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Furundaoturan O, Palamar M, Egrilmez S, Yagci A, Barut Selver O. Effectiveness of surgical approach in the management of non-traumatic corneal perforations. Clin Exp Optom 2024:1-7. [PMID: 39370139 DOI: 10.1080/08164622.2024.2411415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 08/25/2024] [Accepted: 09/25/2024] [Indexed: 10/08/2024] Open
Abstract
CLINICAL RELEVANCE Non-traumatic aetiologies are one of the leading causes of corneal perforations. The management of corneal perforation is quite challenging and complex for anterior segment surgeons. The appropriate surgical approach for each case is usually determined on the basis of a combination of many different parameters. BACKGROUND The study aimed to evaluate surgical approach options and outcomes in the treatment of non-traumatic corneal perforations. METHODS Patient data who underwent surgery for non-traumatic corneal perforation between 2016 and 2023 were retrospectively evaluated. Medical records were assessed in terms of age, gender, perforation aetiology, the first and last examination notes, surgical approach, follow-up time, and additional surgeries and outcomes according to anatomical, therapeutic and functional success. Anterior segment photographs were investigated for thorough explanation of the examinations. RESULTS Forty-five eyes of 45 patients were included (mean age 61.2 ± 22.4 (90-2), female/male ratio 20/25). Surgical approaches applied according to the size and location of the perforation site included fibrin glue application (6), amniotic membrane transplantation (AMT) (9), corneal patch graft application(15), and tectonic keratoplasty (15). The ratio of inflammatory and infectious causes as the two main indications was 29/16. Globe integrity was ensured with the first surgery in 27 eyes. However, 17 eyes required secondary surgical attempts due to failure of the first approach and 1 eye underwent evisceration. AMT was the least successful method among other methods in anatomical, therapeutic, and functional assessment. CONCLUSION There are various surgical approaches for repairing non-traumatic corneal perforations, each with its own advantages and disadvantages. These include high tissue resistance, the ability to remove necrotic tissue, ease of access, and anti-inflammatory activity. It is possible to successfully repair corneal perforations with single and combined methods, considering the above-mentioned features, especially depending on the size and location of the defect. While AMT is a viable and time-saving choice - especially in the lack of donor tissues - further interventions are necessary in most circumstances.
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Affiliation(s)
| | - Melis Palamar
- Department of Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Sait Egrilmez
- Department of Ophthalmology, Private Clinic, Izmir, Turkey
| | - Ayse Yagci
- Department of Ophthalmology, Private Clinic, Izmir, Turkey
| | - Ozlem Barut Selver
- Department of Ophthalmology, Ege University Faculty of Medicine, Izmir, Turkey
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Abu Dail Y, Flockerzi E, Munteanu C, Szentmáry N, Seitz B, Daas L. Rethinking Keratoplasty for Patients with Acanthamoeba Keratitis: Early "Low Load Keratoplasty" in Contrast to Late Optical and Therapeutic Keratoplasty. Microorganisms 2024; 12:1801. [PMID: 39338475 PMCID: PMC11434615 DOI: 10.3390/microorganisms12091801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/09/2024] [Accepted: 08/27/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Early therapeutic penetrating keratoplasty (TKP) for Acanthamoeba keratitis (AK) is thought to have a worse visual prognosis than the delayed optical penetrating keratoplasty (OKP) after successful conservative treatment of AK. This has led to a tendency to prolong conservative therapy and delay penetrating keratoplasty in patients with AK. This retrospective series presents the results of patients with AK that underwent early penetrating keratoplasty after reducing the corneal amoeba load through intensive conservative therapy, so-called "low load keratoplasty" (LLKP). PATIENTS AND METHODS The medical records of our department were screened for patients with AK, confirmed by histological examination and/or PCR and/or in vivo confocal microscopy, which underwent ab LLKP and had a follow-up time of at least one year between 2009 and 2023. Demographic data, best corrected visual acuity (BCVA) and intraocular pressure at first and last visit, secondary glaucoma (SG), and recurrence and graft survival rates were assessed. RESULTS 28 eyes of 28 patients were included. The average time from initiation of therapy to penetrating keratoplasty (PKP) was 68 ± 113 days. The mean follow-up time after LLKP was 53 ± 42 months. BCVA (logMAR) improved from 1.9 ± 1 pre-operatively to 0.5 ± 0.6 at last visit (p < 0.001). A total of 14% of patients were under medical therapy for SG at the last visit, and two of them underwent glaucoma surgery. The recurrence rate was 4%. The Kaplan-Meier graft survival rate of the first graft at four years was 70%. The second graft survival rate at four years was 87.5%. CONCLUSION LLKP appears to achieve a good visual prognosis with an earlier visual and psychological habilitation, as well as low recurrence and SG rates. These results should encourage us to reconsider the optimal timing of PKP in therapy-resistant AK.
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Affiliation(s)
- Yaser Abu Dail
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Straße, Building 22, 66421 Homburg/Saar, Germany
| | - Elias Flockerzi
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Straße, Building 22, 66421 Homburg/Saar, Germany
| | - Cristian Munteanu
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Straße, Building 22, 66421 Homburg/Saar, Germany
| | - Nóra Szentmáry
- Dr. Rolf M. Schwiete Center for Limbal Stem Cell and Congenital Aniridia Research, Saarland University, 66421 Homburg/Saar, Germany
| | - Berthold Seitz
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Straße, Building 22, 66421 Homburg/Saar, Germany
| | - Loay Daas
- Department of Ophthalmology, Saarland University Medical Center, Kirrberger Straße, Building 22, 66421 Homburg/Saar, Germany
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Furundaoturan O, Palamar M, Egrilmez S, Yagci A, Barut Selver O. Patch Transplant in Corneal Perforations: Time, Method, and Cause. EXP CLIN TRANSPLANT 2024; 22:636-640. [PMID: 39254076 DOI: 10.6002/ect.2023.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
OBJECTIVES We present demographic data and clinical features of corneal perforations repaired with patch grafts prepared from residual donor corneal rims. MATERIALS AND METHODS For this retrospective study, we evaluated patients who underwent corneal perforation repair with corneal or corneoscleral patch grafts. We recorded demographic data, as well as perforation cause, examination notes, tissue type-size used, follow-up time, and additional surgeries. Anterior segment photographs were also evaluated. Transplanted tissues were prepared from residual donor corneas used in penetrating keratoplasty and were manually adjusted to the precise size of the wound. RESULTS Fifteen patients were enrolled in the study. Mean age of the patients was 64.9 ± 19.7 years (range, 15-81 years) with a female-to-male ratio of 0.85. The causes of perforation were grouped as inflammation, infection, and trauma. The main indications were inflammation (n = 7; 46.7%) and infection (n = 6; 40%), followed by trauma (n = 2; 13.3%). All patients demonstrated preservation of globe integrity during the follow-up time; however, 1 patient's eye required regrafting with limbal conjunctival excision due to melting and leakage. Three eyes required permanent tarsorrhaphy to control progressive exposure keratopathy, and 2 eyes underwent penetrating keratoplasty to cure scar-related corneal opacity. CONCLUSIONS Patch grafts are effective surgical interventions to assure and maintain globe integrity in corneal perforations. The main advantage seems to be that patch grafting allows special preparations for wound architecture. Moreover, in clinics performing keratoplasty, these patch tissues are readily available.
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Affiliation(s)
- Onur Furundaoturan
- From the Kars Harakani State Hospital, Department of Ophthalmology, Kars, Turkey
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Suh A, Ong J, Gibson CR, Mader T, Berdahl J, Waisberg E, Lee AG. The evaluation and management of corneal penetrating and perforating injuries during long-duration spaceflight. Eye (Lond) 2024; 38:1793-1795. [PMID: 38424146 PMCID: PMC11226600 DOI: 10.1038/s41433-024-02996-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/02/2024] Open
Affiliation(s)
- Alex Suh
- Tulane University School of Medicine, New Orleans, LA, USA.
| | - Joshua Ong
- Department of Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center, Ann Arbor, MI, USA
| | | | | | | | - Ethan Waisberg
- Department of Ophthalmology, University of Cambridge, Cambridge, UK
| | - Andrew G Lee
- Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, TX, USA
- The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, TX, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, NY, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX, USA
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Agrawal P, Tiwari A, Chowdhury SK, Vohra M, Gour A, Waghmare N, Bhutani U, Kamalnath S, Sangwan B, Rajput J, Raj R, Rajendran NP, Kamath AV, Haddadin R, Chandru A, Sangwan VS, Bhowmick T. Kuragel: A biomimetic hydrogel scaffold designed to promote corneal regeneration. iScience 2024; 27:109641. [PMID: 38646166 PMCID: PMC11031829 DOI: 10.1016/j.isci.2024.109641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 01/30/2024] [Accepted: 03/26/2024] [Indexed: 04/23/2024] Open
Abstract
Cornea-related injuries are the most common cause of blindness worldwide. Transplantation remains the primary approach for addressing corneal blindness, though the demand for donor corneas outmatches the supply by millions. Tissue adhesives employed to seal corneal wounds have shown inefficient healing and incomplete vision restoration. We have developed a biodegradable hydrogel - Kuragel, with the ability to promote corneal regeneration. Functionalized gelatin and hyaluronic acid form photo-crosslinkable hydrogel with transparency and compressive modulus similar to healthy human cornea. Kuragel composition was tuned to achieve sufficient adhesive strength for sutureless integration to host tissue, with minimal swelling post-administration. Studies in the New Zealand rabbit mechanical injury model affecting corneal epithelium and stroma demonstrate that Kuragel efficiently promotes re-epithelialization within 1 month of administration, while stroma and sub-basal nerve plexus regenerate within 3 months. We propose Kuragel as a regenerative treatment for patients suffering from corneal defects including thinning, by restoration of transparency and thickness.
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Affiliation(s)
| | - Anil Tiwari
- Pandorum Technologies Pvt., Ltd, Bangalore, India
- Dr. Shroff’s Charity Eye Hospital, New Delhi, India
| | | | - Mehak Vohra
- Pandorum Technologies Pvt., Ltd, Bangalore, India
| | - Abha Gour
- Pandorum Technologies Pvt., Ltd, Bangalore, India
- Dr. Shroff’s Charity Eye Hospital, New Delhi, India
| | | | | | - S. Kamalnath
- Pandorum Technologies Pvt., Ltd, Bangalore, India
| | | | - Jyoti Rajput
- Pandorum Technologies Pvt., Ltd, Bangalore, India
| | - Ritu Raj
- Pandorum Technologies Pvt., Ltd, Bangalore, India
| | | | | | - Ramez Haddadin
- Feinberg School of Medicine Northwestern University, Chicago, IL, USA
| | - Arun Chandru
- Pandorum Technologies Pvt., Ltd, Bangalore, India
| | | | - Tuhin Bhowmick
- Pandorum Technologies Pvt., Ltd, Bangalore, India
- Pandorum International Inc, San Francisco, CA, USA
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Bidzan M, Eter N, Uhlig CE. Efficacy of Emergency Penetrating Keratoplasty with Cryopreserved Human Donor Corneas. Ophthalmol Ther 2024; 13:979-994. [PMID: 38345711 PMCID: PMC10912390 DOI: 10.1007/s40123-024-00889-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/11/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION To investigate the long-term outcomes of emergency penetrating keratoplasty using cryopreserved human donor corneas in the management of actual or imminent corneal perforation. METHODS A retrospective analysis was performed of the treatment efficacy of emergency penetrating keratoplasty using a cryopreserved human donor cornea, in 14 eyes of 14 patients with corneal ulcers of different etiology. For comparison, the medical histories of 14 patients who had undergone penetrating keratoplasty with the same indication, but received a regularly processed human corneal graft, were retrospectively analyzed. In both groups, the primary endpoint for graft failure was repeat surgery, defined as the necessity for amniotic membrane transplantation, conjunctival flap, or repeat penetrating keratoplasty, during a follow-up time of maximally 12 months. RESULTS The difference in the need for repeated surgeries between the cryopreserved human donor cornea group and cultivated tissue graft group was not statistically significant (p = 0.835). Specifically, repeat complex surgery of any kind within 6 months was necessary in 50% of the cryopreserved cornea group and in 57.1% of the control group, with no further surgical interventions during the remainder of the follow-up period. However, repeat penetrating keratoplasty occurred more frequently in the cryopreserved cornea group (n = 5) than in the control group (n = 1) during the first 12 months after treatment (p = 0.048). CONCLUSION Cryopreserved corneas appear to be a viable option for promptly addressing emergencies and stabilizing the corneal situation, providing a faster solution compared to waiting for fresh tissue availability. However, repeat penetrating keratoplasty is more frequent when cryopreserved human donor corneas are used. Cryopreserved human donor corneas may be useful if surgical treatment is urgent and alternative options, such as tissue use, a conjunctival flap, or multilayer amniotic membrane transplantation, are not available.
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Affiliation(s)
- Malik Bidzan
- Department of Ophthalmology, University of Muenster Medical Center, Albert-Schweitzer-Campus 1, Building D15, 48149, Münster, Germany.
| | - Nicole Eter
- Department of Ophthalmology, University of Muenster Medical Center, Albert-Schweitzer-Campus 1, Building D15, 48149, Münster, Germany
| | - Constantin E Uhlig
- Department of Ophthalmology, University of Muenster Medical Center, Albert-Schweitzer-Campus 1, Building D15, 48149, Münster, Germany
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Aghamollaei H, Hashemi H, Fallahtafti M, Daryabari SH, Khabazkhoob M, Jadidi K. Applications of SMILE-extracted lenticules in ophthalmology. Int J Ophthalmol 2024; 17:173-187. [PMID: 38239948 PMCID: PMC10754658 DOI: 10.18240/ijo.2024.01.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/20/2023] [Indexed: 01/22/2024] Open
Abstract
AIM To review recent innovations, challenges, and applications of small incision lenticule extraction (SMILE) extracted lenticule for treating ocular disorders. METHODS A literature review was performed in the PubMed database, which was last updated on 30 December 2021. There was no limit regarding language. The authors evaluated the reference lists of the collected papers to find any relevant research. RESULTS Due to the simplicity and accuracy of modern femtosecond lasers and the extensive development of SMILE surgery, many healthy human corneal stromal lenticules were extracted during surgery, motivating some professionals to investigate the SMILE lenticule reusability in different ocular disorders. In addition, new approaches had been developed to preserve, modify, and bioengineer the corneal stroma, leading to the optimal use of discarded byproducts such as lenticules from SMILE surgery. The lenticules can be effectively re-implanted into the autologous or allogenic corneas of human subjects to treat refractive errors, corneal ectasia, and corneal perforation and serve as a patch graft for glaucoma drainage devices with better cosmetic outcomes. CONCLUSION SMILE-extracted lenticules could be a viable alternative to human donor corneal tissue.
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Affiliation(s)
- Hossein Aghamollaei
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran 1968653111, Iran
| | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran 1983963113, Iran
| | - Mahsa Fallahtafti
- Vision Health Research Center, Semnan University of Medical Sciences, Semnan 1914853185, Iran
| | - Seyed-Hashem Daryabari
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran 1968653111, Iran
| | - Mehdi Khabazkhoob
- Department of Basic Sciences, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran 1968653111, Iran
| | - Khosrow Jadidi
- Vision Health Research Center, Semnan University of Medical Sciences, Semnan 1914853185, Iran
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Zhu Y, Jin X, Fu N, Li J. Medrysone promotes corneal injury repair by promoting M2-like polarization of macrophages. BMC Ophthalmol 2023; 23:503. [PMID: 38082280 PMCID: PMC10712160 DOI: 10.1186/s12886-023-03234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Accumulated evidence suggests that M2-like polarized macrophages plays an important role in reducing inflammation, promoting and accelerating wound healing process and tissue repair. Thus, M2-like TAMs (Tumour-associated macrophages) was an appealing target for therapy intervention. METHOD Flow cytometry and RT-PCR assay were used to detect the polarization of macrophages induced by Medrysone, and the rat corneal mechanical injury model was established to evaluate the efficacy of Medrysone in cornel repair. RESULTS Here we found that Medrysone enhanced IL-4 induced M2 polarization of macrophages, as illustrated by increased expression of CD206, up-regulation of M2 marker mRNAs. Medrysone promoted VEGF and CCL2 secretion in IL-4 induced M2-like polarization. IL-4 triggered STAT6 activation was further enhanced by Medrysone and silencing of STAT6 partially abrogated the stimulatory effect of Medrysone. Medrysone improved migration-promoting feature of M2-like macrophages, as indicated by increased migration of endothelial cells. Further, Medrysone promoted corneal injury repair by inducing M2 polarization of macrophages in vivo. CONCLUSION Our study suggest that Medrysone promotes corneal injury repair by inducing the M2 polarization of macrophages, providing a theoretical basis for the application of Medrysone in the treatment of corneal injury.
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Affiliation(s)
- Yaqin Zhu
- Hangzhou Aier Eye Hospital, Hangzhou, 310000, Zhejiang, China
| | - Xiaohong Jin
- Hangzhou Aier Eye Hospital, Hangzhou, 310000, Zhejiang, China
| | - Ning Fu
- Sir Run Run Shaw Hospital Hangzhou, Hangzhou, 310000, China
| | - Jiuke Li
- Hangzhou Aier Eye Hospital, Hangzhou, 310000, Zhejiang, China.
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Aldihan KA, AlRashedi MJ, Helayel HB, AlMutlak M, Hameed ST. Severe Dry Eye Disease in Charcot-Marie-Tooth Disease: A Comprehensive Case Report. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941094. [PMID: 37964513 PMCID: PMC10660297 DOI: 10.12659/ajcr.941094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/10/2023] [Accepted: 09/29/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Charcot-Marie-Tooth disease (CMT) is a hereditary neurological disorder that primarily leads to peripheral neuropathy, characterized by progressive muscle weakness, atrophy, and loss of sensation in the extremities. It can also present with some ocular manifestations, such as glaucoma, nystagmus, and cranial nerve involvement. The purpose of this article was to report a case of severe dry eye disease (DED) possibly associated with Charcot-Marie-Tooth disease. CASE REPORT We report the clinical presentation, workup, and management of a woman diagnosed with CMT type 2EE based on genetic testing who suffered from severe DED sequelae. The patient had regularly followed up in the cornea service at our hospital due to DED for several years. A thorough workup to exclude causes associated with dry eye disease, including rheumatoid factor, erythrocyte sedimentation rate (ESR), anti-nuclear antibody (ANA), anti-Sjögren's-syndrome-related antigen A (anti-SSA), and anti-Sjögren's-syndrome-related antigen B (Anti-SSB), were performed, and all came out negative. She recently presented to the emergency room with redness, tearing, and a decline in visual acuity after minor ocular trauma 3 weeks before her presentation. The slit lamp examination showed central corneal perforation measuring 2×2 mm with a positive Seidel test. The case was managed first by multiple attempts to seal the defect with cyanoacrylate glue, and then a patch corneal graft was performed as the anterior chamber failed to deepen. CONCLUSIONS DED may be one of the many ocular manifestations associated with CMT. Hence, a thorough assessment and multidisciplinary approach, including supportive therapy, are warranted to prevent long-term ocular sequelae, including visual loss.
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Kusano M, Mohamed YH, Uematsu M, Inoue D, Harada K, Tang D, Kitaoka T. Whole Corneal Descemetocele. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1780. [PMID: 37893498 PMCID: PMC10608096 DOI: 10.3390/medicina59101780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/19/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: To report a case of microbial keratitis complicated by severe corneal melting and whole corneal descemetocele. Methods: A 72-year-old male farmer presented with a right corneal ulcer involving nearly the entire cornea, which was almost completely melted down with the remaining Descemet's membrane (DM). The pupil area was filled with melted necrotic material, with the intraocular lens partially protruding from the pupil and indenting the DM. Corneal optical coherence tomography (OCT) examination revealed a corneal thickness of 37 µm that was attached to its back surface, with the iris and a part of the intraocular lens (IOL) protruding through the pupil. The patient was hospitalized and treated with local and systemic antibiotics until control of the inflammation was achieved. Corneoscleral transplantation plus excision/transplantation of the corneal limbus were performed, and the entire corneal limbus was lamellarly incised. After completely suturing all around the transplanted corneoscleral graft, the anterior chamber was formed. Postoperative treatment included local antibiotics, anti-inflammatory drugs, and cycloplegic drops. Results: There was no recurrence of infection, and the corneal epithelium gradually regenerated and covered the whole graft. Visual acuity was light perception at 6 months after the surgery. The patient was satisfied that the globe was preserved and did not wish to undergo any further treatment. Conclusions: Corneoscleral transplantation is preferred for the treatment of large-sized descemetoceles with active microbial keratitis and extensive infiltrates, especially in cases where the whole cornea has transformed into a large cyst.
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Affiliation(s)
- Mao Kusano
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Yasser Helmy Mohamed
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Masafumi Uematsu
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Daisuke Inoue
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Kohei Harada
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Diya Tang
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
| | - Takashi Kitaoka
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki 852-8501, Japan
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Zehnder K, Reinhold A, Gugleta K, Gatzioufas Z. Spontaneous Corneal Perforation in Treatment-Resistant MPO-ANCA-Associated Small Vessel Vasculitis. Klin Monbl Augenheilkd 2023; 240:385-386. [PMID: 37164414 DOI: 10.1055/a-2004-5200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- Karin Zehnder
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Aja Reinhold
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Konstantin Gugleta
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Zisis Gatzioufas
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
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12
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Li S, Ma X, Zhang Y, Qu Y, Wang L, Ye L. Applications of hydrogel materials in different types of corneal wounds. Surv Ophthalmol 2023:S0039-6257(23)00040-1. [PMID: 36854372 DOI: 10.1016/j.survophthal.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023]
Abstract
Severe corneal injury can lead to a decrease in light transmission and even blindness. Currently, corneal transplantation has been applied as the primary treatment for corneal blindness; however, the worldwide shortage of suitable corneal donor tissue means that a large proportion of patients have no access to corneal transplants. This situation has contributed to the rapid development of various corneal substitutes. The development and optimization of novel hydrogels that aim to replace partial or full-thickness pathological corneas have advanced in the last decade. Meanwhile, with the help of 3D bioprinting technology, hydrogel materials can be molded to a refined and controllable shape, attracting many scientists to the field of corneal reconstruction research. Although hydrogels are not yet available as a substitute for traditional clinical methods of corneal diseases, their rapid development makes us confident that they will be in the near future. We summarize the application of hydrogel materials for various types of corneal injuries frequently encountered in clinical practice, especially focusing on animal experiments and preclinical studies. Finally, we discuss the development and achievements of 3D bioprinting in the treatment of corneal injury.
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Affiliation(s)
- Shixu Li
- Shenzhen Eye Hospital, Jinan University, Shenzhen, China; Shenzhen Eye Institute, Shenzhen, China
| | - Xudai Ma
- Shenzhen Eye Hospital, Jinan University, Shenzhen, China; Shenzhen Eye Institute, Shenzhen, China
| | - Yongxin Zhang
- Shenzhen Eye Hospital, Jinan University, Shenzhen, China; Shenzhen Eye Institute, Shenzhen, China
| | - Yunhao Qu
- Shenzhen Eye Hospital, Jinan University, Shenzhen, China; Shenzhen Eye Institute, Shenzhen, China
| | - Ling Wang
- Shenzhen Eye Hospital, Jinan University, Shenzhen, China; Shenzhen Eye Institute, Shenzhen, China.
| | - Lin Ye
- Shenzhen Eye Hospital, Jinan University, Shenzhen, China; Shenzhen Eye Institute, Shenzhen, China.
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SMILE lenticule versus amniotic membrane graft (AMG) augmented with platelet-rich plasma (PRP) for the treatment of perforated corneal ulcer. Int Ophthalmol 2023:10.1007/s10792-023-02631-3. [PMID: 36692698 DOI: 10.1007/s10792-023-02631-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate the safety and efficacy of stromal lenticule obtained from small-incision lenticule extraction (SMILE) surgery versus amniotic membrane graft (AMG) augmented with platelet-rich plasma (PRP) for the treatment of perforated corneal ulcers and compare the results between the two groups. PATIENTS AND METHODS This is a comparative retrospective study that included 40 eyes with medium-sized corneal perforations, which were classified into two equal groups of 20 eyes each; group (A) was treated with SMILE lenticule graft and group (B) was treated with AMG augmented with PRP. Pre- and postoperative evaluations were carried out using both slit-lamp (SL) examination and anterior segment optical coherence tomography (AS-OCT), including closure of perforation, complete healing, and best corrected visual acuity (BCVA). RESULTS Complete closure of the perforation was achieved in both groups. However, healing was faster in the SMILE lenticule group than in the AMG with PRP group (P < 0.05). Complete healing was achieved in both groups: 100% in SMILE lenticule group and 95% in AMG with PRP group (P > 0.05). Both groups had few insignificant complications (30% in each), which were managed. CONCLUSION Both methods achieved adequate healing of corneal perforations within few weeks without significant complications. However, the stromal lenticule obtained from small-incision lenticule extraction (SMILE) surgery tended to be safer with faster healing than AMG with PRP.
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14
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Recurrence of perforation and overall patient survival after penetrating keratoplasty versus amniotic membrane transplantation in corneal perforation. Graefes Arch Clin Exp Ophthalmol 2023:10.1007/s00417-022-05914-0. [PMID: 36680612 DOI: 10.1007/s00417-022-05914-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/21/2022] [Accepted: 11/15/2022] [Indexed: 01/22/2023] Open
Abstract
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.
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15
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Bouazza M, Amri G, Razzak A, Reda K, Oubaaz A. [Treatment of corneal perforation by autologous sutureless corneal patch]. J Fr Ophtalmol 2023; 46:e45-e48. [PMID: 36437118 DOI: 10.1016/j.jfo.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022]
Affiliation(s)
- M Bouazza
- Service d'ophtalmologie, hôpital universitaire international Cheikh Khalifa, avenue Mohamed-Taieb-Naciri, 82403 Casablanca, Maroc; Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Maroc.
| | - G Amri
- Service d'ophtalmologie, hôpital universitaire international Cheikh Khalifa, avenue Mohamed-Taieb-Naciri, 82403 Casablanca, Maroc; Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Maroc
| | - A Razzak
- Service d'ophtalmologie, hôpital universitaire international Cheikh Khalifa, avenue Mohamed-Taieb-Naciri, 82403 Casablanca, Maroc; Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Maroc
| | - K Reda
- Service d'ophtalmologie, hôpital universitaire international Cheikh Khalifa, avenue Mohamed-Taieb-Naciri, 82403 Casablanca, Maroc; Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Maroc
| | - A Oubaaz
- Service d'ophtalmologie, hôpital universitaire international Cheikh Khalifa, avenue Mohamed-Taieb-Naciri, 82403 Casablanca, Maroc; Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Maroc
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16
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Hu X, Wei R, Liu C, Wang Y, Yang D, Sun L, Xia F, Liu S, Li M, Zhou X. Recent advances in small incision lenticule extraction (SMILE)-derived refractive lenticule preservation and clinical reuse. ENGINEERED REGENERATION 2023. [DOI: 10.1016/j.engreg.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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17
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Elhaddad O, Achiron A, Yahalomi T, Avadhanam V, Tole D, Darcy K. Modified "Top-up sandwich" technique for the management of corneal perforations: A case report and a literature review. Am J Ophthalmol Case Rep 2022; 29:101765. [PMID: 36582846 PMCID: PMC9792391 DOI: 10.1016/j.ajoc.2022.101765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose We describe a modified technique for managing a peripheral, non-infected, corneal perforation using a "Sandwich" technique that combines posterior lamellar keratoplasty, an amniotic membrane patch and a Gundersen conjunctival flap. Observations A 75-year-old female patient presented with Sjogren's syndrome-related corneal perforation. A mini-Descemet stripping automated endothelial keratoplasty (DSAEK) graft (5 mm) was introduced into the anterior chamber and was mobilized to plug the perforation. Then, two amniotic membrane patches were stacked over the perforation and glued. Finally, the whole area was covered with a Gundersen conjunctival flap, mobilized from the inferior conjunctiva and secured in place using interrupted 10-0 nylon sutures. A step-by-step guide is also described. At three months, the final visual acuity was 6/9. A literature review revealed ten cases in which a posterior lamellar graft was effectively employed to treat corneal perforations. Conclusions and Importance We described a modified approach for treating peripheral corneal perforation surgically. This "sandwich" approach is simple to replicate and can give quick healing with few visual repercussions. Our detailed guide may be utilized to obtain similar results and may be added to the array of treatment options for peripheral corneal perforation.
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Affiliation(s)
- Omar Elhaddad
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom,Faculty of Medicine, Alexandria University, Egypt,Corresponding author. Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom. Lower Maudlin St, Bristol, BS1 2LX, UK.
| | - Asaf Achiron
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Yahalomi
- Department of Ophthalmology, Samson Assuta Ashdod Hospital and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Venkata Avadhanam
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Derek Tole
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Kieran Darcy
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
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18
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Sun X, Qiao Y, Zhao L, Shi Z, Zhang X, Cao R, Zhou Q, Shi W. Application of Decellularized Porcine Sclera in Repairing Corneal Perforations and Lamellar Injuries. ACS Biomater Sci Eng 2022; 8:5295-5306. [PMID: 36454184 DOI: 10.1021/acsbiomaterials.2c00972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Scleras are mainly used for the treatment of glaucoma, eyelid damage, and scleral ulcers. Given that the sclera and cornea collectively constitute the complete external structure of the eyeball and both have the same tissue and cell origin, we attempted to identify scleral materials to treat lamellar and penetrating corneal injuries. Based on research in our center, antigenic components in decellularized porcine sclera (DPS) were removed using a simplified decellularization method, leaving the collagen structure and active components undamaged. DPS preserved the mechanical properties and did not significantly inhibit the proliferation and replication of human corneal epithelial cells. In vivo, the graft epithelium healed well after lamellar and penetrating scleral grafting, and the graft thickness did not change evidently. DPS can resist suture traction during scleral transplantation and maintain anterior chamber stability until day 28 post-operatively, especially in penetrating repairs. No obvious immune rejection of lamellar or penetrating scleral grafts was found 28 days after DPS transplantation. This study shows that DPS could be used as an alternative material for the emergency repair of corneal perforations and lamellar injuries, representing another application of sclera.
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Affiliation(s)
- Xiuli Sun
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Jingsi Road, Jinan 271000, China
| | - Yujie Qiao
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Jingsi Road, Jinan 271000, China
| | - Long Zhao
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Jingsi Road, Jinan 271000, China
| | - Zhen Shi
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Jingsi Road, Jinan 271000, China
| | - Xiaoyu Zhang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Jingsi Road, Jinan 271000, China
| | - Rui Cao
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Jingsi Road, Jinan 271000, China
| | - Qingjun Zhou
- Eye Institute of Shandong First Medical University, Qingdao Eye Hospital of Shandong First Medical University, State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, School of Ophthalmology, Shandong First Medical University, 5 Yan'erdao Road, Qingdao 266071, China
| | - Weiyun Shi
- Eye Institute of Shandong First Medical University, Eye Hospital of Shandong First Medical University (Shandong Eye Hospital), State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, School of Ophthalmology, Shandong First Medical University, Jingsi Road, Jinan 271000, China
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19
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Kamel Farag R, Elmowafi K, El-Sharkawy HT, El-Tarshoby S. Combined umbilical cord patching with amniotic membrane graft for corneal surface reconstruction. MEDICAL HYPOTHESIS, DISCOVERY & INNOVATION OPHTHALMOLOGY JOURNAL 2022; 11:129-136. [PMID: 37641642 PMCID: PMC10445317 DOI: 10.51329/mehdiophthal1456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/25/2022] [Indexed: 08/31/2023]
Abstract
Background Umbilical cord patch (UCP) grafts have been successfully used for glaucoma shunt tube coverage and conjunctival surface reconstruction. In recent years, the technique has emerged as a novel alternative for the reconstruction of corneal perforation and descemetocele. This study aimed to evaluate the effectiveness of combined UCP grafting and human amniotic membrane (HAM) transplantation for the management of corneal perforation or descemetocele. Methods This prospective, non-comparative, interventional case series included nine eyes of nine patients with corneal descemetoceles and 28 eyes of 28 patients with corneal perforations, all in a clinically quiescent state. UCP grafting and HAM transplantation were combined to treat all patients. We re-examined the patients daily throughout the first week, weekly for 1 month, and then monthly for the first 6 months using slit-lamp examination and anterior segment optical coherence tomography. Results We included 37 eyes with descemetocele or corneal perforation in a clinically quiescent state. The mean (standard deviation) ages of patients with corneal descemetocele and corneal perforation were 56.3 (18.8) years and 54.3 (18.1) years, respectively. The male-to-female ratios in patients with corneal descemetocele and corneal perforation were 56% to 44% and 61% to 39%, respectively. Postoperative corneal thickness increased significantly in eyes with descemetocele compared to preoperative values (P < 0.001). Postoperative best-corrected distance visual acuity improved significantly compared to preoperative values in eyes with descemetocele or corneal perforation (both P < 0.001), with relief of accompanying ocular symptoms. We did not observe any recurrence or complications such as rejection, infection, suture-related problems, or severe inflammation and all had a formed anterior chamber up to the final follow-up visit. Conclusions Combined UCP grafting and HAM transplantation could be a promising alternative treatment for corneal perforation or descemetocele in clinically quiescent eyes, providing satisfactory reconstruction and functional outcomes. Further studies with robust designs, larger sample sizes, and longer follow-up are needed to verify the efficacy and safety of this modified surgical technique in enhancing vision and restoring anterior segment anatomical integrity in compromised corneas.
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Affiliation(s)
- Rania Kamel Farag
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Karim Elmowafi
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Sahar El-Tarshoby
- Ophthalmology Center, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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20
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Otero E, Mercado C. Limbal advancement technique in managing acute or impending peripheral corneal perforations. Am J Ophthalmol Case Rep 2022; 28:101722. [PMID: 36281263 PMCID: PMC9587362 DOI: 10.1016/j.ajoc.2022.101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Ernesto Otero
- Escuela Superior de Oftalmología, Instituto Barraquer de América, Bogotá, Colombia,Corresponding author. Ac. 100 #18A - 51, Bogotá, Colombia.
| | - Carolina Mercado
- Escuela Superior de Oftalmología, Instituto Barraquer de América, Bogotá, Colombia,Corresponding author. Ac. 100 #18A – 51, Bogotá, Colombia.
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21
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Nitta K, Mukai R, Todokoro D, Akiyama H. Lacrimal Duct Obstruction and Infection Associated with Non-Traumatic Corneal Perforation: A Case Series. Int Med Case Rep J 2022; 15:313-322. [PMID: 35769810 PMCID: PMC9236464 DOI: 10.2147/imcrj.s363034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/08/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To report a case series of lacrimal duct obstruction and infection associated with non-traumatic corneal perforation. Case Series This study included 6 eyes in 6 patients with non-traumatic corneal perforation treated between April 2019 and March 2021. All 6 cases were associated with lacrimal duct obstruction and infection. Purulent discharge caused by lacrimal duct infection was observed in all 6 patients (100%). However, three of the 6 patients (50%) did not show purulent discharge at initial examination and lacrimal duct obstruction was therefore not initially recognized. Dry eye was observed in five of the 6 patients (83%) and may have caused corneal deterioration, increasing susceptibility to perforation. Further, dry eye masks symptoms of lacrimal duct obstruction and infections, such as epiphora and regurgitation of purulent discharge, making the association with lacrimal duct obstruction and infection difficult to determine. All patients were treated for both corneal perforation and lacrimal duct disease, and conditions improved, with no recurrence of either corneal perforation or lacrimal duct disease. Conclusion In patients with a combination of lacrimal duct disease and corneal perforation, treatment of both diseases resulted in stabilization of patient condition. Dry eyes may mask symptoms of lacrimal duct diseases, such as epiphora and purulent discharge, and lacrimal duct disease may thus be underdiagnosed.
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Affiliation(s)
- Keisuke Nitta
- Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
- Correspondence: Keisuke Nitta, Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan, Tel +81-27-220-8338, Fax +81-27-220-3841, Email
| | - Ryo Mukai
- Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Daisuke Todokoro
- Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hideo Akiyama
- Department of Ophthalmology, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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22
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You J, Frazer H, Sayyar S, Chen Z, Liu X, Taylor A, Filippi B, Beirne S, Wise I, Petsoglou C, Hodge C, Wallace G, Sutton G. Development of an In Situ Printing System With Human Platelet Lysate-Based Bio-Adhesive to Treat Corneal Perforations. Transl Vis Sci Technol 2022; 11:26. [PMID: 35767274 PMCID: PMC9251791 DOI: 10.1167/tvst.11.6.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Corneal perforation is a clinical emergency that can result in blindness. Currently corneal perforations are treated either by cyanoacrylate glue which is toxic to corneal cells, or by using commercial fibrin glue for small perforations. Both methods use manual delivery which lead to uncontrolled application of the glues to the corneal surface. Therefore, there is a need to develop a safe and effective alternative to artificial adhesives. Methods Previously, our group developed a transparent human platelet lysate (hPL)-based biomaterial that accelerated corneal epithelial cells healing in vitro. This biomaterial was further characterized in this study using rheometry and adhesive test, and a two-component delivery system was developed for its application. An animal trial (5 New Zealand white rabbits) to compare impact of the biomaterial and cyanoacrylate glue (control group) on a 2 mm perforation was conducted to evaluate safety and efficacy. Results The hPL-based biomaterial showed higher adhesiveness compared to commercial fibrin glue. Treatment rabbits had lower pain scores and faster recovery, despite generating similar scar-forming structure compared to controls. No secondary corneal ulcer was generated in rabbits treated with the bio-adhesive. Conclusions This study reports an in situ printing system capable of delivering a hPL-based, transparent bio-adhesive and successfully treating small corneal perforations. The bio-adhesive-treated rabbits recovered faster and required no additional analgesia. Translational Relevance The developed in situ hPL bio-adhesives treatment represents a new format of treating corneal perforation that is easy to use, allows for accurate application, and can be a potentially effective and pain relief treatment.
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Affiliation(s)
- Jingjing You
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Hannah Frazer
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Sepidar Sayyar
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia.,Australian National Fabrication Facility - Materials Node, Innovation Campus, University of Wollongong, Wollongong, Australia
| | - Zhi Chen
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia
| | - Xiao Liu
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia
| | - Adam Taylor
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia.,Australian National Fabrication Facility - Materials Node, Innovation Campus, University of Wollongong, Wollongong, Australia
| | - Benjamin Filippi
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia.,Australian National Fabrication Facility - Materials Node, Innovation Campus, University of Wollongong, Wollongong, Australia
| | - Stephen Beirne
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia.,Australian National Fabrication Facility - Materials Node, Innovation Campus, University of Wollongong, Wollongong, Australia
| | - Innes Wise
- Laboratory Animal Services, University of Sydney, Sydney, Australia
| | - Constantinos Petsoglou
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, Australia.,New South Wales Tissue Bank, Sydney, Australia
| | - Chris Hodge
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, Australia.,New South Wales Tissue Bank, Sydney, Australia.,Vision Eye Institute, Chatswood, New South Wales, Australia
| | - Gordon Wallace
- ARC Centre of Excellence for Electromaterials Science, Intelligent Polymer Research Institute, AIIM, Innovation Campus, University of Wollongong, Wollongong, New South Wales, Australia.,Australian National Fabrication Facility - Materials Node, Innovation Campus, University of Wollongong, Wollongong, Australia
| | - Gerard Sutton
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, Australia.,New South Wales Tissue Bank, Sydney, Australia.,Vision Eye Institute, Chatswood, New South Wales, Australia
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23
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Corneal stromal repair and regeneration. Prog Retin Eye Res 2022; 91:101090. [DOI: 10.1016/j.preteyeres.2022.101090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/02/2023]
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24
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Bafna RK, Kalra N, Rathod A, Asif MI, Lata S, Parmanand K, Kaur N, Kittur AS, Shakkarwal C, Roop P, Agarwal R, Agarwal T, Sharma N. Hitch suture assisted tuck in Tenon's Patch Graft for management of Corneal Perforations. Eur J Ophthalmol 2022; 32:3372-3382. [PMID: 35234532 DOI: 10.1177/11206721221078682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Rahul Kumar Bafna
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Nidhi Kalra
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Aishwarya Rathod
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Mohamed Ibrahime Asif
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Suman Lata
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Kumar Parmanand
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Navpreet Kaur
- 78595Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi
| | - Amogh Shreekant Kittur
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Chetan Shakkarwal
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Prakhyat Roop
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Rinky Agarwal
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Tushar Agarwal
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
| | - Namrata Sharma
- Rajendra Prasad Centre for Ophthalmic Sciences, 28730All India Institute of Medical Sciences, New Delhi
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25
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Treatment of Non-Infectious Corneal Injury: Review of Diagnostic Agents, Therapeutic Medications, and Future Targets. Drugs 2022; 82:145-167. [PMID: 35025078 PMCID: PMC8843898 DOI: 10.1007/s40265-021-01660-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/03/2022]
Abstract
Corneal injuries can occur secondary to traumatic, chemical, inflammatory, metabolic, autoimmune, and iatrogenic causes. Ocular infection may frequently occur concurrent to corneal injury; however, antimicrobial agents are excluded from this present review. While practitioners may primarily rely on clinical examination techniques to assess these injuries, several pharmacological agents, such as fluorescein, lissamine green, and rose bengal, can be used to formulate a diagnosis and develop effective treatment strategies. Practitioners may choose from several analgesic medications to help with patient comfort without risking further injury or delaying ocular healing. Atropine, cyclopentolate, scopolamine, and homatropine are among the most frequently used medications for this purpose. Additional topical analgesic agents may be used judiciously to augment patient comfort to facilitate diagnosis. Steroidal anti-inflammatory agents are frequently used as part of the therapeutic regimen. A variety of commonly used agents, including prednisolone acetate, loteprednol, difluprednate, dexamethasone, fluorometholone, and methylprednisolone are discussed. While these medications are effective for controlling ocular inflammation, side effects, such as elevated intraocular pressure and cataract formation, must be monitored by clinicians. Non-steroidal medications, such as ketorolac, bromfenac, nepafenac, and diclofenac, are additionally used for their efficacy in controlling ocular inflammation without incurring side effects seen with steroids. However, these agents have their own respective side effects, warranting close monitoring by clinicians. Additionally, ophthalmologists routinely employ several agents in an off-label manner for supplementary control of inflammation and treatment of corneal injuries. Patients with corneal injuries not infrequently have significant ocular surface disease, either as a concurrent pathology or as an exacerbation of previously existing disease. Several agents used in the management of ocular surface disease have also been found to be useful as part of the therapeutic armamentarium for treatment of corneal injuries. For example, several antibiotics, such as doxycycline and macrolides, have been used for their anti-inflammatory effects on specific cytokines that are upregulated during acute injuries. There has been a recent wave of interest in amniotic membrane therapies (AMTs), including topical, cryopreserved and dehydrated variants. AMT is particularly effective in ocular injuries with violation of corneal surface integrity due to its ability to promote re-epithelialization of the corneal epithelium. Blood-based therapies, including autologous serum tears, plasma-enriched growth factor eyedrops and autologous blood drops, have additionally been explored in small case series for effectiveness in challenging and recalcitrant cases. Protection of the ocular surface is also a vital component in the treatment of corneal injuries. Temporary protective methods, such as bandage contact lenses and mechanical closure of the eyelids (tarsorrhaphy) can be particularly helpful in selective cases. Glue therapies, including biologic and non-biologic variants, can also be used in cases of severe injury and risk of corneal perforation. Finally, there are a variety of recently introduced and in-development agents that may be used as adjuvant therapies in challenging patient populations. Neurotrophic corneal disease may occur as a result of severe or chronic injury. In such cases, recombinant human nerve growth factor (cenegermin), topical insulin, and several other novel agents may be an alternate and effective option for clinicians to consider.
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Juarez A, Djallali M, Piché M, Thériault M, Groleau M, Beroual S, McTiernan CD, Lin G, Hélie P, Carrier M, Griffith M, Brunette I. A Liquid Hydrogel to Restore Long Term Corneal Integrity After Perforating and Non-Perforating Trauma in Feline Eyes. Front Bioeng Biotechnol 2022; 9:773294. [PMID: 34976970 PMCID: PMC8714956 DOI: 10.3389/fbioe.2021.773294] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/22/2021] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Alejandro Juarez
- Department of Ophthalmology, Université de Montréal, Montreal, QC, Canada.,Centre Universitaire d'Ophtalmologie de l'Université de Montréal à l'Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada.,Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
| | - Mohamed Djallali
- Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
| | - Marilyse Piché
- Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
| | - Mathieu Thériault
- Department of Ophthalmology, Université de Montréal, Montreal, QC, Canada.,Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
| | - Marc Groleau
- Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada.,Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, QC, Canada
| | - Sharifa Beroual
- Department of Ophthalmology, Université de Montréal, Montreal, QC, Canada.,Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
| | | | - Grace Lin
- Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
| | - Pierre Hélie
- Department of Pathology and Microbiology, Faculty of Veterinary Medicine, Université de Montréal, Montreal, QC, Canada
| | - Michel Carrier
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Montreal, QC, Canada
| | - May Griffith
- Department of Ophthalmology, Université de Montréal, Montreal, QC, Canada.,Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada.,Institute of Biomedical Engineering, Université de Montréal, Montreal, QC, Canada
| | - Isabelle Brunette
- Department of Ophthalmology, Université de Montréal, Montreal, QC, Canada.,Centre Universitaire d'Ophtalmologie de l'Université de Montréal à l'Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada.,Maisonneuve-Rosemont Hospital Research Center, Montreal, QC, Canada
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Kate A, Vyas S, Bafna RK, Sharma N, Basu S. Tenons Patch Graft: A Review of Indications, Surgical Technique, Outcomes and Complications. Semin Ophthalmol 2021; 37:462-470. [PMID: 34932431 DOI: 10.1080/08820538.2021.2017470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Anahita Kate
- The Cornea Institute, KVC Campus, LV Prasad Eye Institute, Vijayawada, India
| | - Sonal Vyas
- The Cornea Institute, KAR Campus, LV Prasad Eye Institute, Hyderabad, India
| | - Rahul Kumar Bafna
- Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sayan Basu
- Brien Holden Eye Research Centre (BHERC), LV Prasad Eye Institute, Hyderabad, India
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Abdelghany AA, Bahrawy ME, Alio JL. Combined Platelet Rich Plasma and Amniotic membrane in the treatment of Perforated Corneal Ulcers. Eur J Ophthalmol 2021; 32:2148-2152. [PMID: 34623187 DOI: 10.1177/11206721211049100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To report the outcomes of using synthetic amniotic membrane with platelet rich plasma for the primary management of corneal perforations. SETTING Ophthalmology department. Faculty of Medicine, Minia University, Minia, Egypt. METHODS A case series of 10 patients diagnosed with corneal perforation underwent emergency surgical procedure for repair of the perforation through the implantation of synthetic amniotic membrane with platelet-rich plasma clot under it and the application of platelet-rich plasma eye drops, with a follow up period of up to 4 weeks. RESULTS All cases demonstrated formation of adequate intraocular pressure digitally, within the first 7 days, and all cases showed complete sealing of the corneal perforation within the 4 weeks follow up period, mild symptoms were reported only in the 1st postoperative week like foreign body sensation and lacrimation. 3 of the treated patients underwent penetrating keratoplasty after 6 months with satisfactory visual outcomes. CONCLUSION The combination of amniotic membrane implant and platelet rich plasma in both the clot and eye drop forms is an effective and easy accessible method for the primary management of corneal perforations.
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Affiliation(s)
- Ahmed A Abdelghany
- Ophthalmology department, 68877Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Jorge L Alio
- VISSUM innovation of Ophthalmology, Alicante, Spain.,Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain
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[Partial visual rehabilitation 5 and 6 years after a Gundersen total conjunctival flap procedure]. Ophthalmologe 2021; 119:203-208. [PMID: 34581853 DOI: 10.1007/s00347-021-01503-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/17/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We present the results of penetrating keratoplasty (PKP) after previous treatment with a total conjunctival flap in two patients. CASE REPORTS Patient 1, a 66-year-old with a history of bilateral cement chemical burn in 1986 and external right-sided limbokeratoplasty in 2008 was treated externally with a total conjunctival flap in the right eye in 2014 due to a persistent corneal ulcer with imminent perforation. Best-corrected visual acuity (BCVA) in the right eye was light sensation, intraocular pressure on palpation was within normal range. Clinically, total conjunctival flap was present. Patient 2 was treated externally in May 2015 due to acanthamoeba keratitis in the left eye with a deep anterior lamellar keratoplasty (DALK). A re-DALK was also performed externally in the same month. A third DALK was performed externally in August 2015 due to a persistent corneal ulcer, followed by a total conjunctival flap 2 weeks later. BCVA of the left eye was light sensation and intraocular pressure on palpation was within the normal range. RESULTS Patient 1 was treated with removal of the conjunctival flap in the right eye and penetrating central re-keratoplasty (hand-held Barron trephine; graft diameter 8.5/8.75 mm). Simultaneously, lens extraction and intraocular lens implantation were performed (as a triple procedure). Additionally, amniotic membrane transplantation (AMT) as patch and a temporal lateral tarsorrhaphy were performed. BCVA 6 months postoperatively was 0.1. The graft was clear, without any signs of rejection. Patient 2 was treated on the left eye with removal of the conjunctival flap and a penetrating central keratoplasty (hand-held Barron trephine; graft diameter 7.0/7.5 mm). An AMT as patch and a temporal lateral tarsorrhaphy were simultaneously performed. Cataract surgery was performed 3 months postoperatively and BCVA of the right eye was 0.1 thereafter. The graft was clear, without any signs of rejection. CONCLUSION The conjunctival flap is a treatment of last resort of the (almost) penetrated corneal ulcer, which is to be used only when a keratoplasty is technically impossible. Provided the eye structure and retinal function are preserved, partial visual rehabilitation can possibly be achieved through a PKP after excision of the conjunctival flap, even years after corneal blindness.
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Zhou L, Wei X. Ocular Immune-Related Adverse Events Associated With Immune Checkpoint Inhibitors in Lung Cancer. Front Immunol 2021; 12:701951. [PMID: 34504488 PMCID: PMC8421677 DOI: 10.3389/fimmu.2021.701951] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/05/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are novel immunotherapy-based drugs that have become increasingly popular in the treatment of lung cancer. Researchers have recognized ocular immune-related adverse events (irAEs) secondary to ICIs because of their vision-threatening characteristics. However, they are incompletely characterized and no studies have reported the ICI-related ocular irAEs in lung cancer. Therefore, we aimed to comprehensively illustrate the clinical characteristics, contributory factors, diagnosis, and management of ICI-related ocular irAEs in lung cancer, based on previously reported 79 patients. Ophthalmoplegia (40.51%), uveitis (20.25%), and dry eye (17.72%) were the most common ICI-related ocular irAEs in lung cancer. Ptosis was the most common (36.71%) and the highest mortality (23.33%) of ophthalmoplegia. Patients in Asia and patients who underwent combination therapy with programmed cell death-1 and cytotoxic T-lymphocyte-associated antigen 4 inhibitors demonstrated significantly higher frequency of ophthalmoplegia than other ocular irAEs. Most ICI-related ophthalmoplegia and uveitis in lung cancer were observed in the first 10 weeks following the initiation of ICIs. Furthermore, the onset time of dry eye and other ocular irAEs was much longer. In addition, 92.31% of the patients with ocular irAEs other than ophthalmoplegia could be remised. In conclusion, ocular irAEs secondary to ICIs in lung cancer are non-negligible, particularly ophthalmoplegia. Ethnicity and the type of ICIs play important roles in the distribution of ocular irAEs. ICI-related ophthalmoplegia in lung cancer presented with early onset and worse prognosis features, thus necessitating further attention.
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Affiliation(s)
- Lin Zhou
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wei
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
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Nguyen HT, Pham ND, Mai TQ, Do HTT, Nguyen DTN, McCluskey P, Pham TV. Tectonic Deep Anterior Lamellar Keratoplasty to Treat Corneal Perforation and Descemetocele from Microbial Keratitis. Clin Ophthalmol 2021; 15:3549-3555. [PMID: 34465975 PMCID: PMC8403223 DOI: 10.2147/opth.s324390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/11/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the result of tectonic deep anterior lamellar keratoplasty (DALK) for keratitis with perforation and descemetocele. Patients and Methods A prospective clinical study of 36 patients (36 eyes) treated with tectonic DALK for corneal perforation or descemetocele from microbial keratitis managed at the Vietnam National Eye Hospital over a two-year period. The surgical technique was manual lamellar dissection. The grafts were harvested from the anterior corneal cap of pre-cut donor tissues used for DSAEK or donor corneas with a low endothelial cell count. Results A mean age was 55.36 ± 13.98 years (ranged from 25 to 75 years). Female gender represented 52%. causative agents were herpes simplex virus (58.3%), bacteria (22.2%), fungi (13.9%) and microsporidia (5.6%). There were 24 eyes with descemetocele (66.7%) and 12 with perforation (33.3%). There were 33 successful cases (91.7%) and 3 failed cases (8.3%). Best corrected visual acuity (BCVA) improved in 28 eyes (84.8%). The range of post-operative BCVA was from hand motions to 20/70. Eleven eyes (33.3%) attained vision 20/200 and higher. Clear graft was obtained in 15 eyes (45.5%), while mild or severe graft opacity was observed in 14 eyes (42.4%), and 4 eyes (12.1%), respectively. Surgical complications included descemet rupture (20.8%), pseudo anterior chamber (41.6%), persistent corneal epithelial defects (8.3%), reinfection (11.1%), glaucoma or ocular hypertension (5.6%) and cataract (8.3%). Conclusion The study demonstrates that DALK is an effective procedure to treat corneal descemetocele, especially when an urgent penetrating keratoplasty (PKP) cannot be performed.
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Affiliation(s)
- Hong The Nguyen
- Department of Ophthalmology, 108 Military Central Hospital, Hanoi, Vietnam.,Department of Ophthalmology, Hanoi Medical University, Hanoi, Vietnam
| | - Ngoc Dong Pham
- Department of Cornea, Vietnam National Eye Hospital, Hanoi, Vietnam
| | - Tung Quoc Mai
- Department of Ophthalmology, Hanoi Medical University, Hanoi, Vietnam
| | - Hang Thi Thuy Do
- Department of Cornea, Vietnam National Eye Hospital, Hanoi, Vietnam
| | | | - Peter McCluskey
- Department of Ophthalmology, University of Sydney, Sydney, NSW, Australia
| | - Trong Van Pham
- Department of Ophthalmology, Hanoi Medical University, Hanoi, Vietnam
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Takahashi S, Ono T, Abe K, Mori Y, Nejima R, Iwasaki T, Miyai T, Miyata K. Prognosis and etiology of traumatic and non-traumatic corneal perforations in a tertiary referral hospital: a 30-year retrospective study. Graefes Arch Clin Exp Ophthalmol 2021; 260:629-635. [PMID: 34468830 DOI: 10.1007/s00417-021-05389-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To clarify the prognosis of corneal perforation, we compared the etiology and characteristics of patients with traumatic and non-traumatic corneal perforations. METHODS This retrospective observational study included patients treated for traumatic or non-traumatic corneal perforations at a single tertiary hospital from 1989 to 2019. The variables collected included the primary cause of corneal perforation, final best-corrected visual acuity (BCVA), and treatment administered. The initial treatment administered and treatment success rates were compared between the traumatic and non-traumatic groups. Multivariate linear regression analysis was performed to determine the predictors of final visual acuity. RESULTS Ninety eyes of 90 patients (mean age, 61.1 ± 19.7 years) were included. Traumatic and non-traumatic corneal perforations occurred in 40 (44.4%) and 50 eyes (55.6%), respectively. Among non-traumatic causes, infection and autoimmune disease were the causes for corneal perforation in 18 (20.0%) and 12 eyes (13.3%), respectively. The success rate for the closure of the perforated site with the initial procedure was significantly higher in traumatic corneal perforations than in non-traumatic corneal perforations (90.0% and 72.2%, respectively; p = 0.038). Patients with traumatic corneal perforation had significantly better final BCVA than those with non-traumatic corneal perforation (0.71 ± 1.18 and 1.52 ± 1.12, respectively; p = 0.0016). On multivariate analysis, older age and non-traumatic corneal perforation were significantly related to the final lower BCVA (p < 0.001 and p = 0.029, respectively). CONCLUSION Traumatic corneal perforation demonstrated a significantly better prognosis than non-traumatic corneal perforation. It is critical to consider the primary cause of corneal perforation to anticipate prognosis.
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Affiliation(s)
- Shigefumi Takahashi
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan
| | - Takashi Ono
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan. .,Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033, Tokyo, Japan.
| | - Kentaro Abe
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan
| | - Yosai Mori
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan
| | - Ryohei Nejima
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan
| | - Takuya Iwasaki
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan
| | - Takashi Miyai
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan.,Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033, Tokyo, Japan
| | - Kazunori Miyata
- Miyata Eye Hospital, 6-3, Kuraharacho, Miyakonojo, Miyazaki, 885-0051, Japan
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Utine CA, Birlik M, Özizmirliler D, Karakaş A, Akbulut B, Durak I. TNF-α Inhibitors for the Management of Intractable Corneal Melt: Report of Three Cases and Review of the Literature. Eye Contact Lens 2021; 47:372-377. [PMID: 33399412 DOI: 10.1097/icl.0000000000000770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To report three consecutive cases with noninfectious corneal melting, whose disease progression could only be halted with tumor necrosis-α (TNF-α) inhibitor infusion, with a review of the relevant literature. MATERIALS AND METHODS Patients with toxic epidermal necrolysis, severe alkaline burn, and Sjögren syndrome had experienced severe corneal melting following penetrating keratoplasty, Boston type 1 keratoprosthesis implantation or spontaneously, respectively. Topical autologous serum eye-drops, medroxyprogesterone, and acetylcysteine formulations; frequent nonpreserved lubrication; systemic tetracyclines and vitamin-C supplements; topical and systemic steroids and steroid-sparing agents; surgical approaches including amniotic membrane transplantation, tectonic graft surgery; and tarsorraphy failed to alter the disease courses. RESULTS Upon consultation with the rheumatology clinic, TNF-α inhibitor infliximab (Remicade; Centocor Ortho Biotech Inc, Horsham, PA) 5 mg/kg infusion was planned for each patient. After 0-, 2-, and 6-week doses, monthly infusion at the same dose was maintained for 12 months because of severe and intractable course of their diseases. Each case showed dramatic improvements in corneal melts; and sterile vitritis in the eye with Boston keratoprosthesis responded, as well. CONCLUSIONS Inhibiting TNF-α-mediated expression of matrix metalloproteinases responsible for collagen breakdown should be considered in refractory cases, as a means of globe salvage.
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Affiliation(s)
- Canan Asli Utine
- Department of Ophthalmology (C.A.U., D.Ö., B.A., I.D.), Dokuz Eylul University, Izmir, Turkey ; Izmir Biomedicine and Genome Center (C.A.U.), Izmir, Turkey ; and Department of Rheumatology (M.B., A.K.), Dokuz Eylul University, Izmir, Turkey
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Acharya M, Dave A. Commentary: Corneal involvement in rheumatoid arthritis. Indian J Ophthalmol 2021; 69:73-74. [PMID: 33323578 PMCID: PMC7926151 DOI: 10.4103/ijo.ijo_878_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Manisha Acharya
- Consultant Cornea and Refractive Surgery Services, Dr. Shroff's Charity Eye Hospital, New Delhi, India
| | - Abhishek Dave
- Consultant Cornea and Refractive Surgery Services, Dr. Shroff's Charity Eye Hospital, New Delhi, India
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Donthineni PR, Shanbhag SS, Basu S. An Evidence-Based Strategic Approach to Prevention and Treatment of Dry Eye Disease, a Modern Global Epidemic. Healthcare (Basel) 2021; 9:healthcare9010089. [PMID: 33477386 PMCID: PMC7830429 DOI: 10.3390/healthcare9010089] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/02/2021] [Accepted: 01/12/2021] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Pragnya R. Donthineni
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad 500034, India; (P.R.D.); (S.S.S.)
| | - Swapna S. Shanbhag
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad 500034, India; (P.R.D.); (S.S.S.)
| | - Sayan Basu
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad 500034, India; (P.R.D.); (S.S.S.)
- Center for Ocular Regeneration (CORE), L V Prasad Eye Institute, Hyderabad 500034, India
- Correspondence: ; Tel.: +91-040-30612555
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36
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Hong H, Kim J, Cho H, Park SM, Jeon M, Kim HK, Kim DS. Ultra-stiff compressed collagen for corneal perforation patch graft realized by in situ photochemical crosslinking. Biofabrication 2020; 12:045030. [PMID: 33000763 DOI: 10.1088/1758-5090/abb52a] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Hyeonjun Hong
- Department of Mechanical Engineering, Pohang University of Science and Technology (POSTECH), Nam-gu, Pohang, Gyeongbuk, 37673, Republic of Korea
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Rana RS, Bajracharya L, Gurung R. Tectonic Graft for Persistent Leakage and Visual Outcome After Corneal Perforation Repair: A Case Series. JNMA J Nepal Med Assoc 2020; 58:696-698. [PMID: 33068094 PMCID: PMC7580337 DOI: 10.31729/jnma.5402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Indexed: 11/01/2022] Open
Abstract
Keratoplasty is a modality of treatment for large and leaking corneal perforation in a tertiary center. We report cases of 20and 30-years old men presented in an emergency with history of road traffic accident 1 and 3 days back. Best corrected visual acuity was hand movement in both injured eye. Slit lamp examination of both cases revealed full thickness corneal laceration with Siedel test positive. Both cases underwent corneal laceration repair with resuturing and corneal glue on consecutive days but couldn't seal the leaking wound. Then ultimately both were undergone for tectonic keratoplasty. The final best corrected visual activity of involved eye was 6/36 in case 1 and 6/24 in case 2. Most cases of traumatic corneal perforation undergone urgent corneal repair but sometimes very difficult to seal the wound. In such cases donor cornea tissue may have to be used to maintain integrity of globe and better visual potential. Keywords: corneal perforation; laceration; siedel test; tectonic keratoplasty.
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Affiliation(s)
| | | | - Reeta Gurung
- Tilganga Institute of Ophthalmology, Gaushala, Nepal
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Singhal D, Nagpal R, Maharana PK, Sinha R, Agarwal T, Sharma N, Titiyal JS. Surgical alternatives to keratoplasty in microbial keratitis. Surv Ophthalmol 2020; 66:290-307. [PMID: 32866469 DOI: 10.1016/j.survophthal.2020.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Deepali Singhal
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Nagpal
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Prafulla K Maharana
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
| | - Rajesh Sinha
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar Agarwal
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Sharma
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Jeewan S Titiyal
- Department of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Zemba M, Stamate AC, Tataru CP, Branisteanu DC, Balta F. Conjunctival flap surgery in the management of ocular surface disease (Review). Exp Ther Med 2020; 20:3412-3416. [PMID: 32905115 PMCID: PMC7465514 DOI: 10.3892/etm.2020.8964] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/16/2020] [Indexed: 12/04/2022] Open
Abstract
Literature regarding conjunctival flap surgery was reviewed to describe and discuss the rationale for this type of procedure. The conjunctival flap is an acknowledged surgery for the treatment of various corneal diseases with a chronically compromised ocular surface, such as severe dry eye, neurotrophic or neuroparalytic disease, or bullous keratopathy. The purpose of this surgery is to restore the integrity of the corneal surface and thus to prevent gradual corneal ulceration and secondary infection, as well as to ameliorate pain, reduce the need for frequent medications, improve cosmetic appearance, and offer an alternative to invasive surgery or enucleation. Since the introduction of more effective methods of treating severe ocular surface diseases, conjunctival flap surgery has rarely been the primary modality of treatment and has usually followed a range of medical and surgical treatments. The availability of improved ocular lubricants, more effective antimicrobials, bandage contact lenses, tissue adhesives, and other corneal and conjunctival surgical interventions, has reduced the need for conjunctival flaps. However, conjunctival flaps remain extremely useful in selected cases and deserve a place in the ophthalmologist's repertoire for the management of ocular surface disease.
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Affiliation(s)
- Mihail Zemba
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Alina-Cristina Stamate
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, Bucharest 050474, Romania
| | - Calin Petru Tataru
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, Bucharest 050474, Romania
| | | | - Florian Balta
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, Bucharest 050474, Romania
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Tourkmani AK, Ansari AS, Hossain PN, Konstantopoulos A, Anderson DF. Tectonic Descemet Stripping Endothelial Keratoplasty for the Management of Corneal Perforation: A Case Series. Cornea 2020; 39:1571-1575. [DOI: 10.1097/ico.0000000000002424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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