Management of Corneal Perforation

Eckardt Keratoprosthesis for Tectonic Repair of a Large Corneal Perforation

PURPOSE

To report on the use of the Eckardt keratoprosthesis as an emergency temporary tectonic seal for a full-thickness, large decentered corneal perforation.

METHODS

Case report and review of the literature.

RESULTS

A 47-year-old male patient with myotonic dystrophy presented with a large corneal perforation as a complication of chronic ulceration caused by lagophthalmia and recurrent herpetic keratitis. The perforation was triggered by a superinfection with Gram-positive bacteria. In an emergency setting where no donor cornea was available, the Eckardt keratoprosthesis was sutured into the debrided corneal defect as a tectonic measure. A secondary procedure, consisting of open sky cataract extraction combined with penetrating keratoplasty was performed 3 weeks later. During this period, the prosthesis was well tolerated and the anterior chamber stayed well formed.

CONCLUSIONS

The Eckardt keratoprosthesis allowed us to convert what would have been an emergency à chaud keratoplasty into a well-controlled elective procedure. In our case, the silicone prosthesis was well tolerated during the 3-week period while awaiting final repair with a corneal donor button.

Solid Platelet Rich Plasma in Corneal Surgery

Abstract

Solid eye platelet-rich plasma (E-PRP) concentrates platelets in a small volume of plasma which contains a high concentration of important growth factors and cell adhesion molecules. These cell adhesion molecules and growth factors occupy a major role in wound healing and enhance the physiological procedure at the site of the injury or the surgery. There are different materials used to tectonically maintain the solid clot attached at the site where treatment is necessary. Although AM may be used for this purpose, other biomaterials such a bovine pericardium or autologous fibrin membrane are at least as effective with less interdonor variations, no biological hazards, providing a better surgical alternative than the biologically so variable amniotic membrane patch. Solid platelet-rich plasma in the form obtained in ophthalmology, E-PRP, is a reliable and effective surgical coadjuvant to promote corneal wound healing in severe corneal ulcers and corneal perforations, and may be associated with other ocular surface reconstruction procedures.

Funding

Supported in part by a grant from the Spanish Ministry of Science and Innovation, Centro para el Desarrollo Tecnológico Industrial (CDTI), CENIT: “Customized Eye Care”, CeyeC (CEN-20091021).

Giant Ocular Horn Occurring in a 10-Year-Old Female

Cutaneous horns uncommonly involve the periocular region. Involvement of the ocular surface is particularly rare. The authors present a patient who underwent a perinatal buccal mucosal graft for corneal perforation due to congenital corneal ectasia, most likely resulting from Peters anomaly. She developed a giant ocular horn 10 years later.

Management of inflammatory corneal melt leading to central perforation in children: a retrospective study and review of literature

PURPOSE

To assess the outcome of early therapeutic penetrating keratoplasty (PKP) for corneal melt leading to perforation in children.

METHODS

Case notes of all the consecutive patients presenting with acute corneal perforation that underwent urgent therapeutic PKP between 2000 and 2010 to the practice of one of the authors, both NHS at Great Ormond Street Hospital for Children and private, were retrospectively reviewed. Onset of perforation, underlying cause, medical and surgical treatment, pre- and post-operative visual acuity, graft clarity, length of follow-up, and post-operative complications were recorded.

RESULTS

Four eyes of four consecutive patients (mean age of 9.5 years and median 8.5 years, range 4-17 years) were treated for acquired acute onset corneal perforations. There were three females and one male. Etiologies included herpes simplex keratitis secondary to immune recovery disease post bone marrow transplantation, acanthamoeba keratitis, recessive dystrophic epidermolysis bullosa, and blepharokeratoconjunctivitis with acne rosacea. Pre-operative visual acuity ranged from hand movements to 6/150. All the patients had severe anterior chamber inflammation. All eyes improved in visual acuity ranging from 6/9 to 6/18 with clear grafts at last follow-up. There was no recurrence of melt or perforation. Mean follow-up was 67 months (median 44 months).

CONCLUSION

PKP during the acute phase together with aggressive medical therapy and close follow-up may achieve good visual outcomes in children with corneal melt with perforation and should be considered. Waiting may sometimes allow the marked inflammatory response seen in children to cause irreversible structural and/or functional damage.

Use of Fish Scale-Derived BioCornea to Seal Full-Thickness Corneal Perforations in Pig Models

The aim of this study was to test the use of BioCornea, a fish scale-derived collagen matrix for sealing full-thickness corneal perforations in mini-pigs. Two series of experiments were carried out in 8 Lan-Yu and 3 Göttingen mini-pigs, respectively. A 2mm central full thickness corneal perforation was made with surgical scissors and 2mm trephines. The perforations were sealed immediately by suturing BioCornea to the wounded cornea. The conditions of each patched cornea were followed-up daily for 3 or 4 days. Status of operated eyes was assessed with slit lamp examination or optical coherence tomography (OCT). Animals were sacrificed after the study period and the corneas operated were fixated for histological examination. Both OCT imaging and handheld slit lamp observations indicated that a stable ocular integrity of the perforated corneas was maintained, showing no leakage of aqueous humor, normal depth of anterior chamber and only mild swelling of the wounded cornea. Hematoxylin and eosin staining of the patched cornea showed no epithelial ingrowths to the perforated wounds and no severe leucocyte infiltration of the stroma. The fish scale-derived BioCornea is capable to seal full-thickness corneal perforation and stabilize the integrity of ocular anterior chamber in pre-clinic mini-pig models. BioCornea seems to be a safe and effective alternative for emergency treatment of corneal perforations.

Treatment of corneal perforation with lenticules from small incision lenticule extraction surgery: a preliminary study of 6 patients

PURPOSE

To evaluate the use of lenticules extracted using small incision lenticule extraction (SMILE) surgery as a surgical alternative for wound closure in corneal perforation.

METHODS

Corneal lenticules obtained through SMILE surgery with central thickness >100 μm were fixed over corneal perforation sites using 10-0 nylon interrupted stitches. Patients were monitored for a minimum of 1 year and were assessed using slit-lamp microscopy, fluorescein, digital tonometry, and best spectacle-corrected visual acuity (BSCVA) measurements. Postoperative complications throughout the study period were recorded.

RESULTS

Corneal perforations were successfully sealed in all 6 patients; 3 patients (50%) exhibited improved postoperative BSCVA. Between 3 and 4 weeks after the operation, part of the lenticules became incorporated into the corneal stroma and complete reepithelialization was achieved. During the follow-up period of 12 months, no evidence of infection, relapse, or perforation was detected in any patient.

CONCLUSIONS

These preliminary findings suggest that the use of corneal lenticules may be a safe and effective surgical alternative for corneal perforation closure, with potential clinical application as relatively simple and inexpensive temporary measures to improve the condition of the cornea for further definitive interventions.

Presentation and Management Outcomes of Corneal and Scleral Perforations in Geriatric Nursing Home Residents

We compared the clinical presentation and treatment outcomes of corneal and scleral perforations in geriatric nursing home residents, geriatric community residents, and non-geriatric population. The medical records of patients who were treated for corneal and scleral perforations at the Prince of Wales Hospital, Hong Kong between January 1, 2004 and May 1, 2013, were reviewed retrospectively. Of 144 cases, 53 (37%) occurred in the geriatric population, of which 16 (11%) lived in nursing homes, and 37 (26%) were community residents. There were 91 (63%) patients in the non-geriatric group. The mean age of the patients in nursing home geriatric group was 86.5 years (87.5% females). The most common etiology of perforation was trauma. Rupture due to fall was more common in geriatric patients (P < 0.001) whereas laceration due to penetrating eye injury was more common in non-geriatric patients (P < 0.001). There were more cases of infection leading to spontaneous perforation in geriatric nursing home group compared to the other groups (P = 0.001). In the geriatric nursing home group, visual acuity at presentation (P < 0.001) and postoperative visual acuity (P = 0.012) was worse compared to the other groups. Our study showed that corneal and scleral perforations in the geriatric nursing home residents carry a poor visual prognosis. The causes and anatomical outcomes of such events in geriatric age group differ from those in the general population. In our study, geriatric patients residing in nursing homes had worse baseline as well as posttreatment visual acuity, compared to community residents.

Eye platelet-rich plasma in the treatment of ocular surface disorders

PURPOSE OF REVIEW

Blood-derived products [autologous serum, eye platelet-rich plasma (E-PRP), plasma rich in growth factors] are successful therapies for ocular surface disorders, which compromise the integrity of the cornea surface and conjunctiva.

RECENT FINDINGS

The most noteworthy and recent research has been directed towards hemoderivatives that include platelets. PRP for ophthalmologic use (E-PRP) has achieved successful outcomes as reported in the peer-review literature in the treatment of dry eye, post-laser in-situ keratomileusis ocular surface syndrome, dormant ulcers, and for ocular surface surgical reconstruction after corneal perforation associated to amniotic membrane transplantation, bovine pericardium membrane transplantation, or autologous fibrin membrane combined with solid PRP clot.

SUMMARY

PRP is a portion of the patient's own blood having a platelet concentration above baseline. The main advantage of PRP over other products is the presence of the platelets and associated with this the prolonged release of growth factors that are involved in the wound healing process of the cornea and conjunctival surface. E-PRP seems to be a reliable and effective therapeutic approach to enhance epithelial wound healing and promote ocular surface regeneration in different pathological conditions.

Lamellar keratoplasty treatment of fungal corneal ulcers with acellular porcine corneal stroma

The fundamental problem of corneal transplantation is a severe shortage of donor tissues worldwide, resulting in approximately 1.5 million new cases of blindness annually. To explore an alternative to donor corneas, we conducted a clinical study in which implanted acellular porcine corneal stromas (APCSs) replaced the pathologic anterior corneas in 47 patients who had experienced fungal corneal infections. Subsequently, we demonstrated the safety and efficacy of APCSs in human keratoplasty for a minimum follow-up period of 6 months, during which time no recurrence of infection was observed. All corneal ulcers healed with the return of neovascularization. In addition, our results indicated that epithelialization occurred in all APCS grafts except four grafts; for these four, the grafts dissolved to varying degrees. Furthermore, most porcine grafts (n = 41) gradually became transparent without rejection, and an improvement of more than two lines in best corrected visual acuity (BCVA) was achieved in 34 eyes (∼72%). Finally, no patients showed any severe adverse reaction or any significant change in postoperative systemic safety indicators. Thus, we concluded that APCS grafts are safe and efficacious during lamellar keratoplasty in treating corneal fungal ulcers and potentially for other clinical diseases.

Therapeutic sectorial full-thickness sclero-keratoplasty for recurrent fungal keratitis

OBJECTIVE

To report the management of a severe and recurrent fungal keratitis that required repeated penetrating keratoplasties. Despite multiple topical, intraocular and systemic antifungal treatments, superotemporal hyphal infiltration repeatedly penetrated the corneal transplant causing continuous recurrences. Cultures collected before and during surgery isolated the same organism, Fusarium spp.

CONCLUSION

Corneal infection extending to the sclera and internal angle structures is the main cause of recurrence of fungal keratitis after corneal transplantation. Sectorial full-thickness sclero-keratoplasty combined with a central penetrating keratoplasty should be a surgical technique to be considered in cases where these locations are suspected to be the source of recurrence. It enables a definitive elimination of the infection, with excellent final visual acuities. No postoperative complications were reported in this case.

Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital

Purpose

To report surgical therapies for corneal perforations in a tertiary referral hospital.

Methods

Thirty-one eyes of 31 patients (aged 62.4±18.3 years) with surgically treated corneal perforations from January 2002 to July 2013 were included in this study. Demographic data such as cause of corneal perforation, surgical procedures, and visual outcomes were retrospectively analyzed.

Results

The causes of corneal perforation (n=31) were divided into infectious (n=8, 26%) and noninfectious (n=23, 74%) categories. Infectious causes included fungal ulcer, herpetic stromal necrotizing keratitis, and bacterial ulcer. The causes of noninfectious keratopathy included corneal melting after removal of a metal foreign body, severe dry eye, lagophthalmos, canaliculitis, the oral anticancer drug S-1, keratoconus, rheumatoid arthritis, neurotrophic ulcer, atopic keratoconjunctivitis, and unknown causes. Initial surgical procedures included central large corneal graft (n=17), small corneal graft (n=7), and amniotic membrane transplantation (n=7). In two cases the perforation could not be sealed during the first surgical treatment and required subsequent procedures. All infectious keratitis required central large penetrating keratoplasty to obtain anatomical cure. In contrast, several surgical options were used for the treatment of noninfectious keratitis. After surgical treatment, anatomical cure was obtained in all cases. Mean postoperative best corrected visual acuity was better at 6 months (logMAR 1.3) than preoperatively (logMAR 1.8).

Conclusion

Surgical therapies for corneal perforations in our hospital included central large lamellar/penetrating keratoplasty, small peripheral patch graft, and amniotic membrane transplantation. All treatments were effective. Corneal perforation due to the oral anticancer drug S-1 is newly reported.

Modified tectonic keratoplasty with minimal corneal graft for corneal perforation in severe Stevens--Johnson syndrome: a case series study

Background

Corneal perforation in severe Stevens-Johnson syndrome (SJS) presenting great therapeutic difficulties, the imperative corneal transplantation always result in graft failure and repeated recurrence of perforation. The aim of this study was to evaluate the effectiveness of a modified small tectonic keratoplasty (MSTK) with minimal corneal graft in the management of refractory corneal perforation in severe SJS.

Methods

Refractory corneal perforations in ten patients (10 eyes) with severe SJS were mended with a minimal corneal patch graft, under the guidance of anterior chamber optical coherence tomography, combined with conjunctival flap covering. The outcome measures included healing of the corneal perforation, survival of the corneal graft and conjunctival flap, relevant complications, and improvement in visual acuity.

Results

Corneal perforation healed, and global integrity was achieved in all eyes. No immune rejection or graft melting was detected. Retraction of conjunctival flap occurred in one eye, which was treated with additional procedure. Visual acuity improved in six eyes (60%), unchanged in three eyes (30%) and declined in one eye (10%).

Conclusions

The MSTK combined with conjunctival flap covering seems to be effective for refractory corneal perforation in severe SJS.

Simultaneous study of matrix metalloproteinases, proinflammatory cytokines, and soluble cytokine receptors in the tears of noninfectious corneal ulcer patients

BACKGROUND

We investigated the presence of matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), proinflammatory cytokines, and soluble cytokine receptors in the tear fluid of patients with noninfectious corneal ulcers in the peripheral cornea.

METHODS

The subjects were 20 eyes of 17 patients with peripheral noninfectious corneal ulcers and 20 eyes of 20 volunteers. Tear samples were taken by the Schirmer test I method and the presence of MMPs (MMP-1, MMP-2, MMP-3, MMP-8, MMP-9, MMP-10, and MMP-13) and TIMPs (TIMP-1, TIMP-2, and TIMP-4) were investigated using an MMP antibody array system. The concentrations of proinflammatory cytokines {IL-1β, IL-6, and TNF-α (tumor necrosis factor-alpha)} and soluble cytokine receptors {soluble (s) IL-1R1, sIL-1R2, sIL-2Rα, sIL-4R, sIL-6R, sTNFR1, sTNFR2, s-vascular endothelial growth factor receptor (VEGFR) 1, sVEGFR2, sVEGFR3, and sgp130} were determined using the multiplex bead immunoassay system.

RESULTS

The concentrations of MMP-8 and MMP-9 were significantly up-regulated in the tear fluid of the ulcer patients, whereas TIMPs concentrations did not change. The concentrations of IL-1β, IL-6, sIL-1R2, sIL-6R, sTNFR1, and sTNFR2 were up-regulated in the ulcer patients, whereas sgp130 and sVEGFR1 concentrations significantly decreased.

CONCLUSIONS

The presence of some MMPs increased significantly in the patients with peripheral noninfectious corneal ulcers, whereas the presence of TIMPs remained unchanged. Although some proinflammatory cytokines were up-regulated, their antagonists, soluble cytokine receptors, were also up-regulated. It is thus possible that the up-regulation of MMPs disrupts the balance between the MMPs and TIMPs and that this balance may play a pivotal role in the pathophysiology of corneal ulceration.

Diagnosis and management of neurotrophic keratitis

Neurotrophic keratitis (NK) is a degenerative disease characterized by corneal sensitivity reduction, spontaneous epithelium breakdown, and impairment of corneal healing. Several causes of NK, including herpetic keratitis, diabetes, and ophthalmic and neurosurgical procedures, share the common mechanism of trigeminal damage. Diagnosis of NK requires accurate investigation of clinical ocular and systemic history, complete eye examination, and assessment of corneal sensitivity. All diagnostic procedures to achieve correct diagnosis and classification of NK, including additional examinations such as in vivo confocal microscopy, are reviewed. NK can be classified according to severity of corneal damage, ie, epithelial alterations (stage 1), persistent epithelial defect (stage 2), and corneal ulcer (stage 3). Management of NK should be based on clinical severity, and aimed at promoting corneal healing and preventing progression of the disease to stromal melting and perforation. Concomitant ocular diseases, such as exposure keratitis, dry eye, and limbal stem cell deficiency, negatively influence the outcome of NK and should be treated. Currently, no specific medical treatment exists, and surgical approaches, such as amniotic membrane transplantation and conjunctival flap, are effective in preserving eye integrity, without ameliorating corneal sensitivity or visual function. This review describes experimental and clinical reports showing several novel and potential therapies for NK, including growth factors and metalloprotease inhibitors, as well as three ongoing Phase II clinical trials.

Fibrin glue-assisted for the treatment of corneal perforations using glycerin-cryopreserved corneal tissue

AIM

To evaluate the outcomes and safety of lamellar keratoplasty (LK) assisted by fibrin glue in corneal perforations.

METHODS

Six eyes of 6 patients affected by different corneal pathologies (2 posttraumatic corneal scar and 3 bacterial keratitis) underwent LK procedures by using fibrin glue. The mean corneal perforation diameter was 1.35±0.64mm (range, 0.7-2.5mm), and the greatest diameter of the ulcerative stromal defect was 2.47±0.77mm in average (range, 1.5-3.5mm). The donor corneal lamella diameters were 0.20-mm larger and thicker than the recipient to restore a physiologic corneal thickness and shape: mean donor diameter was 8.34±0.28mm (range, 8.2-8.7mm) and mean thickness was 352±40.27mm (range, 220-400mm). Mean follow-up was 7.33±1.97 months (range, 6-11 months). Postoperatively, the graft status, graft clarity, anterior chamber response, the visual prognosis, intraocular pressures, and postoperative complications were recorded.

RESULTS

All the corneal perforations were successfully healed after the procedure. The best-corrected visual acuity (BCVA) ranged from 20/1 000 to 20/50 in their initial presentation, and from 20/100 to 20/20 in their last visit, showed increase in all the patients. No major complications such as graft dislocation and graft failure were noted. Neovascularization developed in the superficial stroma of donor graft in 1 case. High intraocular pressure developed on day 2 after surgery, while was remained in normal range after application of anti-glaucomatous eyedrops for 1 week in 1 case.

CONCLUSION

Fibrin glue-assisted sutureless LK is valuable for maintaining the ocular integrity in the treatment of corneal perforations.

Sclerokeratoplasty as the Therapy for Corneal Perforation due to Exposure and Neurotrophic Keratopathy

A case report of exposure and neurotrophic keratopathy after acoustic neuroma surgery resulting in perforation if not managed appropriately and timely is presented. Sclerokeratoplasty on 360 degrees may be an effective treatment method of corneal perforation in complete anaesthetic cornea when the standard penetrating keratoplasty failed. At a 12-month follow-up, the patient is doing well. UCVA is 0.5, the IOP is normal, and the graft remains clear. Systemic immunosuppression is the main disadvantage of this method. Further investigation is needed to assess the effectiveness and safety of this method.

Use of an autologous lamellar scleral graft to repair a corneal perforation

To report the use of an autologous lamellar scleral graft to close a corneal perforation. Our patient was a 55-year-old female who presented with a paracentral 2 × 2 mm perforation in the center of a preexisting corneal opacity. Because of the unavailability of corneal tissue and the failure to seal the perforation with glue, a partial thickness lamellar scleral graft was harvested from the inferotemporal quadrant and used to close the corneal defect. There was gradual adherence and uptake of the scleral tissue into the surrounding cornea along with significant clearing over the next few months. At 9 months, her best-corrected visual acuity was 20/80 with a stable anterior chamber, focal posterior synechiae and early cataract changes. A band of iris tissue was observed within the lens substance extending posterolaterally from 1 to 7 o'clock positions. In the absence of donor corneal tissue and in selective emergency situations, an autologous scleral patch graft can be considered as a viable alternative in the treatment of full-thickness corneal perforations. We also report the presence of a band of iris tissue within the lens, a finding which has not been previously reported.

Risk factors, microbiological profile, and treatment outcomes of pediatric microbial keratitis in a tertiary care hospital in Hong Kong

PURPOSE

To report the risk factors and microbiological profile of pediatric microbial keratitis cases in a tertiary care hospital in Hong Kong.

DESIGN

Retrospective study.

METHODS

Case records of patients <18 years old with microbial keratitis were reviewed over a period of 10 years, between January 2001 and December 2010. Risk factors, microbiological profile, and treatment outcomes were analyzed.

RESULTS

Overall, 18 patients (13 female, 5 male) with unilateral microbial keratitis were included. The mean age was 12.4 years (range: 3-17 years). The most commonly associated risk factor was contact lens wear (15, 83.3%). Seven cases (38.8%) were associated with orthokeratology lenses. Two cases (11.1%) were related to intrinsic keratopathy and 1 case (5.5%) was infected secondary to trauma. Microbiological culture was positive in 16 cases (88.8%). Overall, Pseudomonas sp. was the most commonly isolated organism (10/16, 62.5%), followed by coagulase-negative Staphylococcus (5/16, 31.2%) and Corynebacterium sp. (2/16, 12.5%). All cases responded to intensive medical management with topical antibiotics. One case with posttraumatic keratitis required stepped surgeries with initial tectonic penetrating keratoplasty followed by lens aspiration and retinal detachment repair. At the last follow-up, 13 out of 17 eyes (76.5%) had best-corrected visual acuity ≥20/40.

CONCLUSIONS

Contact lens wear was the most commonly encountered risk factor for the occurrence of microbial keratitis in the pediatric age group in our setting. Orthokeratology remains one of the leading causes of contact lens-related infections. The majority of the cases responded to medical management.).

Surgical treatment of 32 cases of long-term atopic keratoconjunctivitis using the amniotic membrane

PURPOSE

To evaluate the use of surgical treatment with amniotic membrane for long-term atopic keratoconjunctivitis. Damaged corneas were repaired with various techniques: amniotic membrane transplantations, amniotic membrane coverings, amniotic membrane fillings (AMFs), and amniotic membrane inlay fillings, the latter of which were combined with glycerol-preserved corneal transplants.

METHODS

This retrospective study was conducted on 37 eyes belonging to 37 patients with atopic keratoconjunctivitis. Thirty-two patients were classified into four groups according to surgical technique. Five patients undergoing medical management served as controls. Surgical outcome was measured by recovery time and long-term visual improvement.

RESULTS

In all surgical eyes, integrity of ocular tissues was effectively restored and symptoms were reduced at 24.4 ± 13 days post recovery. Mean best-corrected visual acuity improved from 0.6 ± 0.2 to 0.198 ± 0.16 logarithm of the minimum angle of resolution (P<0.001). There were no intraoperative or postoperative complications, with the exception of two recurring cases, both controlled by medication. Recovery time of the control groups lasted 52 ± 16 days. In controls, mean best-corrected visual acuity improved from 0.74 ± 0.15 to 0.54 ± 0.29 logarithm of the minimum angle of resolution (P ≤ 0.05). The vision improvement has significant difference for surgical treatment vs medical. (Mann-Whitney U-test, U = 119, P < 0.05, one tailed).Vision improvements remained stable during a mean follow-up period of 21.7 ± 3.8 months.

CONCLUSION

Patients suffering from severe chronic atopic keratoconjunctivitis and its complications can benefit from suitable surgical treatments: transplants, covers, fillings, or corneal graft surgeries supplemented with AMFs.

Tectonic DSAEK for the Management of Impending Corneal Perforation

Purpose. To report a case of severe corneal thinning secondary to dry eye treated with a tectonic Descemet stripping automated lamellar keratoplasty (DSAEK) and amniotic membrane graft. Methods. A 72-year-old man with a history of long standing diabetes mellitus type 2 and dry eye presented with 80% corneal thinning and edema on the right eye and no signs of infectious disease, initially managed with topical unpreserved lubrication and 20% autologous serum drops. Eight weeks after, the defect advanced in size and depth until Descemetocele was formed. Thereafter, he underwent DSAEK for tectonic purposes. One month after the procedure, the posterior lamellar graft was well adhered but a 4 mm epithelial defect was still present. A multilayered amniotic membrane graft was then performed. Results. Ocular surface healed quickly and reepithelization occurred over a 2-week period. Eight months after, the ocular surface remained stable and structurally adequate. Conclusion. Tectonic DSAEK in conjunction with multilayered amniotic graft may not only provide structural support and avoid corneal perforation, but may also promote reepithelization and ocular surface healing and decrease concomitant inflammation.