Sir,

We have read with interest the article on Superior Forniceal Conjunctival Advancement Pedicles by T Sandinha et al1 in the January 2006 issue of Eye.

While we appreciate the authors' work, we would like to state that the surgical procedure discussed therein has given encouraging results in our hands as well, in cases of impending and acute corneal perforations due to different aetiologies. The various advantages of the procedure, which is indeed a true transposition of the conjunctiva as compared to a rotation or gliding of the conjunctiva to an adjoining area, are very well highlighted in the above article.

We would like to illustrate one particular case where an inferior forniceal conjunctival transposition flap was performed by us in treating a paracentral perforation of the inferior cornea in a lady with Sjogren's syndrome secondary to rheumatoid arthritis (Figure 1). When all conventional treatment failed and a therapeutic graft to save the eye was the next option, a transposition conjunctival pedicle graft from the inferior bulbar conjunctiva was carried out under subconjunctival and limbal anaesthesia to cover the perforation. One month after the conjunctival flap surgery, her vision had improved from HM before the procedure, to 6/9 with pinhole and the eye was comfortable with the infection having resolved. The conjunctival pedicle was divided at its base 6 months after the initial surgery with good corneal stability and the anterior chamber remains well formed to date. The eye is healthy and functional without the need for a corneal graft, recording an unaided visual acuity of 6/9 despite an inferior leucomatous opacity and localized anterior synechia.

Figure 1
figure 1

Transposition flap from lower bulbar conjunctiva. (a) Immediate post-operative photograph. (b) Photograph at 1 month post-operative period.

Full size image

The demonstrable usefulness of this surgical procedure with limbal tissues left undisturbed and providing valuable support to the diseased cornea prompts us to advocate its use in suitable cases more readily from any sector of the bulbar conjunctiva, depending on the site of the corneal pathology. It is also our view that this procedure need not always be a temporary stopgap measure to make an eye safe but can be used to restore structural and functional integrity of the eye.