Combined surgery preserves eye structure in severe herpes-related corneal ulcers

A retrospective case series from a regional hospital in China reports that a three-part surgical approach combining corneal ulcer debridement, conjunctival flap grafting, and amniotic membrane transplantation was associated with short-term preservation of corneal structure and suppression of intraocular inflammation in eyes affected by severe necrotizing stromal herpes simplex keratitis. The condition, in which herpes simplex virus infection destroys the corneal stroma, can progress to full-thickness perforation of the cornea and threaten the survival of the globe itself. The study, published in BMC Ophthalmology, followed 14 eyes of 14 patients treated at Qiandongnan Miao and Dong Autonomous Prefecture People’s Hospital between January 2020 and December 2025.

All patients in the series had a stromal thickness of 210 micrometers or less at the ulcer bed and either an established perforation or an impending one. Six eyes, or 42.9 percent of the cohort, had overt corneal perforation before surgery, and eight eyes had hypopyon, a collection of inflammatory cells in the anterior chamber of the eye. The cohort comprised six men and eight women with a mean age of 55.3 plus or minus 7.6 years. In addition to the surgical intervention, all patients received standardized topical and systemic anti-infective and anti-inflammatory therapy.

Corneal ulcer debridement removes necrotic and infected tissue from the ulcer bed. The conjunctival flap graft brings vascularized tissue over the thinned or perforated area, providing a biological patch that supports healing. Amniotic membrane transplantation adds a further layer derived from the fetal membrane, which is used in ophthalmic practice to support epithelial regrowth.

Follow-up was scheduled at postoperative day 1, week 1, week 2, month 1, month 3, month 6, and month 12. The researchers assessed best-corrected visual acuity, corneal opacity score, corneal neovascularization grade, conjunctival and limbal injection scores, anterior chamber depth, thickness of the composite repair layer at the ulcer bed, time to epithelialization, resolution of hypopyon, and postoperative complications. Statistical comparisons between baseline and one month used paired t-tests and Wilcoxon signed-rank tests, while follow-up at three, six, and twelve months relied on qualitative telephone interviews rather than in-person examination.

The short-term anatomical results were notable. Time to full epithelialization averaged 5.6 plus or minus 1.0 days. All six eyes that had tested positive for aqueous leakage on preoperative Seidel testing showed no detectable leakage after postoperative week 1. Among the eyes with hypopyon, complete resolution occurred at a median of 7.0 days, with a range of 0 to 14 days, and stromal edema resolved within 9.6 plus or minus 3.2 days. Every conjunctival flap remained viable, with no necrosis, retraction, or displacement recorded.

Quantitative measurements at one month showed statistically significant changes across most parameters. Best-corrected visual acuity, measured on the Logarithm of the Minimum Angle of Resolution scale, improved from 2.07 plus or minus 0.66 to 1.52 plus or minus 0.69, at a P value below 0.001. The median corneal opacity score declined from 4, with an interquartile range of 3 to 4, to 2, with an interquartile range of 2 to 3, at P equal to 0.003. Median conjunctival and limbal injection grades fell from 2, with an interquartile range of 1 to 3, to 0, with an interquartile range of 0 to 1, both at P equal to 0.001. Anterior chamber depth increased from 1.84 plus or minus 0.92 millimeters to 2.49 plus or minus 0.24 millimeters at P equal to 0.048. The thickness of the composite repair layer at the ulcer bed increased from 99.53 plus or minus 63.38 micrometers to 516.49 plus or minus 84.14 micrometers at P below 0.001.

One parameter moved in the opposite direction. The corneal neovascularization grade increased from a median of 2, with an interquartile range of 2 to 3, to a median of 3, with an interquartile range of 3 to 3, at P equal to 0.008. The authors also documented no secondary glaucoma, endophthalmitis, persistent epithelial defects, flap necrosis, or herpes simplex virus recurrence across the variable follow-up durations.

The authors are explicit about the interpretive limits of their data. They note that the observed clinical changes represent associations derived from combined surgical and pharmacologic management and cannot be solely attributed to the surgical intervention alone. Because every patient received both the three-part procedure and standardized drug therapy, the design cannot separate the contribution of the surgery from that of the medication. The retrospective, uncontrolled case-series format, with 14 eyes and no comparison group, further constrains causal inference. Follow-up beyond one month depended on telephone interviews, which cannot substitute for measured visual acuity or slit-lamp examination.

The conclusion the authors draw is measured rather than triumphant. They describe the operation as a multimodal globe-salvaging tectonic procedure that yielded limited visual rehabilitation despite statistically improved short-term best-corrected visual acuity, and they emphasize that it is not intended for optical reconstruction. In practical terms, the operation aims to keep the eye intact and quiet, not to restore clear vision. The study was not registered as a clinical trial, and the authors present it as an observational description of a surgical approach used in a specific clinical setting.

Subject of Research: Surgical management of perforated or impending perforated necrotizing stromal herpes simplex keratitis using combined corneal debridement, conjunctival flap grafting, and amniotic membrane transplantation

Article Title: Combined corneal ulcer debridement, conjunctival flap grafting, and amniotic membrane transplantation for perforated or impending perforated necrotizing stromal herpes simplex keratitis

Article References: Ran, M., Liu, Y., Liu, Y., Yang, Q., Qin, Y., Ding, M., He, K., Ouyang, X., & Pang, K. (2026). Combined corneal ulcer debridement, conjunctival flap grafting, and amniotic membrane transplantation for perforated or impending perforated necrotizing stromal herpes simplex keratitis. BMC Ophthalmology. https://doi.org/10.1186/s12886-026-05477-2

Image Credits: AI Generated

DOI: 10.1186/s12886-026-05477-2

Keywords: herpes simplex keratitis, corneal perforation, conjunctival flap, amniotic membrane transplantation, corneal debridement, necrotizing stromal keratitis, tectonic surgery, case series, ophthalmology, corneal neovascularization, globe salvage, BMC Ophthalmology