Double-Layer Gundersen Flap as an Eye-Saving Procedure

Joelle Thorgrimson1 and Sanjoy K. Gupta*1

1Northern Ontario School of Medicine, Lakehead University, Thunder Bay, Canada. 

*Corresponding Author: Sanjoy K. Gupta, MD, PhD, FRCSC, Northern Ontario School of Medicine, Lakehead University, Thunder Bay, Canada. Email:

Received: April 15, 2019; Accepted: May 03, 2019; Published: May 31, 2019


Purpose:  To present a case that illustrates how double-layer Gundersen flaps are a useful procedure to treat full-thickness corneal perforations, especially in rural and remote communities.

Design/Methods: Case report.

Results: A double-layer Gundersen flap was used to repair a perforated corneal ulcer secondary to a rheumatoid melt. Evisceration of the eye was prevented and vision was returned to baseline within one week.

Conclusions: Gundersen flaps are an under-utilized modality to treat corneal perforations.  This procedure is a facile eye-saving procedure especially in rural and remote communities.

Keywords: Gundersen flap, corneal perforation


Since the nineteenth century, conjunctival flaps have been used as a conventional treatment to resistant corneal disease such as herpetic ulcers, recurrent erosions, bullous keratopathy, marginal ulcers, painful blind eyes and filamentary keratitis (Gundersen, 1958). In 1960, Gundersen described a new technique, now called the Gundersen or bucket-handle flap, which provided a permanent option with increased efficacy for treatment resistant corneal disease (Gundersen, 1960). The Gundersen flap is repeatedly cited as an under-utilized modality in treating complicated corneal disease with chronically compromised corneal surfaces (Alino et al., 1998; Gundersen, 1960; Kim et al., 2013; Lim et al., 2009). Other extenuating circumstances, particularly true to the patient population in Northern Ontario, include difficulty in the transportation of patient due to location, age and comorbidities. We present a case in which a Gundersen flap was used to treat a full-thick corneal perforation in an elderly patient as an eye-saving procedure, preventing imminent evisceration or enucleation.

Case Report

A 92-year-old female with known macular degeneration was referred for an urgent ophthalmologic consult for a progressive 1-month-old non-healing corneal ulcer in the right eye. The initial treatment with a fourth-generation fluoroquinolone led to worsening of the ulcer.

On further questioning, the patient reported a long-standing history of rheumatoid arthritis. Therefore, a diagnosis of a corneal melt secondary to rheumatoid arthritis was considered more likely.  On examination, the patient had a visual acuity of 20/400 and a mid-peripheral corneal ulcer with thinning to 80-90% at the centre. The ulcer spanned 2 mm and was approximately 4 mm from the limbus at the 4 o’clock position. There was early formation of a descemetocele. There was no evidence of a hypopyon.

A bandage lens was placed over the eye and the patient was scheduled for an urgent Gundersen flap in 5 days. However, in 48 hours, the patient returned to the clinic with reported decrease in vision. There was marked flattening of the anterior chamber on slit-lamp examination with no evidence of a hypopyon. The patient was brought to the operating room the same evening for emergency repair via a double-layer Gundersen flap.

Using two Q-tips, the eyelids were retracted and an Op-site dressing placed over the eye. One drop of 0.5% tetracaine and one drop of 5% povidone-iodine were placed in the right eye. A head drape was fashioned with two sterile towels. With an operating microscope, two 6-0 silk sutures were place at the 6-o’clock and 12-o’clock positions as retraction sutures. First, the eye was retracted to the downward position to expose the superior conjunctiva. Using a marker, a 3×3 mm square of conjunctival tissue was marked near the limbus. As the conjunctival patch was carefully excised, 9-0 sutures were placed at each corner of the conjunctival square tissue (Figure 1).

Figure 1: Conjunctival tissue used to patch corneal perforation.
Figure 1: Conjunctival tissue used to patch corneal  perforation.

Using four 9-0 sutures, the conjunctival flap was sutured to the cornea to cover the perforation acting as a plug.  Care was taken to ensure the primary conjunctival flap was tight, and covered the entire perforation.  Next, a 3 mm wide circumferential conjunctival flap from 12-o’clock to 6-o’clock was raised along with underlying Tenon’s membrane and lifted to cover the perforation.

The ‘bucket-handle’ conjunctival flap, which was still attached at 12-o’clock and 6-o’clock, was then sutured to the cornea using a combination of 7-0 vicryl and 9-0 nylon sutures. 9-0 nylon sutures were used to anchor the flap at the limbus and alternating 7-0 vicryl and 9-0 nylon sutures were placed along each side of the conjunctival flap from limbus to limbus. Care was taken to avoid sutures through the visual axis as far as possible. At the end of the procedure, the anterior chamber was deep and formed (Figure 2). A double eye patch was placed overnight.

Figure 2: Post-operative Gundersen flap.

One-week post-operatively, the patient reported an improvement in vision to her original baseline of 20/200. The anterior chamber was formed and deep with no signs of infection. The visual acuity remained stable over the next three-months and nylon sutures were subsequently removed one at a time (Figure 3).

Figure 3: Three-month post-operative Gundersen flap.


Gundersen flaps have been used for corneal perforation, non-healing epithelial defects secondary to herpetic keratitis, and exposure keratopathy, as well as corneal thinning secondary to previous ulcers, herpetic disease, bacterial infections, and trichiasis (Gundersen, 1958). The advantage over corneal transplants are fourfold. First, the patient’s own tissue is readily available, avoiding the delay in accessing donor tissue. Second, follow-up guidelines are less stringent as corneal rejection is not a complication (Kim et al., 2016).  This is a significant advantage in rural and remote communities. Third, the procedure can be done in an ambulatory care setting if needed. Fourth, there is an extremely high success rate. Two studies discussing success rate of Gundersen flaps quote complication rates <30% (Gundersen and Pearlson, 1969; Lim et al., 2009). Complications included buttonhole, partial flap retraction, epithelial inclusion cyst, fluid accumulation under flap, fenestration in flap and <5% enucleation.  The advantages of the Gundersen flap as a eye-saving procedure were highlighted by Lim and co-workers: “The Gundersen flap is still an important procedure and should be considered as a means of stabilizing globe integrity in the management of cases of severe ocular surface disease, particularly when visual potential is poor” (Lim et al., 2009).

Specific to Northwestern Ontario, over the last 14 years, there have been 21 Gundersen flaps completed in Thunder Bay for impending/full thickness corneal perforations and for corneal pain control (Table 1) by a single surgeon (S.K.G.).  Of the impending/full thickness perforated cases, there were six different etiologic presentations including exposure keratopathy, herpetic, rheumatoid melt, bacterial ulcers, penetrating trauma and anesthetic cornea. Six cases of exposure keratopathy were secondary with Amyotrophic Lateral Sclerosis, diabetes, thyroid eye disease and Grave’s disease. One case of anesthetic-induced non-healing ulcers was secondary to morphine-desensitization in a patient with metastatic cancer. All of these procedures prevented enucleation.  Of note was the patient with metastatic cancer who expressed a wish to die without losing her eye to enucleation.  The Gundersen flap was also successful in pain control in five patients with bullous keratopathy.

Etiology Number of patients
Impending/full-thickness corneal perforation
Exposure keratopathy 6
Herpetic 5
Rheumatoid melt 2
Bacterial ulcers 1
Penetrating trauma 1
Anesthetic cornea 1
Corneal pain control
Bullous keratopathy 5

Table 1: Etiologic reason for Gundersen flap surgery in Thunder Bay, Ontario.

Vision loss has the highest direct health care cost of any disease category in Canada, surpassing diabetes, cancer, musculoskeletal, respiratory, mental health, and cardiovascular diseases (Cruess et al., 2011). Specifically, Northern Ontario has a higher disease burden than the rest of Canada (Ministry of Health and Long-Term Care, 2011). We wish to highlight the Gundersen flap as a facile procedure to reduce the frequency of enucleation and overall healthcare cost in rural, remote communities.


With the high success rate, the Gundersen flap technique, single-layer or double-layered as described here, should be considered as a viable option for treatment of many ophthalmologic conditions that eventually would result in removal of the eye. Extenuating circumstances including location, age and comorbidities of the patient may also affect the ophthalmologist’s decision to proceed with this facile eye-saving procedure. Ultimately, this could reduce the associated cost to the Canadian healthcare system.


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