Sudanese Journal of Ophthalmology

LETTER TO EDITOR
Year
: 2020  |  Volume : 12  |  Issue : 1  |  Page : 33--34

Corneal fistula in a phthisical eye: Presentation and management


Siddharth Madan, Rajiv Garg 
 Department of Ophthalmology, Lady Hardinge Medical College and Associated Hospitals, University of Delhi, New Delhi, India

Correspondence Address:
Dr. Siddharth Madan
Department of Ophthalmology, Lady Hardinge Medical College and Associated Hospitals, University of Delhi, New Delhi
India




How to cite this article:
Madan S, Garg R. Corneal fistula in a phthisical eye: Presentation and management.Sudanese J Ophthalmol 2020;12:33-34


How to cite this URL:
Madan S, Garg R. Corneal fistula in a phthisical eye: Presentation and management. Sudanese J Ophthalmol [serial online] 2020 [cited 2020 Oct 21 ];12:33-34
Available from: https://www.sjopthal.net/text.asp?2020/12/1/33/293637


Full Text

Sir,

Patients with a corneal wound, keratitis, or a corneal ulcer present to any ophthalmologist in their routine clinics and emergencies. In the healing stage of all these lesions, the tendency to stain the cornea with fluorescein dye at every visit is not a common practice to follow and it is at this time a corneal fistula may form due to inadequate apposition of the stromal tissue. Corneal fistula is mostly central in location.[1] The reports available on corneal fistulas are anecdotal.[1],[2],[3] The point thought worth writing this letter was to highlight the management challenges faced by us in a rare case of corneal fistula in a phthisical eye. A 65-year-old female suffered a traumatic corneal ulcer in her left eye (LE) 15 years back following which she lost all vision in her LE. She received topical medications for 2 months at a village. When she presented to us, her right eye was pseudophakic with a visual acuity of 6/9. The LE was phthisical with a flat, opaque cornea demonstrating superficial vascularization and dystrophic calcification [Figure 1]a and [Figure 1]b. A central corneal fistula measuring 3 mm × 3 mm having a thick, rounded edge [Figure 1]a and [Figure 1]b was seen, which gave a direct access into the potential space posteriorly, causing stagnation of tears that was responsible for watering and purulent discharge for the last 7 years, which was quite bothering for the patient. The nasolacrimal system was patent without any obvious eyelid deformity. A true anterior chamber was absent.[1],[4] The LE was soft as felt on digital palpation over the closed eyelids. The left globe was deformed, which was confirmed on ultrasound B-scan.{Figure 1}

We know that a fistula tract is an easy access inside the eye, and results can be blinding in the form of endophthalmitis, panophthalmitis, or phthisis bulbi.[1],[2],[3],[4] The clinical appearance in this case is somewhat unusual and was possibly a consequence of the long-standing perforation in her eye, which then progressed to phthisis. We could consider quite a few management options, but each has a limited utility in closing this fistula due to its considerable size. A large opening with a flat cornea deferred the placement of cyanoacrylate glue with a bandage contact lens. Cauterization of the edges of the fistula could fail to achieve adequate closure as the fistula was large in size.[2] Ocular muscle tendon grafts and tenon patch grafts have also been used as a convenient source to repair corneal fistula.[2],[3] Because conjunctiva is a richly vascularized tissue which can provide enough structural support for corneal rehabilitation, a Gunderson conjunctival flap was used to seal this fistula and worked well in this patient. Poor cosmesis and poor postoperative vision are limiting features of this procedure but were not pertinent to our patient who was already visually disabled. The management strategy of utilizing a standard conjunctival flap seemed appropriate as it works well in select cases.[1],[2],[3],[4],[5] Considering this simple and quick technique of rehabilitation in this female was rewarding. However, it is observed that this procedure is underutilized and must be considered wherever appropriate.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Singhal D, Sahay P, Maharana PK, Amar SP, Titiyal JS, Sharma N. Clinical presentation and management of corneal fistula. Br J Ophthalmol 2019;103:530-3.
2Jhanji V, Young AL, Mehta JS, Sharma N, Agarwal T, Vajpayee RB. Management of corneal perforation. Surv Ophthalmol 2011;56:522-38.
3Maharana PK, Singhal D, Sahay P, Titiyal JS. Tenon patch graft for corneal fistula: A rare entity treated by a simple technique. BMJ Case Rep 2017;2017:bcr2017222790.
4Cheng KC, Chang CH. Modified Gunderson conjunctival flap combined with an oral mucosal graft to treat an intractable corneal lysis after chemical burn: A case report. Kaohsiung J Med Sci 2006;22:247-51.
5Sun YC, Kam JP, Shen TT. Modified conjunctival flap as a primary procedure for nontraumatic acute corneal perforation. Ci Ji Yi Xue Za Zhi 2018;30:24-8.