Tuli said the easiest thing she likes to address is peripheral ulcer. It’s usually easy to use a glue in these cases, and there are several glue options available. She noted that these come in pipettes, are soft, and release about a molecule at a time. You want to paint it in and mind the amount of glue you’re using, Dr. Tuli said, because it does expand as it dries. If you have peripheral ulcer, let it heal, and a few months later, the glue falls off, and you don’t need surgical intervention. However, if you have a lot of inflammation, glue will cause even more inflammation.
Amniotic membrane could work well, as this helps with inflammation and has growth factors that let the epithelium heal over it.
You don’t always have to cover the entire cornea. Dr. Tuli went on to discuss micro PKP, which she said are nice for peripheral infections. The advantage is that only a small percentage of corneal endothelium is replaced, so rejection is not an issue. You don’t have to make a big central corneal graft.
Also for peripheral infections, a crescent graft could be used. Dr. Tuli described this as using a smaller size trephine to make the outer edge and larger trephine to make the inner curve. You make a crescent in the donor as well and sew it on. You’ve only replaced a small amount, and they heal very well, she said.
Lastly, Dr. Tuli noted that intrastromal injections are particularly useful in fungal keratitis.