Incidence, severity and outcomes of traumatic wound dehiscence following penetrating and deep anterior lamellar keratoplasty

Tomographic and topographic predictive factors of big bubble formation during deep anterior lamellar keratoplasty in keratoconus

PURPOSE

To identify preoperative predictors of big bubble (BB) formation during deep anterior lamellar keratoplasty (DALK) in patients with keratoconus (KC).

METHODS

DESIGN: Retrospective cohort study in an Italian tertiary centre.

STUDY POPULATION

Consecutive patients with KC undergoing DALK from January 2021 to July 2023.

OBSERVATION PROCEDURE

Tomographic and topographic data including K-max, K-mean, keratometric astigmatism, thinnest point, mean peripheral corneal thickness, difference between the mean peripheral corneal thickness and the thinnest point (peripheral-minimal corneal thickness), position (central/paracentral) and cone area (%), Amsler-Krumeich classification and anterior segment optical coherence tomography (AS-OCT) analysis to assess the severity stage.

MAIN OUTCOME MEASURES

Rate of BB formation and type; multivariate logistic regression analysis was used to analyse all preoperative parameters in patients with BB formation versus failure.

RESULTS

Pneumatic dissection succeeded in 98 of 140 eyes (70.0%), with 94 type 1 bubbles (67.1%) and four type 2 bubbles (2.9%). BB formation succeeded more frequently in patients with lower K-max (p=0.032), lower K-mean (p=0.010), higher thinnest point (p=0.017), lower peripheral-minimal corneal thickness (p=0.009) and lower Amsler-Krumeich stages (p=0.021). According to the AS-OCT analysis, BB formation was more frequent in the lower stages (p<0.001). After the logistic regression (pseudo-R²=0.176, constant=3.21, 95% CI 1.14 to 5.29, p=0.002), AS-OCT classification was found to be the only factor that predicted BB formation (coefficient=-0.81, 95% CI -1.18 to -0.43, p<0.001).

CONCLUSIONS

AS-OCT classification is a reliable predictor for BB formation. Tomographic and topographic analyses indicated that a steeper and more ectatic cornea is more prone to BB failure.

Influence of Opacity Depth on Big Bubble Formation During Deep Anterior Lamellar Keratoplasty in Corneal Stromal Scars

PURPOSE

To identify the key preoperative predictors of big bubble (BB) formation during deep anterior lamellar keratoplasty in patients with corneal stromal scars (CSS).

METHODS

This retrospective cohort study included consecutive patients with CSS after infective keratitis who underwent BB-deep anterior lamellar keratoplasty between January 2021 and July 2023 at a tertiary referral center. Topographic and tomographic data were collected to compare the rates and types of BB formations. Anterior segment optical coherence tomography (AS-OCT) was employed to assess the maximum depth of opacity by dividing the stroma into 3 zones of equal thickness: anterior (stage A), mid (stage B), and posterior stroma (stage C). Multivariate logistic regression analysis was performed to identify the potential preoperative predictors of bubble formation.

RESULTS

Pneumatic dissection was achieved in 13 of 33 eyes (39.4%), with 11 BB type 1 eyes (33.3%) and 2 BB type 2 eyes (6.1%). According to AS-OCT grading, bubble formation was more frequent with CSS involving more superficial stromal layers (P <0.032). In the eyes with stage C, bubble formation failed 12 out of 14 times (85.7%, P <0.026). Spearman correlation showed that bubble formation was inversely associated with the AS-OCT grading (rho = -0.443, P = 0.001). After logistic regression analysis, AS-OCT grading was found to be the sole factor that predicted bubble formation (coeff. -1.58, confidence interval 95% -3.03 to -0.12, P = 0.034).

CONCLUSIONS

Depth of opacity in CSS was the key determinant for predicting the success of pneumatic dissection, as advanced AS-OCT stages are strongly associated with BB failure.

Endothelial Migration and Regeneration after Penetrating Trauma Injury in a Deep Anterior Lamellar Keratoplasty Graft: Case Presentation and Literature Overview

Background: Traumatic injuries in eyes previously treated with Deep Anterior Lamellar Keratoplasty (DALK) can lead to ruptures in the Descemet Membrane (DM) and damage to the corneal endothelium, a crucial layer for maintaining corneal clarity. Due to cell cycle constraints, the human corneal endothelium cannot proliferate; instead, it compensates for injury through cell enlargement and migration from adjacent areas. Methods: This study examines a notable case of corneal endothelial cell migration following a penetrating eye injury in a patient previously treated with DALK for keratoconus, supplemented by a review of relevant literature to contextualize the regenerative response. Results: A 39-year-old male with a history of DALK suffered a traumatic eye injury, resulting in damage to the Descemet Membrane and loss of the crystalline lens. After primary repair and considerations for further surgery, the patient's cornea cleared remarkably, with an improved visual acuity. This demonstrates the DM's potential for self-repair through endothelial cell migration. Conclusions: The outcomes suggest that delaying corneal transplant surgery for up to 3 months following Descemet Membrane injury due to ocular trauma could be advantageous. Allowing time for natural healing processes might eliminate the need for further invasive surgeries, thereby improving patient recovery outcomes.

Incidence of wound dehiscence after keratoplasty: a meta-analysis of observational studies

Background

The comprehensive investigation of the association between keratoplasty and wound dehiscence remains limited, despite corneal disease being a leading cause of visual impairment.

Methods

A meticulous search strategy was executed across prominent databases such as Web of Science, PubMed, Cochrane Library, and Embase. Data relevant to our research objective were extracted from eligible studies. The methodological quality of each study was assessed using the ROBINS-I tool, while statistical analysis was conducted utilizing STATA 17.0. To evaluate potential publication bias, the Funnel plot and Egger's test were employed.

Results

A total of 11 articles were deemed suitable for inclusion in our analysis. Our findings indicate that the overall incidence of wound dehiscence following keratoplasty was estimated to be 1.9% (95% CI: 0.013, 0.026), although substantial heterogeneity was observed (I2 = 72.798%). Notably, developed countries exhibited a higher incidence of wound dehiscence compared to their developing counterparts. Furthermore, the occurrence of wound dehiscence was found to be lower in deep anterior lamellar keratoplasty (DALK) procedures when compared to penetrating keratoplasty (PK). Analysis utilizing Egger's linear regression method yielded no evidence of publication bias (p = 0.91). Moreover, within the first year post-keratoplasty, approximately 31.4% of patients experienced wound dehiscence (95% CI: 0.149, 0.503), and 43.1% exhibited a decline in best-corrected visual acuity (BCVA) (95% CI, 0.341, 0.522).

Conclusion

The results of our study unveiled the occurrence rate of wound dehiscence following keratoplasty, exhibiting variations based on economic level and the specific surgical procedure employed. Furthermore, onset time of wound dehiscence and visual acuity warrant consideration.

Penetrating Keratoplasty Versus Deep Anterior Lamellar Keratoplasty for Advanced Stage of Keratoconus

PURPOSE

To compare visual acuity, refractive error, and complications after penetrating keratoplasty (PK) vs deep anterior lamellar keratoplasty (DALK) in the management of advanced stage of keratoconus.

DESIGN

Retrospective, comparative, interventional study.

METHODS

This study enrolled 411 consecutive keratoconus eyes with preoperative mean keratometry ≥60 diopters (D) that received either PK (218 eyes) or DALK (193 eyes). The outcome measures were postoperative visual acuity, refraction, complications, and further surgical interventions.

RESULTS

The mean follow-up duration was 77.9±46.5 and 72.9±47.8 months in the PK and DALK groups, respectively (P = .28). Compared with baseline values, postoperative visual acuity and refraction significantly improved in both groups. Postoperative corrected distance visual acuity was 0.18±0.13 and 0.26±0.19 logMAR in the PK and DALK groups, respectively (P < .001). Postoperative spherical equivalent refraction was -2.89±2.89 D after PK and -4.58±3.62 D after DALK (P < .001). Final keratometric astigmatism was comparable between the 2 groups (P = .82). Suture-related complications were observed in 48.6% of the PK eyes and 72.0% of the DALK eyes (P < .001). The incidence of graft rejection was 33.5% after PK and 19.7% after DALK (P = .002). At the last visit, 98.2% of PK grafts and 94.8% of DALK grafts remained clear (P = .06).

CONCLUSION

Both techniques of corneal transplantation led to a significant improvement in the visual and refractive variables in eyes with advanced keratoconus. PK resulted in a better visual acuity and refraction with less suture-related complications compared to DALK. However, PK was associated with a higher rate of graft rejection. The 2 techniques were comparable in terms of graft survival.

Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery

The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.

A 10-Year Retrospective Case Series on Wound Dehiscence Following Corneal Transplant

Background and objective

Corneal transplants are associated with multiple well-known complications, one of them being wound dehiscence. It results in unfavorable outcomes, such as ocular structure damage, graft failure, repeated surgeries, and possibly a poor prognosis in terms of vision quality. Although the wound site may appear well-healed clinically, as the strength at the graft-host junction is weak, the site is susceptible to dehiscence. Wound dehiscence can be secondary to suture removal and/or trauma. In this study, we assessed the incidence of wound dehiscence secondary to trauma following corneal transplant and evaluated its occurrence in terms of patient age, type of corneal transplant performed, duration between corneal transplantation and wound dehiscence, mechanism of injury, and final outcome.

Methods

This was a case series that included all patients who suffered from wound dehiscence secondary to trauma post-corneal transplant between January 1, 2009, and December 31, 2019, at Hospital Kuala Lumpur.

Results

A total of 492 patients underwent corneal transplant surgery during the 10-year study period. Based on specified inclusion and exclusion criteria, only 13 patients were eligible for inclusion in this study. The incidence of wound dehiscence secondary to trauma post-penetrating keratoplasty (PK) was low (2.64%). Twelve patients had undergone PK, while one patient had undergone deep anterior lamellar keratoplasty (DALK). Blunt ocular trauma post-transplant can cause wound dehiscence regardless of patient age and duration post-corneal transplantation. Males are at a higher risk as their active lifestyle contributes to higher exposure to ocular injury.

Conclusion

As corneal transplant patients are at life-long risk of wound dehiscence post-transplant, they must be counseled about this possible risk and the need to take adequate precautions in their daily lives. Based on our findings, the use of newer technologies and partial- rather than full-thickness corneal transplants should be explored further.

A Liquid Hydrogel to Restore Long Term Corneal Integrity After Perforating and Non-Perforating Trauma in Feline Eyes

Purpose: To evaluate long-term in vivo functionality of corneas regenerated using a cell-free, liquid hydrogel filler (LiQD Cornea) after deep corneal trauma in the feline model.

Methods: Two healthy cats underwent 4 mm diameter stepwise 250/450 µm deep surgical corneal ablation with and without needle perforation. The filler comprising 10% (w/w) collagen-like peptide conjugated to polyethylene glycol (CLP-PEG) and 1% fibrinogen and crosslinked with 2% (w/w) 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride (DMTMM), was applied to the wound bed previously coated with thrombin (250 U/ml). In situ gelation occurred within 5 min, and a temporary tarsorrhaphy was performed. Eyes were examined weekly for 1 month, then monthly over 12 months. Outcome parameters included slit-lamp, Scheimpflug tomography, optical coherence tomography, confocal and specular microscopy, and immunohistochemistry studies.

Results: The gelled filler was seamlessly incorporated, supporting smooth corneal re-epithelialization. Progressive in-growth of keratocytes and nerves into the filler corresponding to the mild haze observed faded with time. The regenerated neo-cornea remained stably integrated throughout the 12 months, without swelling, inflammation, infection, neovascularization, or rejection. The surrounding host stroma and endothelium remained normal at all times. Tomography confirmed restoration of a smooth surface curvature.

Conclusion: Biointegration of this hydrogel filler allowed stable restoration of corneal shape and transparency in the feline model, with less inflammation and no neovascularization compared to previous reports in the minipig and rabbit models. It offers a promising alternative to cyanoacrylate glue and corneal transplantation for ulcerated and traumatized corneas in human patients.

Comparison of the characteristics and outcomes of traumatic wound dehiscence after penetrating or Lamellar Keratoplasty for Keratoconus

PURPOSE

To examine the incidence, causes, characteristics, and the visual outcome of traumatic wound dehiscence (TWD) after penetrating keratoplasty (PK) compared to lamellar keratoplasty (LKP) for keratoconus.

METHODS

The medical records of all keratoconus patients undergoing TWD repair after PK or LKP over a 7-year period at the King Khaled Eye Specialist Hospital (KKESH), Riyadh were reviewed. Data were collected on patient demographics, interval between keratoplasty and trauma, and characteristics and visual outcomes of TWD.

RESULTS

During January 2006 to December 2012, 2863 eyes in KKESH underwent PK. Another 1716 eyes underwent LKP. Of these, 55 (1.9%) and 30 (1.7%) sustained TWD, respectively (p = 0.675). Approximately two-thirds of patients with traumatic wound dehiscence (TWD) were males in both groups (63.6% and 70.0%, respectively). The mean age at trauma was 24.6 ± 6.7 years (range 12-41 years) in the PK group compared with 22.6 ± 6.0 years (range 13-34 years) in the LKP group (p = 0.166). The median interval between keratoplasty and trauma was 6.2 (the interquartile range (IQR), 10.9) months for the PK group and 4.6 (IQR, 7.4) months for the LKP group (p = 0.116). At the last follow-up after wound repair, visual acuity was similar between the PK and LKP groups (p = 0.595).

CONCLUSION

In our study, the incidence of TWD after PK and LKP in patients with keratoconus was within the previously reported range of values. All patients undergoing these procedures, especially males, should receive adequate information regarding this lifelong risk, and the need for protective eye-wear and seeking early medical advice when complications occur.

Corneal graft failure: an update

Corneal graft surgery is one of the most successful forms of human solid-tissue transplantation, and nowadays, there is a worldwide expansion of the surgical volume of corneal grafts. This surgery is continuously evolving, with new surgical techniques and postoperative treatments that have considerably increased the chance of survival for the grafts. Despite the high rate of success, corneal transplantation is still complicated by a relevant risk of graft failure. This study investigates the causes that lead to the failure of the different corneal graft surgical techniques and provides an updated synthesis on this topic. A comprehensive review of the main pathological pathways that determine the failure of corneal grafts is provided, analysing the main risk factors and disclosing the survival rates of the principal form of corneal grafts. Our results revealed that penetrating keratoplasty has higher failure rates than lamellar keratoplasty, with immunological rejection being the leading cause of graft failure, followed by late endothelial failure (LEF) and ocular surface disorders. Postoperative glaucoma and dehiscence of the surgical wound represent other important causes of failure. Endothelial keratoplasty showed the lowest rates of failure in the mid-term, with LEF, detachment of the graft and primary graft failure representing the most common pathological reasons for failure.

Posttraumatic deep anterior lamellar keratoplasty dehiscence: Descemet's resistance

An 18-year-old girl who had undergone deep anterior lamellar keratoplasty in her left eye for keratoconus a year back presented with inferonasal graft dehiscence with intact host Descemet's membrane and intact anterior chamber after sustaining blunt injury a week prior. The graft was sutured to the host bed, and complete resolution of graft edema was seen in 4 weeks. One year later, she underwent cataract surgery with foldable intraocular lens implantation. At her final follow-up, the best-corrected visual acuity in her left eye was 20/40 with a clear corneal graft and a stable posterior chamber intraocular lens implantation.

Finite Element Analysis of Air Gun Impact on Post-Keratoplasty Eye

Purpose

Due to the mechanical vulnerability of eyes that have undergone penetrating keratoplasty (PKP), it is clinically important to evaluate the possibility of corneal wound dehiscence by blunt impact. We have previously developed a simulation model resembling a human eye based on information obtained from cadaver eyes and applied three-dimensional finite element analysis (FEA) to determine the physical and mechanical response to an air gun impact at various velocities on the post-PKP eye.

Methods

Simulations in a human eye model were performed with a computer using a FEA program created by Nihon, ESI Group. The air gun pellet was set to impact the eye at three-different velocities in straight or 12° up-gaze positions with the addition of variation in keratoplasty suture strength of 30%, 50% and 100% of normal corneal strength.

Results

Furthermore to little damage in the case of 100% strength, in cases of lower strength in a straight-gaze position, wound rupture seemed to occur in the early phase (0.04-0.06 ms) of impact at low velocities, while regional break was observed at 0.14 ms after an impact at high velocity (75 m/s). In contrast, wound damage was observed in the lower quadrant of the suture zone and sclera in 12° up-gaze cases. Wound damage was observed 0.08 ms after an impact threatening corneoscleral laceration, and the involved area being larger in middle impact velocity (60 m/s) simulations than in lower impact velocity simulations, and larger damaged area was observed in high impact velocity cases and leading to corneoscleral laceration.

Conclusion

These results suggest that the eye is most susceptible to corneal damage around the suture area especially with a straight-gaze impact by an air gun, and that special precautionary measures should be considered in patients who undergo PKP. FEA using a human eyeball model might be a useful method to analyze and predict the mechanical features of eyes that undergo keratoplasty.

Malapposition of graft-host interface after penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK): an optical coherence tomography study

Backgroud

Previous studies of internal graft-host malappositions have not dealt with the precise ways in which each malapposition affected post-penetrating keratoplasty (post-PK) visual outcomes. In this study, we reviewed our post-PK and post-deep anterior lamellar keratoplasty (post-DALK) keratoconic patients and used anterior segment optical coherence tomography (AS-OCT) to evaluate the associations between graft-host interface (GHI) characteristics and visual outcomes.

Methods

Novel GHI metrics included: mean graft-host touch (GHT), total prevalence of malapposition proportion (Pm), frequency of apposition (F), size of malapposition (Sm), junctional graft thickness (Tg), junctional host thickness (Th) and the absolute value of difference between Tg and Th (|Tg-Th|). We connected the external and internal junction points of GHI (GHT) and drew a straight line through the central point, perpendicular to both sides of the cornea. Tg and Th were the thicknesses at cross-points 1 mm away from the meeting point on the external side of the graft and host, respectively. Linear regression analysis was used to describe associations between GHI metrics and postsurgical visual outcomes [logarithm of minimum angle of resolution best-corrected visual acuity (logMAR BCVA), spherical equivalent diopter (SE), diopter of spherical power (DS), diopter of cylindrical power (DC) and keratometric astigmatism (Astig value)].

Results

We enrolled 22 post-PK and 23 post-DALK keratoconic patients. Compared with the regular-apposition results, GHT was decreased in step and gape patterns, and increased in hill and tag patterns. SE increased averagely by 6.851, 5.428 and 5.164 diopter per 1% increase in: F (step) [β = 6.851; 95% Confidence interval (CI) = 2.975–10.727; P = 0.001]; F (graft step) [β = 5.428; 95% CI = 1.685–9.171; P = 0.005]; and Pm [β = 5.164; 95%CI = 0.913–9.146; P = 0.018], respectively. SE increased averagely by 0.31 diopter per 10-μm increment in |Tg-Th| [β = 0.031; 95% CI = 0.009–0.054; P = 0.007]. LogMAR BCVA increased (on average) by 0.01 per 10-μm increment in both GHT [β = 0.001; 95% CI = 0–0.002; P = 0.030]. and Tg [β = 0.001; 95% CI = 0.001–0.002; P = 0.001]. Astig value increased on average by 0.17 diopter per 10-μm increment in Sm [β = 0.017; 95% CI = 0–0.033; P = 0.047].

Conclusion

This investigation of GHI characteristics suggests explanations for varied ametropia in keratoconic eyes and has potential significance as a reference for promoting pre-surgical planning and technology for corneal transplantation.

Comparative Evaluation Of Clinical Characteristics And Visual Outcomes Of Traumatic And Non-Traumatic Graft Dehiscence Following Corneal Transplantation Surgery

Purpose

To compare patient demographics, clinical associations and visual outcomes between traumatic and non-traumatic wound dehiscence, following corneal transplantation.

Methods

Retrospective review of all patients presenting with post-keratoplasty wound dehiscence to the Royal Victorian Eye and Ear Hospital between January 2005 and December 2017. Patients with wound dehiscence following keratoplasty of any cause were included.

Results

Of 71 eyes from 71 patients included, 60 (85%) were penetrating keratoplasty patients. The mean age was 56.4 years (SD=22.7, range 17.6-97) and 62% (n = 44) of patients were male. There were 28 (39%) cases of traumatic dehiscence and 43 (61%) cases of non-traumatic dehiscence. The median time interval from keratoplasty to dehiscence was significantly less in non-traumatic patients than traumatic patients (0.2 years, IQR 0.1-2.0 vs 2.3 years, IQR 0.3-14.8, p=0.01). There was no significant difference in best-corrected visual acuity at 6 months between traumatic and non-traumatic dehiscence (6/60 vs 6/36, p=0.62), suture technique (continuous vs interrupted, p=0.12), or graft type (penetrating keratoplasty vs deep anterior lamellar keratoplasty) after adjusting for keratoconus (p=0.41).

Conclusion

Post-keratoplasty wound dehiscence is a serious complication and can cause significant loss of vision. While the risk of dehiscence is lifelong, the first 3 years post-keratoplasty carry the highest risk, with non-traumatic dehiscence tending to occur earlier than traumatic dehiscence.

Comparison of corneal biomechanical properties following penetrating keratoplasty and deep anterior lamellar keratoplasty for keratoconus

IMPORTANCE

Keratoplasty is a surgical procedure to create a more regular optical surface following biomechanical weakening of the cornea in keratoconus. The ideal keratoplasty procedure should also restore corneal biomechanics to that of the healthy cornea.

BACKGROUND

This study aimed to evaluate and compare the biomechanical properties of corneas following penetrating keratoplasty (PKP) and predescematic deep anterior lamellar keratoplasty (DALK) to those of healthy eyes.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

Two cohorts of post-keratoplasty eyes (42 eyes with PKP and 27 eyes with DALK) with each other, and with a cohort of 152 healthy eyes.

METHODS

All eyes were examined by slit-lamp biomicroscopy, tomography, anterior segment-OCT and non-contact tonometry CorVis ST (CST).

MAIN OUTCOME MEASURES

CST biomechanical parameters, maximum corneal deformation (MCD) and corneal energy dissipation were compared between keratoplasty techniques, and with healthy eyes.

RESULTS

The mean age of participants with PKP and DALK were 35 ± 13.7 and 36.1 ± 12.6 years, respectively. None of the CST parameters were significantly different between PKP and DALK eyes. However, when compared to healthy corneas, numerous parameters were significantly different for both keratoplasty techniques. Of note, MCD was significantly higher in PKP compared to DALK and healthy corneas, after controlling for co-factors.

CONCLUSIONS AND RELEVANCE

Neither type of keratoplasty technique utilized in keratoconus completely restored corneal biomechanical properties to that of healthy corneas. However, PKP resulted in a greater number of parameters significantly different to healthy corneas, compared to DALK.

Management of Descemet Membrane's Folds After Deep Anterior Lamellar Keratoplasty: Descemet Membrane-Tucking Technique

PURPOSE

To describe a surgical maneuver that allows for correction of central Descemet membrane (DM) folds at the end of a deep anterior lamellar keratoplasty (DALK) procedure. We term the present technique "DM tucking."

METHODS

A blunt tip spatula is introduced vertically into the trephination cut, 90 degrees away from the main direction of the DM folds, and advanced until it touches the host layer. Gentle pressure is applied, resulting in tucking of the redundant host layer toward the periphery. The tucking maneuver is repeated at different clock hours until a regular graft-host interface is obtained.

RESULTS

We applied the present technique to several DALK procedures performed for keratoconus, and found it to be safe and effective.

CONCLUSIONS

DALK is the procedure of choice for the surgical treatment of corneal stromal diseases with a healthy endothelium, such as keratoconus. DM folds are a possible complication after DALK in patients with advanced corneal ectasia, arising from the compression of the redundant host DM by the donor graft, once it is sutured to the recipient. DM folds after DALK, when they involve the visual axis, cause permanent visual disturbances DM tucking allows the displacement of the central DM folds toward the graft margin, where they do not affect the patient's quality of vision.

Visual and ocular morbidity in severe open-globe injuries presenting to a regional eye centre in New Zealand

IMPORTANCE

Open-globe injuries (OGI) are a leading cause of monocular blindness world-wide with considerable cost to the individual and society.

BACKGROUND

To characterize the epidemiology, severity and outcomes of OGI treated at a major ophthalmology centre in New Zealand.

DESIGN

Retrospective study.

PARTICIPANTS

A total of 385 eyes of 381 patients over a 10-year period.

METHODS

Eligible patients were identified using diagnosis and surgery codes on hospital discharge summaries. Clinical notes were reviewed to determine patient demographics, injury details, treatments and outcomes.

MAIN OUTCOME MEASURES

Complications of injury, visual acuity at 3 months and final follow-up, and final status of the eye.

RESULTS

The estimated annual incidence of OGI was 2.8 per 100 000. Working-age males predominated but age at injury ranged from 9 months to 90 years. Maori and Pacific peoples were over-represented. Injuries were severe with 58.7% presenting with vision of hand movements or worse. Penetrating injuries (56.4%) were most common, followed by globe ruptures (35.6%). Major complications included retinal detachment (15.8%), enucleation/evisceration (9.1%), phthisis bulbi (9.9%), endophthalmitis (2.6%) and sympathetic ophthalmia (0.26%). Despite the injury severity, 46% of eyes achieved final BCVA of ≥6/12. The Ocular Trauma Score (OTS) was a useful prognostic tool for stratifying severity of injury and predicting visual outcome (Fisher's exact test P < 0.001).

CONCLUSIONS AND RELEVANCE

The incidence and severity of OGI in NZ are comparable to global statistics. Surgical repair can effectively recover vision, predicted well by the OTS. We identified at-risk groups to target with education and prevention strategies.

Outcomes of Wound Dehiscence after Penetrating Keratoplasty and Lamellar Keratoplasty

Objective

To investigate the incidence, causes, occurrence time, and range of wound and outcomes of wound dehiscence in patients treated by penetrating keratoplasty (PK) or lamellar keratoplasty (LK).

Methods

We retrospectively reviewed medical records of keratoplasty in Shandong Eye Hospital from January 2006 to June 2017. Thirty-one eyes of 30 patients had sustained wound dehiscence (WD) after surgical treatment. The surgical type, causes, occurrence time, extent of the wound, treatment, and outcomes were recorded.

Results

The study population consisted of 26 men and 4 women. The mean age at the occurrence of WD was 44.6 years old (range: 12-78 years), and the mean time from keratoplasty to WD was 45.9 months (range: 1-204 months). WD occurred in 23 eyes (23/1385, 1.66%) after PK and 8 eyes (8/1632, 0.49%) after LK (p < 0.05). Twenty-seven eyes (27/31, 87.0%) had trauma-induced dehiscence. The mean range of dehiscence was 5.5 o'clock. The vision ranged from 20/50 to light perception after wound suture. The eyes receiving LK had fewer serious complications than PK.

Conclusions

Compared with LK, PK seems to be more prone to result in wound dehiscence. The WD after LK may be less severe. The visual acuity after treatment of WD can be worse in the eyes with PK than LK.

Traumatic globe rupture after deep anterior lamellar keratoplasty-A novel management technique

A traumatic wound dehiscence can occur many years after surgery in 2-6% of all keratoplasties. Intraocular tissue prolapse can lead to severe visual loss. Deep anterior lamellar keratoplasty (DALK) leads to higher wound stability because of the intact Descemet membrane. We report a case of a novel management of wound dehiscence following DALK. A 59-year-old patient underwent uncomplicated DALK for advanced keratoconus. Eighteen months later he experienced a traumatic wound dehiscence (globe rupture) after a fall. Visual acuity decreased to light perception on the affected eye, the iris and prolapsed vitreous were incarcerated, and no retinal details were recognizable. The corneal graft was dehiscent over eight clock hours, the Descemet membrane was ruptured, and the stroma dissolved over 30% of its surface in a bell shape. Primary wound closure was performed with nylon 10-0 single interrupted corneal sutures. One day after emergency treatment, a 23-gauge pars-plana-vitrectomy for vitreous hemorrhage was conducted and a retinal tear was treated with laser photocoagulation. The Descemet membrane was repositioned using a 23 g vitrectomy probe under air and the globe was filled with SF₆ gas. Postoperatively, visual acuity increased to 6/15 and the cornea cleared up. Corneal graft and Descemet membrane repositioning after trauma can avoid a further keratoplasty and the risk of immunological rejection of donor endothelial cells. Clin. Anat. 31:56-59, 2018. © 2017 Wiley Periodicals, Inc.