196
3 March 2003
CE Article #3 (1.5 contact hours)
Refereed Peer Review
KEY FACTS
■ The location and depth of the
corneal lesion, as well as the
desired optical result, determine
the choice of surgical procedure.
■ Conjunctival flaps and grafts
can be configured in various
shapes and sizes to best match
the corneal lesion.
■ Grafting with corneal tissue is
the most physiologic choice for
surgical repair of corneal ulcers.
■ More controlled studies of
xenografts are required
before use of this type of graft
becomes common in surgical
management of deep corneal
ulcers.
V Vol. 25, No.
Comments? Questions?
Email: compendium@medimedia.com
Web: VetLearn.com • Fax: 800-556-3288
Management of
Deep Corneal Ulcers
Veterinary Eye Care
Birmingham, Alabama
Kristina R. Vygantas, DVM, DACVO
Auburn University
R. David Whitley, DVM, MS, DACVO
ABSTRACT: Deep corneal ulcers are one of the most common vision-threatening ocular disor-
ders in domestic animals. Rapidly progressing corneal ulcers—those that have progressed
despite medical therapy and those that involve one-half to two-thirds of the depth of the
corneal stroma—should be repaired surgically because of the danger of perforation. Both
medical and surgical approaches to the management of deep corneal ulcers are reviewed. The
choice of surgical procedure is determined by the location and depth of the corneal lesion, as
well as by the desired optical result.
C
orneal ulceration is a relatively common, potentially vision-threatening
disease of the cornea of companion animals. Although many corneal
ulcers are superficial and heal quickly, a progressive or deep ulcer requires
more aggressive therapy.
NORMAL CORNEAL WOUND HEALING
Within 1 hour of the formation of a corneal wound, the epithelial cells lose
their surface microvilli and begin to flatten in preparation for migrating to fill
the epithelial defect. As the individual cells begin to migrate, fibronectin, which
lines the corneal ulcer bed, helps mediate temporary transmembrane adhesions
between the epithelial cells and the extracellular matrix. Contact inhibition
assists in halting the migration of the cells after the defect has been corrected.
Factors that may further speed epithelialization of the wound include human
epidermal growth factor, transforming growth factor-β, and hyaluronan.1 The
presence of excessive polymorphonuclear cells associated with inflammation
within the wound may slow the epithelialization process. Even though an ulcer
may quickly epithelialize, the attachment of the epithelium to the underlying
basement membrane may be fragile for the first 6 to 8 weeks.2
If a wound extends to the corneal stroma, healing is more complicated and
protracted. Because the hydrophobic barrier of the corneal epithelium is lost,
fluid is imbibed by the collagen fibrils of the stroma, which results in corneal
edema. Exposure of the corneal stroma results in chemotaxis of leukocytes.
Within 24 hours, leukocytes from the tear film and limbus coat the bottom of
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Compendium March 2003
the lesion. The stromal keratocytes become reactive,
transform into fibroblasts, and migrate into the lesion.
These fibroblasts then produce collagen fibrils that are
randomly deposited into the corneal wound. Various
enzymes, such as collagenases and proteases, are
released by the leukocytes and fibroblasts and cause
dissolution of the corneal stroma. In an infected ulcer,
bacteria can also cause release of these enzymes and
contribute to this dissolution. In deep corneal ulcers,
vascularization, resulting in a bed of granulation tissue,
is usually necessary to fill the defect.2 Because the normal
lamellar architecture of the corneal stroma is not
preserved, transparency is lost and a scar results.1
CLINICAL SIGNS
Animals with a corneal ulcer exhibit the classic signs of
ocular pain: blepharospasm, excessive lacrimation, and
photophobia. Conjunctival hyperemia and a miotic pupil
may be seen as a result of reflex uveitis caused by irritation
of the ophthalmic branch of the trigeminal nerve.
Various degrees of corneal opacity result from edema,
leukocytic infiltration, and neovascularization (Figure 1).
ETIOLOGY
It is always important to identify and, if possible,
eliminate the cause of a corneal ulcer. The causes are
numerous and include trauma, foreign bodies, diseases
of the eyelashes, and anatomic deformities of the eye-
lids such as entropion. Exposure of the cornea because
of a prominent eyelid fissure or facial nerve paralysis
can also result in corneal ulceration. Decreased tear
production in keratoconjunctivitis sicca can be an
important contributing factor to the genesis of corneal
ulcers. In cats and horses, infection of the cornea with
herpesvirus may lead to ulceration. Ulcers may also
occur after exposure of the cornea to caustic chemicals,
such as strong acids or bases, and dysfunction of the
corneal endothelium that results in diffuse severe edema
may predispose an animal to develop recurrent ulcers.
DIAGNOSIS
A corneal ulcer is diagnosed by use of fluorescein
staining. When the corneal epithelium is denuded, the
hydrophilic corneal stroma interacts with the sodium
fluorescein stain, which results in typical green staining
in the area of the ulcer. A full ophthalmic examination,
including a Schirmer tear test and assessment of the
palpebral and corneal reflexes, should be performed to
identify any predisposing ophthalmic conditions or
concurrent ocular diseases. Ancillary tests to facilitate
identification of infectious organisms that may complicate
healing include culture and antibiotic sensitivity assays
and cytology of the edges of the ulcer with subsequent
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Deep Corneal Ulcers 197
Gram’s stain. Routine hematoxylin and eosin staining
may reveal intranuclear inclusion bodies that occur
with herpesvirus infection.
THERAPY
Medical Management
Medical therapy is a mainstay of the management of
corneal ulcers. For superficial uncomplicated ulcers,
prophylactic use of a broad-spectrum topical antibiotic
assists in preventing a corneal infection from becoming
established. For infected corneal ulcers, culture and
sensitivity testing, as well as cytology of the ulcer edges,
help guide the choice of topical antimicrobial. Frequent,
up to hourly, application of a topical antimicrobial may
be necessary in patients with severe corneal infection.
Topical atropine to dilate the pupil is also important to
prevent synechiae formation, to stabilize the blood aqueous
barrier, and to relieve pain by relaxing spasm of the iridal
muscles. The frequency of topical atropine application
varies according to the degree of intraocular inflammation.
In uninfected superficial ulcers, one to three applications
may be sufficient; in more complicated ulcers, application
even four to six times a day may not achieve maximal
papillary dilation. Elizabethan collars, by preventing
self-trauma and thereby exacerbation of the ulcer, are a
useful adjunct to medical management. Systemic
NSAIDs such as carprofen can help address the intraoc-
ular inflammation that accompanies severe corneal disease.
Medical management alone, however, is not always
successful in achieving resolution of corneal ulcers.
Surgical Repair
As a rule, ulcers that involve one-half to two-thirds of
the depth of the stroma should be surgically repaired
because of the danger of perforation. Rapidly progressing
ulcers, or those that have progressed despite medical
therapy, may also require surgical intervention.3,4 Various
surgical techniques have been proposed for repair of
deep corneal ulcers.
Controversial Techniques
Direct suturing of descemetoceles or deep ulcers up
to 5 mm in diameter has been described,2 but it is not
currently recommended. Use of this technique may
result in distortion of the globe. Also, the cornea at the
edges of the descemetocele may not be healthy enough
to retain the sutures.
Third eyelid flap placement has been used in the
treatment of deep ulcers in dogs.5,6 The flap helps mini-
mize exposure of the damaged cornea by providing a
physical barrier that covers the ulcer. This therapy is
not ideal, however, in that it obstructs visualization of
the cornea and thereby precludes frequent monitoring of
198 Small Animal/Exotics Compendium March 2003

A B
Figure 1—(A) Rapidly progressing, melting corneal ulcer illustrating conjunctival hyperemia and corneal opacity caused by edema
and infiltration of leukocytes. (B) The same eye 1 week after placement of a conjunctival pedicle graft.

healing. Third eyelid flaps may even impede the efficacy
of topically applied medications 6 and trap necrotic
debris on the corneal surface.7 In addition, third eyelid
flaps do not provide a corneal lesion with a direct blood
supply. Used as a sole therapeutic entity, they are of
limited value and are considered by some practitioners
to be potentially detrimental.7
Application of ophthalmic tissue adhesive (e.g.,
N-butyl cyanoacrylate) has been advocated as a means
of primary repair for corneal ulcers as well as corneal
perforations and lacerations.8–11 Not only does the tissue
glue serve to “bandage” the cornea, it also has antibacterial
properties.7 The ulcer bed will epithelialize underneath
the glue, which causes sloughing of the glue as healing
progresses. It is critical that the ulcer bed be thoroughly
dried before glue application. A 1-ml syringe with a 30-
gauge hypodermic needle allows for precise application
of a thin layer of glue to the ulcer bed. The animal must
not be allowed to blink until the glue has completely
dried. Although some authors advocate the use of
cyanoacrylate adhesives with small descemetoceles, this
use is controversial. In clinical experience, the heat
caused by polymerization of the glue can be deleterious to
Descemet’s membrane, and perforation can result after
application of the glue to the descemetocele. Although
general anesthesia may provide optimal conditions for
glue application, this technique is commonly performed
with compliant patients under sedation or without
sedation. This method may, therefore, be an especially
attractive choice for patients that are poor candidates
for general anesthesia.
Conjunctival Flaps
Conjunctival flaps have been used successfully to
repair deep corneal ulcers. 2–5,12–14 This type of flap
consists of a thin sheet of conjunctival tissue that has
been cut away from the underlying episcleral fascia and
pulled over the corneal defect. Conjunctival flaps can
assume a variety of configurations, the size and shape
of which are determined by the nature of the defect
(Figure 2). All flaps provide mechanical strength to the
ulcer bed by filling the defect with fibrovascular tissue.

Figure 2A—Conjunctival pedicle flap Figure 2B—Hood flap Figure 2C—Bridge flap

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Compendium March 2003
Conjunctival flaps also provide the lesion with an
immediate blood supply and a source of epithelial cells
and fibroblasts, thereby facilitating healing. Conjunctival
flaps provide some antimicrobial and anticollagenase or
antiprotease properties as well.7
In conjunctival pedicle flaps, a strip of conjunctiva
that is slightly wider than the corneal defect is cut from
the conjunctiva adjacent to the limbus5,7,12 (Figures 2A and
1B). The base of the pedicle remains attached, the free end
of the conjunctival pedicle is rotated to cover the corneal
defect, and the pedicle is sutured to the edge of the ulcer.
It is essential that the ulcer bed is free of corneal epithe-
lium because the conjunctival flap will not adhere to
any epithelialized tissue. In preparing the ulcer bed for a
conjunctival flap or a corneal graft, it is important to
remove any necrotic or malacic tissue from the edges of
the ulcer. Absorbable suture material is most commonly
used to secure the pedicle, thereby obviating the need for
suture removal. For dogs and cats, 7-0 to 9-0 polyglactin
910 (Vicryl, Ethicon) on a micropoint spatula needle is
often chosen, whereas 6-0 to 7-0 polyglactin 910 may be
selected for horses.2 The suture pattern may be a simple
interrupted, a simple continuous one, or a combination
of the two patterns. Sutures should be placed at least
two-thirds into the depth of the corneal stroma without
penetrating the full thickness of the cornea. All varieties of
conjunctival flaps typically result in significant scarring of
the cornea.3,5,12 This scarring is confined to the nonepithe-
lialized area that has been covered by conjunctiva.
Conjunctival “hood” flaps are created by making a
single incision in the conjunctiva adjacent to the limbus,
undermining the tissue, pulling the conjunctiva down
to cover the defect, and suturing it to the opposite edge
of the defect7 (Figure 2B). Hood flaps are particularly
suited to peripheral or perilimbal corneal defects.3
Another variation of the conjunctival flap is the bridge
flap (Figure 2C). In bridge flaps, two incisions parallel
to the limbus are made for approximately 180˚ so that
Figure 2D—360˚ Conjunctival flap Figure 2E—Conjunctival island graft
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Deep Corneal Ulcers 199
both ends of the flap are left attached to the globe.7 The
strip of tissue is freed from the underlying fascial attach-
ments and pulled centrally to cover the defect. This type
of flap is especially useful for providing additional
support to linear corneal lesions such as lacerations.3
Severing the blood vessels supplying both conjunctival
pedicle flaps and bridge flaps is recommended at
approximately 3 to 8 weeks to allow atrophy of the
grafted tissue and decreased scar formation.3,5 The hood
flap, in contrast, may be left in place permanently if it
does not pose a significant obstruction to vision.
Another variant flap is the 360˚ or total conjunctival
flap, which can be used for extensive lesions of the
cornea. In this flap, the conjunctiva is incised circum-
ferentially at the limbus, undermined, pulled together
in purse-string fashion over the cornea, and sutured to
itself (Figure 2D). The conjunctival tissue will adhere to
the cornea where the epithelium is absent. This technique
is easy to perform because direct suturing to the cornea
is not required. Graft failure may be increased with this
technique because direct conjunctiva to cornea apposition
is not achieved by suturing.7 Additional disadvantages
of this flap include the fact that vision is severely, if not
totally, compromised in the operated eye during the
healing period. Furthermore, monitoring of the eye
during the healing phase is not possible because of
obstruction by the flap.3 Some authors assert that the
delivery of topical medications is impeded by 360˚
flaps.7 General anesthesia is usually required a second
time to cut the flap free from the cornea. Usually, a large
corneal scar remains after the cornea has healed. This
scarring may be a reflection of the fact that the initial
corneal lesion is extensive when a 360˚ flap is chosen.
Island Graft
The conjunctival island graft is a variant of a
conjunctival flap.15 In the island graft, the attachment
of a piece of bulbar conjunctiva to the globe is severed,
creating a free “island” of conjuncti-
val tissue (Figure 2E). The diameter
of the island of conjunctival tissue
should be slightly larger than the
diameter of the corneal defect. The
island of tissue is then sutured to the
defect, thereby serving a tectonic
purpose.3 Another option is a tarso-
conjunctival graft, harvested from
the center of the upper eyelid of the
affected eye.4 An inherent blood sup-
ply is not provided with either type
of island graft; instead, the graft
Figure 2—Types of conjunctival flaps.
202 Small Animal/Exotics Compendium March 2003

A B
Figure 3—(A) Deep corneal stromal abscess in a horse. (B) The same eye 1 year after penetrating keratoplasty with a frozen
corneal graft. The graft is translucent.

eventually becomes vascularized by means of corneal
neovascularization. Island grafts may result in less dra-
matic scarring of the cornea than that seen with con-
junctival flaps. However, because island grafts do not
provide a ready blood supply, they are not as efficacious
as flaps for infected ulcers.7
Keratoplastic Procedures
The use of various keratoplastic procedures for repair
of deep corneal ulcers has also been described. Grafts
used in these procedures are classified according to the
source of the grafted tissue, as autografts, allografts, or
xenografts. An autograft is composed of tissue from the
same animal, whereas an allograft consists of tissue from
an animal of the same species. A xenograft is composed
of tissue from an animal of a different species; the term
xenograft is also used to indicate graft material that
is not of corneal origin (e.g., porcine small intestinal
Compendium March 2003
submucosa). Grafts are also defined according to the
extent of the cornea that is replaced (e.g., lamellar
versus penetrating). Lamellar grafts are partial-thickness
grafts, whereas penetrating corneal grafts replace a full-
thickness piece of cornea. Another consideration affecting
keratoplastic procedures is the manner in which the
graft has been stored. Is it frozen? Has it been stored in
specialized tissue medium? Is it fresh? All these fac-
tors—source of tissue, extent of cornea replaced, type
of graft storage—play a role in determining the optical
clarity of the resultant graft.
Corneal tissue is obviously the most physiologic
choice for grafting into a diseased cornea. Compared
with conjunctival flaps or xenografts consisting of non-
corneal tissue, grafts of corneal origin are expected to
minimize scarring. Corneal transplantation has become
common in human ophthalmic practice, but it is not used
routinely in veterinary ophthalmology. There are several
explanations for this difference. First, accessibility to
fresh donor material is limited in veterinary practice.
The practice of eye banking requires a well-developed
system of communication and network of persons
involved in the collection of cadaver eyes. Corneal stor-
age materials are expensive. Because of difficulties in
harvesting and maintaining a supply of fresh donor
corneas, frozen corneal tissue has been used.16,17 These
corneas are stored in antibiotic solution in the freezer
section of a standard refrigerator. The corneas can be
stored for months (possibly years) and still serve as a
tectonic graft for a corneal defect. Unfortunately,
corneal endothelial and epithelial cells do not survive
frozen storage. Because these cells are vital for maintaining
corneal clarity, grafts lacking the cells are often opaque.
Corneal grafting of any variety, partial thickness or
full thickness, necessitates the use of microsurgical
instruments and adequate magnification, preferably
provided by an operating microscope. The surgeon must
also be skilled at microsurgery, with a thorough under-
standing of microsurgical techniques and procedures.
Partial-thickness (i.e., lamellar) keratoplasty has been
described for repair of deep ulcers, descemetoceles, and
perforated corneas.3,18,19 In these and other keratoplastic
procedures, as for conjunctival flaps and grafts, the
ulcer bed must first be debrided of any necrotic or
unhealthy tissue. A partial-thickness piece of cornea is
sutured directly over the corneal lesion, thereby providing
mechanical support to the diseased area. The potential
sources of donor tissue include self (autogenous lamellar
keratoplasty), another animal of the same species
(allogeneic lamellar keratoplasty), or possibly an animal of
another species (lamellar keratoplasty with xenograft).
Corneoscleral or corneoconjunctival transpositions are
similar to autogenous lamellar grafts, except that the grafts
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Deep Corneal Ulcers 203
remain attached to their original base.3,20 In corneoscleral
transpositions, a partial-thickness strip of cornea and
adjacent sclera is advanced into the defect and sutured in
place. Corneoscleral transpositions are particularly suited
for repair of a central corneal defect. Clear, healthy cornea
from a peripheral area is used to repair the central diseased
region, thereby attempting to preserve the clarity of the
visual axis. Because tissue from the same animal is used,
concern about rejection of the graft is reduced. Also,
fresh corneal tissue is advanced into the defect, thereby
theoretically reducing the amount of scarring.
Penetrating keratoplasty employs a full-thickness
graft of corneal tissue, either fresh or frozen, to correct
a full-thickness corneal defect.3,16,17,21–24 Penetrating ker-
atoplasty may be used to repair deep corneal ulcers or
descemetoceles, to excise corneal stromal abscesses in
horses (Figure 3) or corneal sequestra in cats, and to
provide a clear visual axis in severely scarred or edema-
tous corneas. A corneal trephine is used to prepare both
the donor and the recipient bed. Typically, the diameter
of the trephine used to harvest the donor corneal tissue
is slightly larger (0.2 to 0.5 mm) than that used to
prepare the recipient bed to allow slight shrinkage of
the donor graft. 3 Viscoelastic materials can be used
intraoperatively to fill the anterior chamber and prevent
its collapse until the donor cornea is sutured in place.3
Xenografts
Because of the difficulty and expense of obtaining
and storing fresh donor corneas of the same species to
be used in keratoplastic procedures, alternative tissues
have been proposed as graft materials. Experimental
penetrating keratoplasty has been performed with fresh
porcine corneal tissue but resulted in vascularization and
opacification in almost all cases.25 Equine amnion and
equine renal capsule have been used to repair corneal
defects in dogs.26–28 The cartilage of the third eyelid has
also been described as a possible xenograft for corneo-
scleral defects.29 Other tissues that have been applied in
human surgical procedures include split-thickness dermal
grafts30 and periosteal-fascia temporalis pedicle flaps.31
Perhaps the most commonly used xenograft today is a
biomaterial manufactured from porcine small intestinal
submucosa (Vet Bio SIS T, Cook Veterinary Products). It
is theorized that the submucosa provides a dense acellu-
lar collagen matrix that serves as a scaffold ingrowth of
cells, in this case, keratocytes. Vet Bio SIS T has been
used with a conjunctival graft in the repair of a cor-
neoscleral defect in a dog.32 Other authors have used this
material in cats as a lamellar graft for deep corneal ulcers
with minimal scarring.33 We have used this product to
replace corneal tissue after excision of corneal stromal
abscesses in horses. We have also used it in conjunction
204 Small Animal/Exotics
with a conjunctival pedicle flap to repair very deep or
perforated ulcers in dogs, cats, and horses. In eyes with
perforating ulcers, a conjunctival pedicle graft does not
always prevent the leakage of aqueous humor because
sutures are not placed around the entire circumference of
the lesion. When the Vet Bio SIS T graft is placed in the
ulcer bed, it can be circumferentially sutured to achieve a
watertight seal. The addition of the conjunctival pedicle
over the submucosa graft then facilitates growth of blood
vessels, which speeds healing and resolution of a corneal
infection, if present. Compared with other xenografts, Vet
Bio SIS T used alone may result in less significant scarring.
Further controlled studies are warranted to document
the usefulness and tissue reactions to these xenografts.
Postoperative Care
Postoperative care of these eyes, regardless of the
surgical procedure performed, is similar to postoperative
care of deep corneal ulcers that have been treated by
nonsurgical means. For tissues to heal well after surgery,
infection must be aggressively controlled by topical use
of antimicrobials.
Both medical and surgical therapy can have a role
in the management of deep corneal ulcers. Often, a
combination of both approaches is necessary to effectively
treat ulcers that are deeper than one-half to two-thirds
of the depth of the stroma, are rapidly progressing, or
do not respond to medical therapy alone. The various
surgical procedures can be tailored to suit the location
and depth of a particular lesion, as well as to achieve
the desired optical result.
ACKNOWLEDGMENT
The authors would like to thank Drs. Will Eward, Stephen
Swaim, and James Winkler for their review of this manuscript.
REFERENCES
1. Kenyon K, Chaves H: Morphology and pathologic response of
corneal and conjunctival disease, in Smolin G, Thoft RA (eds):
The Cornea. Boston, Little, Brown, 1994, pp 69–111.
2. Severin GA: Cornea, in Severin GA (ed): Severin’s Veterinary
Ophthalmology Notes. Fort Collins, CO, Design Pointe Commu-
nications, 1996, pp 289–292.
3. Gilger BC, Whitley RD: Surgery of the cornea and sclera, in
Gelatt K (ed): Veterinary Ophthalmology. Philadelphia, Lippincott
Williams & Wilkins, 1999, pp 675–700.
4. Scagliotti RH: Tarsoconjunctival island graft for the treatment
of deep corneal ulcers, descemetocoeles, and perforations in
35 dogs. Semin Vet Med Surg (Small Anim) 3:69–76, 1988.
5. Hakanson N: Conjunctival pedicle grafting in the treatment of
corneal ulcers in the dog and cat. JAAHA 23:641–648, 1987.
6. Nasisse M: Canine ulcerative keratitis. Compend Contin Educ
Pract Vet 7:686–701, 1985.
7. Wilkie DA, Whitaker CJG: Surgery of the cornea. Vet Clin
North Am Small Anim Pract 27:1067–1107, 1997.
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8. Refojo MF: Adhesives in ophthalmology: A review. Surv
Ophthalmol 15:217–236, 1971.
9. Erdey RA, Lindahl KJ, Temnycky GO, Aquavella JV: Techniques
for application of tissue adhesive for corneal perforations.
Ophthalmic Surg 22:352–354, 1991.
10. Kublin KS, Refojo MF: Closure of ocular lacerations with
an adhesive. JAVMA 156:313–318, 1970.
11. Leahy AB: Clinical experience with N-butyl cyanoacrylate
(Nexacryl) tissue adhesive. Ophthalmology 100:173–180, 1993.
12. Hakanson N: Further comments on conjunctival pedicle grafting
in the treatment of corneal ulcers in the dog and cat. JAAHA
24:602–605, 1988.
13. Holmberg DL: Conjunctival pedicle grafts used to repair
corneal perforations in the horse. Can Vet J 22:86–89, 1981.
14. Peiffer Jr RL, Gelatt KN, Gwin RM: Tarsoconjunctival pedicle
grafts for deep corneal ulceration in the dog and cat. JAAHA
13:387–391, 1977.
15. Kuhns EL: Conjunctival patch grafts used to repair corneal
lesions in dogs. Mod Vet Pract 31:301–305, 1979.
16. Hacker DV: Frozen corneal grafts in dogs and cats: A report on
19 cases. JAAHA 27:387–398, 1991.
17. Whitaker CJG, Smith P, Brooks D: Therapeutic penetrating
keratoplasty for deep corneal stromal abscesses in eight horses.
Vet Comp Ophthalmol 7:19–28, 1997.
18. McLaughlin SA, Brightman A, Brogdon J: Autogenous, partial-
thickness corneal graft for repair of a perforated corneal ulcer in
a horse. Vet Clin North Am Equine Pract 7:34–38, 1985.
19. Brightman A, McLaughlin SA: Autogenous lamellar corneal
grafting in dogs. JAVMA 195:469–475, 1989.
20. Parshall CJ: Lamellar corneal-scleral transposition. JAAHA
9:270–277, 1973.
21. Jensen EC: Experimental corneal transplantation in the dog.
JAVMA 142:11–22, 1963.
22. Keller WF, Blanchard GL: The clinical application of homologous
corneal and scleral grafts in the dog. JAAHA 9:265–269, 1973.
23. Dice PF, Severin GA, Lumb WV: Experimental autogenous and
homologous corneal transplantation in the dog. JAAHA 9:245–
251, 1973.
24. Asakura S: Experimental keratoplasty in the dog: The process of
graft clearing and the histological findings in the transplant in a
dog showing a typical keratoplasty reaction. J Vet Med Tokyo
606:22–28, 1974.
25. Chaves N: A histopathological study of swine corneas implanted
in dogs treated with cyclosporin A. Vet Noticias 3:87–93, 1997.
26. Barros PSM: Preserved equine aminiotic membrane used in the
repair of the cornea of the dog. Invest Ophthalmol Vis Sci
36:982–985, 1995.
27. Barros PSM: The use of xenologous amniotic membrane to repair
canine corneal perforation created by penetrating keratectomy.
Vet Ophthalmol 1:119–123, 1998.
28. Andrade AL, Laus JL: The use of preserved equine renal capsule
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2:79–82, 1999.
29. Blogg JR, Dutton AG, Stanley RG: The use of third eyelid grafts
to repair full-thickness defects in the cornea and sclera. JAAHA
25:505–512, 1989.
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to repair corneal and scleral defects—A study of 10 patients.
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31. Spoor TC, Ramocki JM, Cowden JW: A periosteal-temporalis
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extruding keratoprostheses. Am J Ophthalmol 109:704–708, 1989.
32. Lewin GA: Repair of a full thickness corneoscleral defect in a
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Annu Meet Am Coll Vet Ophthalmol:27, 1999.
ARTICLE #3 CE TEST
CE
The article you have read qualifies for 1.5 con-
tact hours of Continuing Education Credit from
the Auburn University College of Veterinary Med-
icine. Choose the best answer to each of the follow-
ing questions; then mark your answers on the
postage-paid envelope inserted in Compendium.
1. Possible indications for surgical management of
corneal ulcers include all of the following except
a. a rapidly progressing corneal ulcer.
b. an ulcer that has not responded to medical therapy.
c. an ulcer that has eroded one-half of the depth of
the corneal stroma.
d. an ulcer that has abundant corneal neovascularization.
2. Which of the following is not an advantage of
conjunctival flaps?
a. They provide increased mechanical strength to the
ulcer bed.
b. They cause decreased scarring of the cornea compared
with that achieved by medical management.
c. They are a source of anticollagenases and antiproteases
from serum.
d. They provide a source of fibrovascular tissue to line
the ulcer bed and fight infection.
3. The main disadvantage of conjunctival flaps is
a. opacification of the graft site that can interfere with
vision.
b. the high rate of dehiscence.
c. the high rate of corneal perforation during surgery.
d. the prolonged period until the flap heals in the
corneal ulcer bed.
4. Which of the following is not considered an advantage
of frozen corneal tissue used in grafts?
a. graft clarity once healing is complete
b. stronger wound closure compared with conjunctival
grafts
c. decreased scarring compared with conjunctival
grafts
d. inexpensive storage in the freezer section of a
standard refrigerator
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Deep Corneal Ulcers 205
5. What is the main disadvantage of frozen corneal grafts?
a. the need for microsurgical instruments and clinician
experience in microsurgical technique
b. the need for expensive corneal storage media that
must be replaced frequently
c. a high rate of wound dehiscence
d. the need for extensive tissue typing
6. Cyanoacrylate ophthalmic tissue adhesive can be
employed in which of the following situations?
a. extensive perforating corneal lacerations
b. corneoscleral lacerations
c. temporary tarsorrhaphy
d. deep stromal ulcer
7. Which of the following is not considered a problem of
direct suturing of descemetoceles?
a. Distortion of the globe is possible.
b. Unhealthy edges of the descemetocele may not be
strong enough to retain sutures.
c. With large descemetoceles, the sutures may be
under substantial tension.
d. Substantial corneal scarring may result.
8. Which of the following is not considered an advantage
of orneoscleral transpositions?
a. The central visual axis is preserved.
b. Peripheral corneal scarring is substituted for central
corneal scarring.
c. Autogenous corneal tissue is used, thereby reducing
the potential for scarring.
d. The potential for scarring is reduced because full-
thickness tissue is used.
9. Which of the following does not characterize medical
therapy for deep corneal ulcers?
a. Culture and sensitivity testing help in determining
the proper choice of antimicrobial.
b. Aggressive medical therapy is often required in
addition to surgical therapy.
c. Cytology and Gram’s staining are useful for deter-
mining the initial choice of antimicrobial, until
results of definitive testing become available.
d. Surgical therapy often obviates the need for intensive
medical therapy.
10. Possible causes of corneal ulcers include all of the
following except
a. prolonged exposure to ultraviolet light.
b. keratoconjunctivitis sicca.
c. viral infections.
d. trauma.