Tuck-In Tenon Patch Graft in Corneal Perforation

Extending the utility of anterior corneal buttons through refrigeration and glycerol cryopreservation: utility rate and outcome analysis

BACKGROUND/AIMS

To evaluate the utility rate, indication, outcome, and cost of refrigeration and glycerol cryopreservation for storing anterior corneal buttons during endothelial keratoplasty for subsequent use in tectonic lamellar patch grafting.

METHOD

Anterior corneal buttons collected after precutting or prestripping during endothelial keratoplasty from January 2014 to December 2019 were preserved using the following protocol: (1) refrigeration for up to 4 weeks at 4°C in Optisol-GS and (2) glycerol cryopreservation for up to 2 years. The utility rate, outcome and cost of these cryopreserved anterior corneal buttons were retrospectively examined.

RESULTS

During the 6-year study period, 26 anterior corneal buttons were refrigerated and 49 were cryopreserved for extended use. The utility rates for the refrigerated and cryopreserved anterior corneal buttons were 69.2% and 73.5%, respectively. Their average preservation periods were 0.53±0.05 and 12.76±0.94 months, respectively. Noninfection-related perforation was the leading indication for using the extendedly preserved anterior corneal buttons. The average postoperative follow-up periods were 10.03±2.91 and 14.35±2.17 months for refrigerated and cryopreserved anterior corneal buttons. Secondary keratoplasty was required by 7 of 18 (38.9%) and 6 of 36 (16.7%) patients receiving refrigerated and cryopreserved anterior corneal buttons, respectively. None of our patients developed graft infection from donor tissues.

CONCLUSION

Cryopreservation can safely extend the utility of anterior corneal buttons. This method not only reduced the wastage of the limited donor tissue but also was cost-effective.

Freeze-dried amniotic membrane graft with a spongy layer in bilateral peripheral ulcerative keratitis: a case report

BACKGROUND

Peripheral ulcerative keratitis (PUK) is a group of inflammatory corneal ulcers with stromal thinning and peripheral localization. Amniotic membranes (AM) are used for their anti-inflammatory and healing properties. A freeze-drying process now allows maintaining the AM viable for a long time at room temperature without altering its physical, biological, and morphologic characteristics. The effectiveness of spongy freeze-dried amniotic membrane (FD-AM) graft with multimodal imaging in the management of severe corneal thinning PUK has not been reported.

CASE PRESENTATION

A 67-year-old Caribbean man histologically diagnosed with ulcerative colitis, was referred to our tertiary eye care center for a deep nasal juxtalimbal ulcer of the left eye. He was treated with topical steroids and antibiotics, methylprednisolone pulses, and oral prednisone. Due to continuous stromal thinning with 100 μm of residual corneal thickness, the decision was made to perform surgery. Conjunctival resection, inlay and overlay spongy FD-AM (Visio Amtrix® S, Tissue Bank of France, FR) were performed to preserve globe integrity. Despite tapering off oral steroids, PUK developed in the fellow eye on the 2 months follow-up. Treatment with human monoclonal antibody against tumor necrosis factor-alpha was initiated to control the active underlying inflammation. Six months following surgery, the ulcer was healed and corneal thickness in front of the former ulceration was measured at 525 μm on anterior segment-optical coherence tomography. Confocal microscopy confirmed the integration of the amniotic membrane between the corneal epithelium and the anterior stroma.

CONCLUSION

Transplantation of FD-AM with a spongy layer was associated with restoration of normal corneal thickness in the PUK area. It seems to be a safe, effective, and easily accessible solution for the surgical management of PUK with impending perforation.

Recurrence of perforation and overall patient survival after penetrating keratoplasty versus amniotic membrane transplantation in corneal perforation

PURPOSE

The following is a comparative analysis on the treatment outcomes of corneal perforations using amniotic membrane transplantation (AMT) or penetrating keratoplasty (PK).

METHODS

This monocentric retrospective study was performed at the Department of Ophthalmology, University Hospital Ulm, Germany. A total of 78 eyes of 78 patients were included. Thirty-nine eyes received an AMT, and 39 patients were treated with a PK. Primary outcome was recurrence of perforation. Secondary outcomes were patient mortality and visual acuity.

RESULTS

No statistically significant difference was observed with regard to a recurrence of perforation between the two groups (26% in AMT vs 23% in PK, p > 0.99). The time of recurrences was within the first two years and did not differ statistically (p = 0.97). In addition, a proportional hazards model with cox regression regarding recurrent perforation showed no significant differences (p = 0.5). After AMT, 41% and after KP, 28% of the patients died during follow-up (p = 0.2), respectively. The Charlson Comorbidity Index (p < 0.0001) and the age at the time of surgery (p = 0.0002) were statistically significantly higher in those who were deceased. A mean follow-up of 485 ± 517 days was recorded.

CONCLUSION

Both surgical methods show good results and no statistically significant difference regarding recurrent perforation rate. About a third of the patients died during the follow-up period. The decision regarding the appropriate method should therefore be based on a combination of all factors.

Tenon's patch graft to the rescue during COVID-19 pandemic

Objective

To report a case of bilateral Mooren's ulcer with impending corneal perforation in the right eye and perforated peripheral corneal ulcer in the left eye which successfully underwent Tenon's patch graft (TPG) with multilayered amniotic membrane grafting (AMG) as globe salvaging procedure during COVID-19 pandemic.

Methods

Conjunctival resection was done on both the eyes followed by autologous Tenon's grafting with overlay amniotic membrane grafting in the left eye with perforation and multilayered AMG with AMG overlay in the right eye with impending perforation. Post-operatively topical antibiotics and steroids were prescribed.

Results

At one month follow-up, the Tenon's graft and multilayered AMG were well-integrated with the surrounding healthy cornea with a good anatomical and visual outcome.

Conclusion

Autologous Tenon's patch graft is a simple and cost-effective alternative to preserve globe integrity and prevent complications in emergency cases when immediate access to cornea transplantation is practically challenging.

Clinical outcome and course of Tenon's patch graft in corneal perforation and descemetocele

Purpose

To assess the efficacy and clinical outcome of Tenon's patch graft (TPG) in corneal perforation and descemetocele.

Methods

In this retrospective study, medical records of 83 patients (85 eyes) who underwent TPG for corneal perforation (58, 68%) or descemetocele (27, 32%) between July 2018 and October 2021 were reviewed. Clinical examination and anterior segment optical coherence tomography (AS-OCT) were performed on every follow-up visit. Anatomical success was considered as the restoration of the structural integrity with the formation of scar and anterior chamber (AC).

Results

The mean size of the corneal lesions (corneal perforation or descemetocele) was 4.20 ± 1.01 mm. The mean follow-up period was 9.2 ± 5.48 months. The common underlying etiologies were infectious keratitis in 48% and autoimmune disorders in 35% of cases. TPG successfully restored the globe integrity in 74 (87%) eyes (83% in perforation and 96% in descemetocele). Anatomical failure occurred in 11 eyes (13%). The failures were due to graft dehiscence (8 eyes), graft ectasia (1 eye), and scarring with flat AC (2 eyes). The median time to epithelialization and scar formation were 3 and 15 weeks, respectively. Logistic regression analysis showed few predictors for a successful outcome: descemetoceles, noninfective causes, viral keratitis in infectious etiology, and paracentral or peripheral lesions.

Conclusion

TPG can be considered an effective and inexpensive treatment for restoring the structural integrity in the eyes with perforations and descemetoceles, particularly when the donor tissue is unavailable. AS-OCT is a valuable noninvasive tool for monitoring the graft status.

Tenon Patch Graft With Vascularized Conjunctival Flap for Management of Corneal Perforation

PURPOSE

Traumatic paracentral corneal perforations may lead to irregular astigmatism and opacification from lamellar grafts. We present an alternative surgical technique using a Tenon patch graft and a conjunctival flap.

METHODS

A 42-year-old man presented with a 1-mm paracentral corneal perforation 6 weeks after penetrating trauma by a metallic foreign body. A region of Tenon fascia was excised and sutured to cover the perforation, and a conjunctival flap was then created and sutured over this Tenon graft. A bandage contact lens was placed postoperatively. Serial imaging was conducted to document healing including optical coherence tomography (OCT) and slit lamp photography.

RESULTS

At postoperative day 1, uncorrected distance visual acuity (UDVA) was hand motion, the anterior chamber was formed, and OCT revealed Tenon fascia and conjunctiva covering the defect. By postoperative week 2, the leak resolved and UDVA was 20/30. At postoperative week 4, UDVA improved to 20/20, the Tenon graft was noted to be undergoing contraction, and a single feeder vessel remained prominent in the conjunctival flap. By postoperative month 4, UDVA was 20/25 and only mild paracentral cornea clouding was noted. Initial, focal steepening and thickening normalized by month 4 leaving mild, normal astigmatism. OCT revealed integration of the Tenon graft into the corneal stroma.

CONCLUSIONS

For paracentral corneal perforations, a Tenon patch graft in conjunction with a conjunctival flap may aid healing with favorable postoperative refractive outcomes.

Limbal advancement technique in managing acute or impending peripheral corneal perforations

Purpose

To describe the outcomes of a novel technique for the repair of peripheral corneal perforations using autologous limbal tissue.

Methods

Two patients with peripheral corneal perforations with contraindications to other corneal procedures underwent limbal advancements. This technique involves creating a pedicle of the limbus, sclera and conjunctiva to cover the perforation.

Results

The tissue had optimal integration in both patients; no aqueous leaks or flat anterior chambers were noted. None of the patients had recurrence of perforation or ocular discomfort.

Conclusion

In conclusion, this technique is a cost-effective and straightforward alternative for the repair of impending acute peripheral perforations.

Neurotization of the human cornea - A comprehensive review and an interim report

We present a comprehensive review of existing literature on surgical corneal neurotization (SCN) as a treatment modality for neurotrophic keratopathy (NK) with an interim report of seven cases where SCN was performed using the indirect approach and followed up till 18 months postoperatively to look for improvement in ocular surface, corneal sensations, and nerve regeneration by using in vivo confocal microscopy (IVCM). A literature search was performed for publications with keywords “corneal nerves,” “neurotization,” “esthesiometry,” “corneal anesthesia,” and “neurotrophic keratopathy.” All literature available till December 31, 2020 was reviewed and included to describe NK and its management options, particularly SCN. NK is associated with absent or reduced corneal sensations and is managed using a step-ladder algorithm ranging from medical management for symptomatic relief to surgical corneal neurotization. Both direct and indirect approaches of SCN have a favorable outcome with reduced surgical morbidity in the indirect approach using sural nerve graft. Post neurotization, corneal sensation recovery may take up to 3–6 months, while nerve regeneration on confocal microscopy can take as long as 6 months–1 year.

Hitch suture assisted tuck in Tenon's Patch Graft for management of Corneal Perforations

PURPOSE

To describe a novel modification of tuck-in Tenon's patch graft (TPG) using temporary horizontal mattress sutures and fibrin glue to hitch the graft in the management of corneal perforations.

DESIGN

Ambispective interventional case series.

METHODS

Modified technique of autologous TPG was used to seal corneal perforations measuring 3-5 mm, using horizontal mattress sutures to hitch the graft in a lamellar pocket, followed by application of fibrin glue. The horizontal mattress sutures were removed after the reformation of the anterior chamber. The primary outcome measure was a well formed anterior chamber in the post-operative period and the secondary outcome was epithelization time.

RESULTS

The surgery was performed in 22 eyes. The mean age was 43.86 ± 16.02 (26-66) years, with 14 males and eight females. The etiologies of corneal perforation included dry eye (n = 10), neurotrophic keratitis (n = 6), trauma (n = 2), chemical injury (n = 2) and exposure (n = 2). The mean size of the perforation with the thinned-out area was 4.3 mm (range 3-5 mm). The mean duration of epithelialization was 14.31 ± 2.63 days (7-21 days). No intraoperative complications were observed. All eyes had a well-formed anterior chamber in the immediate postoperative period. Postoperatively, two eyes had graft pseudoectasia due to a thick graft and supra tenon haemorrhage each; one eye each had graft thinning with the formation of pseudopterygium and graft melting.

CONCLUSION

Tenon's patch graft, along with the use of temporary horizontal mattress sutures and fibrin glue, is an effective modification of the technique for managing corneal perforations measuring 3-5 mm.

Gore-Tex- as an adjuvant to Tenon's patch graft for large perforated corneal ulcers during Covid times

Purpose

Observations

Conclusions and Importance

Tenons Patch Graft: A Review of Indications, Surgical Technique, Outcomes and Complications

PURPOSE

Corneal perforations are common corneal emergencies faced by ophthalmologists across the globe. There are multiple modalities of management, most of which require an eye bank support or availability of tissue adhesives. Tenons patch graft (TPG) is a technique that does not depend on these factors as the graft is harvested from the same eye of the patient. The aim of this review is to provide an overview of the indications, technique, normal postoperative course, and management of complications.

METHODS

After carrying out a literature search on "tenons capsule", "corneal patch graft", "tenons patch graft", "multilayered amniotic membrane" and "corneal perforations", 28 articles were included for this review.

RESULTS

TPG graft can be performed in cases of small to moderate perforations without active suppuration. The procedure can also be combined with amniotic membrane grafting or tissue adhesives to provide additional tectonic support. Postoperatively, the epithelium heals over a course 2-3 weeks and restoration of a stable ocular surface with a corneal scar is completed by the third postoperative month. Complications following the surgical procedure are rare but can include graft displacement, melt and pseudoectasia. Subsequent visual rehabilitation with contact lenses or keratoplasties can be planned in these eyes that yields good visual outcomes.

CONCLUSIONS

Tenons patch graft is a simple yet viable option in management of small to moderate corneal perforations. The procedure does not necessitate the prior availability of specialized products and can be performed with routine equipment of an ophthalmic theatre, making it an attractive option in low resource settings.

Long term outcome of Tenon's patch graft in corneal perforation secondary to neurotrophic keratitis: A case report on a 4-year anatomical functional outcome

INTRODUCTION

This report describes the long-term outcomes of Tenon's patch graft (TPG) in a corneal perforation secondary to neurotrophic keratitis and outcome of subsequent successful cataract surgery.

PRESENTATION OF THE CASE

A 60-year gentleman presented with a corneal perforation secondary to Herpes Zoster ophthalmicus (HZO). After multiple unsuccessful attempts of cyanoacrylate tissue adhesive application over the perforation, he was referred for a corneal patch graft. Following TPG, he had a tectonically stable cornea that was managed with topical steroids and prophylactic oral Acyclovir. Sequential imaging of the cornea using high-resolution anterior segment- optical coherence tomography (HR-ASOCT) was done to monitor wound healing. Fifteen months later, he underwent uneventful cataract surgery with best-corrected visual acuity improving to 20/30 at 1-month.

DISCUSSION

Serial imaging of the site of perforation with HR-ASOCT revealed that a fluffy, oedematous TPG in the early postoperative period transitioned into a hyper-reflective, thin, and compact graft over 3-4 months. Despite the corneal thickness at the site of perforation being only 142 μm, the wound had adequate tensile strength to withstand the altered anterior chamber dynamics during phacoemulsification. The resultant translucent nature of the scar provided superior media clarity and better visual outcomes.

CONCLUSION

This case demonstrates the efficacy of TPG in acute phase management of corneal perforation following HZO thereby restoring the tensile strength of the cornea, enabling it to withstand the stress of future surgeries like phacoemulsification.

Emulsion polymer isocyanate-gluing: Autologous epithelial transplant with cyanoacrylate glue application for small corneal perforations

Cyanoacrylate glue (CG) is a commonly employed modality for sealing small corneal perforations. Presently, we describe the technique of emulsion polymer isocyanate (EPI)-gluing, a modification of its application, and its results in nine eyes with noninfectious, nontraumatic sterile corneal perforation with size ≤3 mm. The method involves harvesting a small patch of autologous epithelium adjacent to the melt area with the help of 10% alcohol and transplanting to the site of melt with its basement membrane facing downwards. CG, loaded on the reverse side of Sinskey hook or Weck-Cel sponge, is instilled on this epithelium-melt site complex and withdrawn immediately following which a bandage contact lens is placed on the corneal surface. In our series of patients with nine eyes where EPI-gluing was undertaken, all eyes reported a healed corneal scar with spontaneously dislodged glue and no underlying vascularization at 3-months follow-up. EPI-gluing is an inexpensive and host-friendly technique for the treatment of small noninfectious corneal perforations particularly with iris tissue prolapse.

Peripheral ulcerative keratitis

Peripheral ulcerative keratitis (PUK) is an inflammatory condition of the peripheral cornea with hallmark features of epithelial defects and stromal destruction as a result of a complex interplay of factors including host autoimmunity and the peculiar anatomic and physiologic features of the peripheral cornea and environmental factors. PUK may be the result of local or systemic causes and infectious or noninfectious causes. Arriving at a specific etiological diagnosis requires a meticulous clinical workup that may include a battery of laboratory and radiological investigations. Management by a team of internists or rheumatologists and ophthalmologists and judicious use of immunosuppressive agents may yield favorable results minimizing adverse effects. We review current clinical knowledge on the diagnosis and management of PUK.

An Evidence-Based Strategic Approach to Prevention and Treatment of Dry Eye Disease, a Modern Global Epidemic

Dry eye disease (DED) is an emerging health concern causing significant visual, psychological, social, and economic impact globally. In contrast to visual rehabilitation undertaken at late stages of DED, measures instituted to prevent its onset, establishment, or progression can alter its natural course and effectively bring down the associated morbidity. This review attempts to present the available literature on preventive strategies of DED at one place, including strategies for risk assessment and mitigation, targeting a wide range of population. A literature search was conducted using PubMed and an extensive literature review on preventive strategies for DED was compiled to put forth a holistic and strategic approach for preventing DED. This can be undertaken at various stages or severity of DED directed at different tiers of the health care system. Conclusion: This review intends to put emphasis on preventive strategies being adopted as an integral part of routine clinical practice by general ophthalmologists and specialists to tackle the burden of DED and improve the quality of the lives of the patients suffering from it.

Ultra-stiff compressed collagen for corneal perforation patch graft realized by in situ photochemical crosslinking

Despite the potential of a collagen construct, consisting of a major extracellular matrix component of the native cornea, as a patch graft to treat the corneal perforation, there has still been difficulty in acquiring sufficient mechanical properties for clinical availability. This study developed a novel in situ photochemical crosslinking (IPC)-assisted collagen compression process, namely, the IPC-C² process, to significantly enhance the mechanical properties of the collagen construct for the development of a collagenous patch graft. For the first time, we found that compressed collagen construct was rapidly rehydrated in an aqueous solution, which inhibited effective riboflavin-mediated photochemical crosslinking for mechanical improvement. The IPC-C² process was designed to concurrently induce the physical compaction and photochemical crosslinking of a compressed collagen construct, thereby avoiding the loosening of collagen fibrillar structure during rehydration and ultimately improving crosslinking efficiency. Hence, the suggested IPC-C² process could fabricate a collagen construct with a high collagen density (∼120-280 mg ml^-1) and ∼10³-fold increased mechanical properties (an elastic modulus of up to ∼29 MPa and ultimate tensile strength of ∼8 MPa) compared with collagen gel. This construct can then be used as a clinically applicable collagenous patch graft. With sufficient mechanical strength for surgical suture and the controllable thickness for patient specificity, the potential of the fabricated IPC-compressed collagen construct for clinical applications was demonstrated by using an in vivo rabbit corneal perforation model. It effectively protected aqueous humor leakage and maintained the integrity of the eye globe without an additional complication.

Surgical alternatives to keratoplasty in microbial keratitis

Penetrating keratoplasty is often required in microbial keratitis not responding to the standard treatments available or the development of complications like corneal perforation. Performing keratoplasty in microbial keratitis has several challenges, the major ones being the availability of donor corneal tissue and the poor success of the corneal graft performed in such a setting. For overcoming these challenges, several alternatives to keratoplasty have been described. Broadly, these options could be categorized into autologous tissues such as conjunctival and tenon tissue, synthetic products like tissue adhesives and therapeutic contact lenses, or biological tissues like amniotic membrane graft. These alternative modalities are not universal. They have their specific indications in microbial keratitis. Most of these alternatives are useful only for small corneal perforations. While autologous tissues are cost-effective and readily available, lack of tectonic support is a significant limitation. Tissue adhesives are excellent alternatives in terms of tectonic support, but surface irregularity and tissue reaction are their potential limitations. The amniotic membrane is useful for small corneal perforations, but availability, cost, and poor tectonic support restrict its use. Herein, we discuss these various alternatives to keratoplasty in microbial keratitis, their indications, advantages, disadvantages, and the various techniques of performing these procedures.

Amniotic Membrane as a Main Component in Treatments Supporting Healing and Patch Grafts in Corneal Melting and Perforations

Purpose

To report on surgical approaches using amniotic membrane applications and patch grafts in corneal melting and perforations. Anatomical and functional results, including advantages and disadvantages of the interventions, will also be explored.

Methods

A five-year retrospective analysis of 189 surgical treatments involving corneal melting with perforation was performed. In one evaluated treatment type, a graft of amniotic membrane, often folded one to three times, was sutured with the epithelial side facing the previously mechanically debrided corneal tissue. A larger monolayer amniotic patch was then sutured, with the epithelial side facing the top of the first membrane, to the perilimbal conjunctiva. For corneal patch grafts, the size-fitting technique of graft trephination was applied, and the donor-recipient junctions were sewn with interrupted sutures. All the procedures were evaluated, noting outcomes and complications of surgery, preoperative and postoperative visual acuities, postoperative intraocular pressures, graft rejection, and other late comorbidities and complications.

Results

We performed 119 amniotic membrane applications (63%) and 70 corneal patch grafts (37%). Anatomical reconstruction of the anterior chamber was achieved in 157 eyes, of which 102 eyes (86%) received an amniotic membrane and 55 eyes (79%) were treated with the patch graft technique. In 63 eyes (33%), more than one amnion or graft treatment was necessary to close the corneal perforation.

Conclusions

The success of medical and surgical management depends on the cause of corneal melting, and amniotic membrane applications often require further intervention; nevertheless, patch grafts deliver better tectonic reconstruction than amniotic membrane alone.