Tectonic Mini-DSAEK Facilitates Closure of Corneal Perforation in Eyes With Healthy Endothelium

Patch endothelial keratoplasty for corneal perforations secondary to ocular surface disease: case series

BACKGROUND

Corneal perforation is an ophthalmic emergency. The conventional management of corneal perforation can be associated with severe complications especially in patients with ocular surface disease. Endothelial keratoplasty has been suggested as an alternative surgical technique for the management of corneal perforations. We present a case series of nine patients with corneal perforation and ocular surface disease managed with secondary patch endothelial keratoplasty.

METHODS

This is a retrospective case series of nine patch endothelial keratoplasties performed between 2016 and 2022 at a quaternary eye hospital in Australia. The surgical technique is similar to conventional endothelial keratoplasty except descemetorhexis was not performed.

RESULTS

A total of 9 cases were treated during the review period. Eight of the nine cases had an improvement in visual acuity. One case failed to achieve corneal tectonic objective.

CONCLUSION

Patch endothelial keratoplasty is a safe secondary procedure for the management of corneal perforations in patients with ocular surface disease.

DALK combined intralamellar tectonic patch graft: an alternative approach to treat frank corneal perforation

BACKGROUND

Deep anterior lamellar keratoplasty (DALK) has gained popularity in cases of corneal thinning and leaking descemetocele. In this study, we introduced an intralamellar tectonic patch graft in addition to conventional DALK procedures to treat frank cornea perforation.

METHODS

This retrospective case series included 13 patients (13 eyes) with frank corneal perforations who underwent DALK combined with intralamellar tectonic patch graft between December 2015 and December 2021. In addition to the standard DALK procedure, the perforation site was repaired with an extra intralamellar tectonic patch graft. The collected data included patient demographics, aetiology, size and location of the corneal perforation, visual acuity, surgical details, and postoperative complications.

RESULTS

Seven patients underwent autologous intralamellar patch grafts, whereas six received allogeneic ones. Anatomical success was achieved in all patients. The mean postoperative follow-up was 33.31 ± 25.96 months (6-73 months). The postoperative visual acuity (0.90 ± 0.65 logMAR) was significantly improved (P = 0.003) compared to the preoperative score (1.74 ± 0.83 logMAR). Best corrected visual acuity (BCVA) improved in 12 eyes (92.3%). The mean endothelial cell density was 2028 ± 463 cells/mm2, 6-12 months postoperatively. There was no recurrence of perforation, and the anterior lamellar graft remained transparent in 12 patients (92.3%). Postoperative complications included epithelial defects (23.1%), ocular hypertension (15.4%), and cataract (7.7%).

CONCLUSIONS

DALK combined with intralamellar tectonic patch graft may serve as a secure and effective alternative in treating frank corneal perforation, with reduced complications compared to conventional penetrating keratoplasty.

Indications and outcomes of keratoplasty ≤ 5.5 mm diameter ("mini-keratoplasty")

PURPOSE

To report indications and clinical outcomes of corneal grafts ≤ 5.5 mm in diameter ("mini-KP") in a German tertiary referral center.

METHODS

Patients who had undergone mini-KP to treat corneal ulcers with or without perforation between 2011 and 2018 at the Department of Ophthalmology, University of Düsseldorf, Germany, were identified from the local keratoplasty registry. All patient records were reviewed for age, gender, laterality, systemic and ophthalmological diseases, etiology of the corneal ulcerative disease, pre- and postoperative visual acuity over a follow-up time of up to 12 months, graft size, postoperative complications and the need for and timing of further corneal interventions.

RESULTS

37 eyes of 37 patients (male: n = 20; female: n = 17) with a mean age (± standard deviation) at presentation of 70 ± 18.8 years (range: 22-92 years) were identified. Most common etiologies were neurotrophic keratopathy (n = 15), dysfunctional tear syndrome (n = 9) and atopic keratoconjunctivitis (9). Mean graft diameter was 4.51 ± 0.63 mm (range: 3-5.5 mm). 23/37 eyes (62%) required no further intervention in the acute phase. 14/37 patients (38%) required secondary corneal intervention, due to complications. One-year graft survival was 78.4%. One eye had to be eviscerated due to recurrent corneal ulceration and endophthalmitis. 36 of 37 eyes were preserved. We found a highly significant correlation between type 2 diabetes and the development of postoperative complications (r = .46; p = .005). Corrected distance visual acuity (CDVA) improved from 1.42 ± 0.75 logMAR to 0.9 ± 0.65 logMAR postoperatively (t (23) = 5.76; p < .001).

CONCLUSION

Mini-KP can be used successfully in eyes with advanced corneal ulcers due to various infectious and noninfectious etiologies to restore tectonic stability in the long-term and with moderate visual gains.

Early Endothelialization of Ab Interno Stromal Tectonic Patch in the Management of Corneal Perforation Secondary to Bacterial Keratitis

PURPOSE

The purpose of this study was to describe a novel surgical technique using an ab interno stromal patch to treat corneal perforation and to present the histological findings of the patch after its removal during definitive mushroom keratoplasty.

METHODS

The endothelium had already been removed with the submerged cornea using backgrounds away (SCUBA) technique.

RESULTS

The patient was managed successfully with a sutureless ab interno stromal tectonic patch. Two months later, definitive mushroom keratoplasty was performed and the patch was sent for histological examination. Immunohistochemistry revealed a reactive endothelium covering the posterior surface of the graft. Nine months later, her best-corrected visual acuity was 6/9.

CONCLUSIONS

This is the first case to our knowledge demonstrating that stromal tectonic grafts without the endothelium can successfully attach to the host tissue and seal a perforation. The stroma may undergo reendothelialization and begin to restore vision, even before penetrating keratoplasty.

Tectonic Descemet's stripping automated endothelial keratoplasty for corneal perforation

We report the use of Descemet stripping automated endothelial keratoplasty (DSAEK) for the treatment of sterile corneal perforation after trauma. In an eye with corneal perforation and cataract due to trauma, cataract surgery and DSAEK were performed. Corneal integrity was promptly restored and the patient avoided tectonic anterior lamellar and penetrating keratoplasty. DSAEK may be performed for the management of corneal perforation.

Sutureless Tectonic Mini-Descemet's Stripping Automated Endothelial Keratoplasty ("mini-DSAEK") for the management of corneal perforations

PURPOSE

To report the outcomes of a new technique, pull-through sutureless 'mini-DSAEK', to manage corneal perforations secondary to different aetiologies including trauma, neurotrophic ulcer following penetrating keratoplasty (PK), herpes simplex keratitis and microbial keratitis.

METHODS

In this retrospective case series, we report the clinical outcomes of five cases of sutureless tectonic mini-DSAEK performed in patients presenting with large corneal perforations to Southend University Hospital between November 2019 and October 2020. One corneal perforation was sufficiently peripheral for the tectonic mini-DSAEK graft to be successfully positioned outside of the central visual axis. Four corneal perforations were central or paracentral for which the tectonic grafts involved the visual axis.

RESULTS

Anterior chambers remained deep and formed with no evidence of leak in all subsequent follow ups in all patients representing 100% tectonic success. All tectonic grafts remained attached except one partially detached graft. One patient underwent uneventful phacoemulsification with intraocular lens implant 8 months after the primary intervention with excellent visual outcome. Two patients underwent two-piece mushroom PK and one patient underwent triple procedure (cataract extraction   +   intraocular lens   +   PK) for visual rehabilitation 2-6 months after the primary intervention with good visual outcome.

CONCLUSION

Sutureless tectonic pull-through mini-DSAEK is a useful technique in the management of corneal perforations, with a number of advantages compared with conventional techniques.