Corneal Patch Research Articles

Effectiveness of surgical approach in the management of non-traumatic corneal perforations

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.

In silico evaluation of corneal patch eluting anti-VEGF agents concept

This study introduces a novel approach utilizing a temporary drug-eluting hydrogel corneal patch to prevent neovascularization, alongside a numerical predictive tool for assessing the release and transport kinetics of bevacizumab (BVZ) after the keratoplasty. A key focus was investigating the impact of tear film clearance on the release kinetics and drug transport from the designed corneal patch. The proposed tear drug clearance model incorporates the physiological mechanism of lacrimal flow (tear turnover), distinguishing itself from previous models. Validation against experimental data confirms the model’s robustness, despite limitations such as a 2D axisymmetrical framework and omission of blink frequency and saccadic eye movements potential effects. Analysis highlights the significant influence of lacrimal flow on ocular drug transport, with the corneal patch extending BVZ residence time compared to topical administration. This research sets the stage for exploring multi-layer drug-eluting corneal patches as a promising therapeutic strategy in ocular health.

Corneal stromal structure replicating humanized hydrogel patch for sutureless repair of deep anterior-corneal defect

A critical shortage of donor corneas exists worldwide. Hydrogel patches with a biological architecture and functions that simulate those of native corneas have garnered considerable attention. This study introduces a stromal structure replicating corneal patch (SRCP) composed of a decellularized cornea-templated nanotubular skeleton, recombinant human collagen, and methacrylated gelatin, exhibiting a similar ultrastructure and transmittance (above 80 %) to natural cornea. The SRCP is superior to the conventional recombinant human collagen patch in terms of biomechanical properties and resistance to enzymatic degradation. Additionally, SRCP promotes corneal epithelial and stromal cell migration while preventing the trans-differentiation of stromal cells into myofibroblasts. When applied to an ocular surface (37 °C), SRCP releases methacrylated gelatin, which robustly binds SRCP to the corneal stroma after activation by 405 nm light. Compared to gelatin-based photocurable hydrogel, the SRCP better supports the restoration of normal corneal curvature and withstands deformation under an elevated intraocular pressure (100 mmHg). In an in vivo deep anterior-corneal defect model, SRCP facilitated epithelial healing and vision recovery within 2 weeks, maintained graft structural stability, and inhibited stromal scarring at 4 weeks post-operation. The ideal performance of the SRCP makes it a promising humanized corneal equivalent for sutureless clinical applications.

Clinical application and outcome of Tenon's patch graft: A comprehensive review.

Corneal perforations are potentially sight-threatening conditions if not promptly treated. Management depends on the size, location, cause, and severity of the perforation. Various methods, including tissue adhesives, amniotic membrane grafting (AMG), and keratoplasty, are available. However, the limited availability of donor tissue in emergencies poses a significant challenge. Recently, Tenon's patch grafting (TPG) has emerged as a promising treatment option due to its autologous nature, availability, and lack of immunogenicity. This review provides a comprehensive overview of various aspects of TPG, along with relevant images. A literature search using keywords such as "Tenon's patch graft," "Tenon's capsule," "corneal patch graft," "amniotic membrane," and "corneal perforations" yielded 37 articles, included in this review. TPG is suitable for cases involving corneal tissue degradation leading to perforation, impending perforation, or descemetocele, with lesion sizes ranging from 2 to 6 mm. For larger perforations, the procedure may be modified by combining it with AMG or tissue adhesives. Postoperatively, the graft undergoes characteristic changes, including epithelialization and collagen deposition, resulting in the formation of a thick scar. Complications such as delayed epithelialization, wound leaks, and graft dehiscence can occur. High success rates have been reported, ranging from 74% to 87%. However, TPG may result in suboptimal visual outcomes, particularly when the graft is centrally located, necessitating future keratoplasty for visual rehabilitation. Overall, TPG is a safe and cost-effective technique for restoring structural integrity in corneal thinning disorders and perforations, especially in emergency settings when donor tissue is unavailable.

A New Technique of Sterile Polyethylene Instrument Cover as Temporary Corneal Patch to Reconstruct Anterior Chamber in Penetrating Keratoplasty Combined with Intraocular Surgery.

Complications such as explosive choroidal hemorrhage, residual cortex, and capsule rupture often occur during intraocular surgery combined with penetrating keratoplasty (PKP) due to poor maintenance of the anterior chamber. To address these challenges, we have innovatively utilized a sterile polyethylene instrument cover to temporarily reconstruct the anterior chamber. In this report, we describe a technique where a 'temporary corneal patch' was created from a sterile instrument cover, using a trephine to ensure a diameter approximately 1-2 mm wider than the corneal bed or perforation. This patch was then sutured into the host corneal bed or the perforation with 10-0 nylon sutures during intraocular surgery combined with PKP. Each case was evaluated for surgical efficacy and complications. We successfully applied this technique in three cases of combined corneal transplantation surgery. In two cases, PKP, phacoemulsification, and intraocular lens implantation were successfully performed. In the third case, PKP, vitrectomy, and other intraocular procedures were performed. No intraoperative or postoperative complications were observed. The use of a sterile polyethylene material as a temporary corneal patch for anterior chamber reconstruction represents a safe, effective, and cost-efficient approach for intraocular surgery combined with PKP or posterior segment surgery as a keratoprosthesis.

Patch Transplant in Corneal Perforations: Time, Method, and Cause.

We present demographic data and clinical features of corneal perforations repaired with patch grafts prepared from residual donor corneal rims. 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. 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. 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.

Rosuvastatin-laden nanofibrous patches for effective treatment of corneal ulcer in experimental animals

Corneal ulceration is a "silent epidemic" that impacts laborers’ lives, particularly in low-income countries, and calls for a unique ophthalmic drug delivery strategy that overcomes ocular barriers to promptly achieve therapeutic outcomes while remaining cost-effective. Rosuvastatin, a third-generation statin that significantly accelerates tissue regeneration and wound healing, could be proposed as a potential treatment for corneal ulcers. Based on these pillars, the current study aims to develop a nanofibers-based corneal patch laden with rosuvastatin, for the first time, as a novel approach for the treatment of corneal ulcers. Several characterizations were performed for the rosuvastatin-laden nanofibers (e.g., drug encapsulation efficiency, drug loading capacity, morphological analysis, elemental mapping, compatibility with other ingredients, and in vitro release studies) indicating the nanofibers' feasibility for the stated purpose. The therapeutic effects of rosuvastatin-laden nanofibers were examined on a surgically generated corneal ulcer rabbit model. The treatment outcomes were evaluated both macroscopically (e.g., corneal opacity degree and area of ulceration) and histologically demonstrating that the rosuvastatin-laden nanofibers heal corneal ulcers promptly. In light of this, the study emphasizes that rosuvastatin has a significant potential for healing corneal ulcers and that fast-release nanofibers may be an ideal drug delivery platform for treating corneal diseases topically.

Sympathetic ophthalmia following corneal patch graft for corneal perforation

Introduction : Sympathetic ophthalmia (SO) is a rare, bilateral, diffuse granulomatous uveitis that usually occurs after open globe injury or intraocular surgery. We report a rare case of SO after the closure of corneal perforation using a corneal patch graft.
 Case Illustration : A 12 year old boy diagnosed as corneal perforation in the right eye, with visual acuity (VA) 20/100, underwent a corneal patch graft. He presented with redness and decreased vision in both eyes 2 weeks after surgery. The patient had VA of hand movements in the RE and 20/200 in the LE. Anterior segment examination showed a corneal patch graft with iris adherent to the graft posteriorly in RE, endothelial dusting, 2+ cells in both eye. Fundus examination showed optic disc oedema in both eye and inferior retinal detachment with macular involvement in RE. The patient was managed with pulse steroids for three days followed by oral steroids in tapering doses along with continued topical steroids. Three months follow-up showed improvement of VA to 20/60 in RE and 20/25 in LE
 Discussion : SO is thought to be an autoimmune response to uveal injury. The incarceration of uveal tissue in the wound is a major risk factor. SO has been reported 5 days to 66 years after penetrating insult to the eye. In this case, incarceration of uvea in corneal pacth resulted in SO 2 weeks after surgery.
 Conclusion : In a case of a perforated cornea, the possibility of iris incarceration in the wound is high and hence SO can develop

Case Report: Managing a case of Tubercular Phlycten presenting as Sterile Corneal Perforation

A 22-year-old Indian male presented with a sterile perforation at 5 o’clock in the left eye, and a visual acuity of 20/80. A month prior to presentation, he had nodular lesion in lower part of left cornea and was undergoing medical management from a local ophthalmologist. After ocular and systemic examination, probable diagnosis of phlyctenular keratoconjunctivitis (PKC) was established. Since the perforation was large and not amenable to application of tissue adhesives, it was managed with a corneal patch graft. After investigations, we found that this was a case of latent tuberculosis infection. He was referred to physician and was started on appropriate anti-tubercular therapy. At the final follow-up, the perforation healed, and he regained a vision of 20/20. Even though perforation with tubercular PKC is a rare entity, this case highlights that timely diagnosis and multimodal intervention is the key to successful management.

A Case of Corneal Melt and Perforation Associated with Rheumatoid Arthritis Managed by Corneal Patch Graft

Corneal melt is a rare yet severe complication of Peripheral Ulcerative Keratitis (PUK), observed in patients with Rheumatoid Arthritis (RA). The mortality rate associated with corneal melt is high, warranting aggressive treatment. A 50-year-old female, a known case of RA for 20 years, presented with complaints of blurred vision, watering, irritation, and photophobia in both eyes for the last year, with worsening symptoms in the Right Eye (RE) for the past 15 days. She was diagnosed elsewhere in a private hospital with RE corneal melt and perforation and inferior corneal thinning in the Left Eye (LE), with an ulcer defect. She underwent corneal perforation suturing in the RE before reaching the present facility. On examination, a sutured corneal perforation was present in the RE, and corneal thinning and melt were seen para-centrally and inferiorly in the LE. Surgical treatment with RE corneal patch graft repair was performed. The patient was given oral methotrexate and prednisolone for aggressive systemic control of RA and to ensure the survival of the patch graft. The vision in the RE improved following the procedure, maintaining the tectonic integrity of the cornea. On follow-up, aleucomatous opacity was noted in the RE patch graft tissue. Corneal thinning in the LE was treated topically with artificial tears and antibiotic eyedrops, which eventually healed, forming macular corneal opacity. Overall, corneal patch graft repair enabled the maintenance of tectonic support and corneal integrity, as well as vision improvement in the patient with RA presenting with the complication of corneal melt and perforation.

Amniotic Membrane Transplantation-A Surgical Alternative in Peripheral Ulcerative Keratitis

Introduction: Peripheral ulcerative keratitis (PUK) is a group of inflammatory corneal ulcers with stromal thinning and peripheral localization. It begins with immune cellular infiltrates in the juxtalimbal cornea, followed by a crescent-shaped ulcer that appears parallel to the limbus. Medical management includes intense lubrication, antibiotics, along with topical and systemic steroids and immunosuppressants. Definitive surgical management is lamellar patch or penetrating corneal graft. Amniotic membrane has wide array of biological properties, including anti-inflammatory, anti-bacterial, anti-angiogenic, antifibrotic, healing properties hence can be used as an alternative to keratoplasty. Material and Methods: This mono institutional observational retrospective study was conducted on 15 eyes of 15 patients having PUK in a tertiary health care centre. Patients underwent single-layered amniotic membrane transplantation (AMT) in case of corneal thinning involving <1/2 corneal stroma, multi-layered or rolled AMT in cases of corneal thinning involving >1/2 corneal stroma or with moderate to large perforations along with systemic steroids and immunosuppression. Results: All 15 Patients (100%) initially had symptomatic relief,2 patients (13.33%) underwent repeat AMT (86%success rate), 2 failures were noted, out of which 1 patient (6.67%) underwent corneal patch graft while 1 patient (6.67%) underwent large penetrating keratoplasty which failed and landed in Phthisis. Conclusion: AMT is a safe and effective alternative for the surgical management of PUK in combination with local and systemic immunosuppressive therapy. A close collaboration between the ophthalmologist and the physician is mandatory to prevent corneal perforation and decrease patient morbidity and risk of mortality

Keratitis and corneal perforation in reactive arthritis: A case report and review

To report a rare case of corneal perforation in reactive arthritis and review the scientific basis for it. A case report. A 22-year-old male patient presented with redness, foreign body sensation, and blurred vision associated with knee and lumbar arthritis after an episode of urethritis was diagnosed with reactive arthritis (ReA). Ophthalmological examination revealed keratitis and corneal perforation at the time of admission. The patient received antibiotic drops and systemic steroids and underwent a corneal patch graft, which improved his visual acuity and outcome; however, he developed chronic arthritis and had to be treated with infliximab. The classical ocular manifestations of ReA are conjunctivitis, anterior uveitis, keratitis, and scleritis; however, this case report demonstrates a rare but severe presentation of ReA that should be considered.

Graft Outcome of Corneal Patch for Perforated Corneal Ulcer

Background: Corneal patch graft (CPG) is a part of the tectonic penetrating keratoplasty procedure performed on the perforated corneal ulcer. This procedure involves filling affected areas with full or partial-thickness cornea donors. This study aimed to determine the clinical results of corneal patch grafts in perforated corneal ulcers.
 Methods: A retrospective study assessing clinical results of CPG on the perforated corneal ulcer with iris prolapse. Clinical assessments include graft condition, anterior chamber depth (ACD), and visual acuity after surgery, with a follow-up duration of up to 8 weeks.
 Results: Twenty-one cases of perforated corneal ulcer with iris prolapse in 15 males (71.4%) and 6 females (28.6%). Locations of ulcer are peripheral and paracentral corneal. Visual acuity showed around light perception (LP) to 0.4. The most common etiology for corneal ulcers was infection (88.9%), followed by non-infection (Mooren’s ulcer) (11.1%). The graft condition after surgery showed promising results in 18 cases (85.7%), infection in 1 case (4.8%), and melting in 2 cases (9.5%). Adequate ACD was obtained in 77.8% of cases. An increase in visual acuity was shown in 44.4% of cases, depending on the location and severity of the ulcer.
 Conclusion: A corneal patch graft is an appropriate choice in treating perforated corneal ulcers to maintain ocular integrity (tectonic keratoplasty). However, in non-infectious ulcers, this procedure has not shown a good result, which may be related to disease progressivity.

Presentation, aetiology and outcomes of corneal ulceration in Sjogren's Syndrome.

To report the clinical course of corneal ulceration/perforation in patients with Sjogren's syndrome. Retrospective descriptive study of patients diagnosed with Sjogren's syndrome (primary and secondary) and corneal ulceration over past 8 years at tertiary eye care network. Assessed parameters were demographics, clinical details, microbiological profile, types of intervention and their outcomes. Forty-six eyes of 44 patients (11 males; mean age, 50 years) had corneal ulceration (28 eyes) or perforation (18 eyes) at the time of presentation. Of 46 eyes, 38 had sterile ulceration/perforation and rest 8 showed microorganism on microscopy or culture. The location was peripheral in 63% of eyes and it was the first presenting sign of Sjogren's syndrome in 26% of patients. All 43 eyes (3 lost to follow-up after intervention) had successful management of corneal ulceration/perforation. Twenty-eight eyes with ulceration required medical management alone in 15 eyes, soft contact lens and isobutylcyanoacrylate in 12 eyes, and amniotic membrane grafting in one eye. Four eyes with ulceration worsened and required penetrating keratoplasty (n = 2), and amniotic membrane grafting (n = 2). Corneal perforations were successfully managed with isobutylcyanoacrylate patch and BCL (n = 15), corneal patch graft (n = 2) and multilayered amniotic membrane grafting (n = 1). The average time taken for ulcers to heal was 49 days over a mean follow-up duration of 10 months. Corneal ulceration or perforation in Sjogren's syndrome is often sterile and can be a presenting sign of undiagnosed SS. These patients usually respond to intensive medical therapy and bandage contact lens and isobutylcyanoacrylate patch application.

Comparison of conjunctiva-related complications between scleral and corneal patch grafts in Ahmed glaucoma valve implantation.

Comparison of the conjunctiva related complication rates and success rates among eyes with Ahmed glaucoma valve (AGV) implantation in which eye bank derived scleral and corneal patch grafts had been used to cover the tube. Retrospective comparative study. Patients who underwent AGV implantation between January 2000 to December 2016 were included. Demographic, clinical data, intra and post operative data was obtained from electronic medical records. Conjunctiva related complications were divided into two groups: with and without implant exposure. Conjunctiva related complication rates, success rate, risk factors among eyes with corneal and scleral patch graft were compared. Three hundred and twenty three eyes of 316 patients underwent AGV implantation. Scleral patch graft was used in 214 eyes of 210 patients (65.9%) and corneal patch graft was used in 109 eyes of 107 patients (34%). Median follow up was 14 months. There was no significant difference in the conjunctiva related complication rate (7.3 % in corneal patch graft versus 7.0% in scleral patch graft;p=0.5) and conjunctival dehiscence rate (3.7% versus 4.6%, P = 0.7) among the two groups. Success rate was significantly higher in the corneal patch graft group versus the scleral patch graft group (98% versus 72%; p=0.001). Eyes with corneal patch graft had a higher survival rate (P = 0.01). There was no significant difference in the rate of conjunctiva related complications following corneal and scleral patch grafts used to cover the AGV tube. Eyes with corneal patch graft had a higher success rate and survival rate.

Commentary: Comparison of conjunctiva-related complications between scleral and corneal patch grafts in Ahmed glaucoma valve implantation.

Commentary: Comparison of conjunctiva-related complications between scleral and corneal patch grafts in Ahmed glaucoma valve implantation.

Tissue adhesives for wound closure

AbstractTissue adhesives have raised much attention from scientists in recent years. They have been extensively utilized in various medical fields, such as wound closure, due to the advantages of being simple, time‐saving, and avoiding the problems and complications associated with surgical sutures. Besides, the tissue adhesives can absorb wound exudates and promote tissue repair. The rapid evolution in the field of tissue adhesives has resulted in the development of various adhesives with excellent mechanical properties and superior functions. However, many challenges still restrict their use in numerous clinical applications. In this paper, we present an up‐to‐date review of tissue adhesives for wound closure. We mainly discussed the fundamental design requirements for the adhesives, the fabrication of tissue adhesives, and the application of tissue adhesives on skin healing, corneal patch, and gastrointestinal tissues. We then highlighted the current challenges and unmet needs and delineated potential new clinical development directions for future adhesives. The progress in tissue adhesives will provide novel approaches for wound management and has the potential to supply effective treatments for a variety of medical applications.

Ocular manifestations in a case of herpes zoster ophthalmicus with human immunodeficiency virus

Abstract This is a case report of human immunodeficiency virus infection whose primary presentation was with herpes zoster ophthalmicus with sterile corneal perforation which is unusual. A 48-year-old female patient presented with redness and painful decrease in vision in the right eye for the past two weeks. Examination revealed skin lesions in right side of face, with complete ptosis in right eye with restricted ocular movements suggestive of third nerve palsy. Slit lamp examination revealed sterile perforated peripheral corneal ulcer in right eye. Screening of viral markers revealed that patient was positive for human immunodeficiency virus. The case was treated conservatively with oral antivirals, topical antibiotics, and lubricants. The patient was started on highly active antiretroviral therapy from nearby antiretroviral therapy centre. We planned to do a corneal patch graft for the patient but the patient was not willing for any surgical intervention.

Tissue Adhesives for the Management of Corneal Perforations and Challenging Corneal Conditions.

Corneal perforations are ophthalmological emergencies which can have serious and detrimental consequences, if not managed timely and appropriately. These are a significant cause of ocular morbidity and can result in decreased vision, blindness, and even loss of the eye. Corneal perforations can be managed using a range of treatment approaches, including temporary solutions such as the application of corneal glue and bandage contact lens, as well as definitive treatment such as corneal transplantation. Tissue glues/adhesives were developed as substitutes for sutures in ophthalmic surgery. Unlike sutures, these glues are associated with shorter overall surgical times and reduced inflammation, thus improving postoperative comfort without compromising wound strength. The available tissue adhesives can be broadly classified into two types: synthetic (eg, cyanoacrylate derivatives) and biological (eg, fibrin glue). Cyanoacrylate glue is chiefly used as a corneal patch to manage acute corneal perforations and improve visual outcomes. Fibrin glue can be used instead of cyanoacrylate glue in many conditions with the benefits of reduced conjunctival and corneal inflammation and reaction. Apart from this, each type of adhesive is distinct in terms of its benefits as well as limitations and is accordingly used for different indications. The present review focuses on the two main types of tissue adhesives, their applications in the management of corneal perforations, the associated complications, safety and efficacy data related to their use available in the literature and the need for newer adhesives in this field.

Management of simultaneous bilateral immune-mediated peripheral ulcerative keratitis.

Peripheral ulcerative keratitis (PUK) is a sight threatening disease, often immune mediated and can rapidly progress to corneal perforation. Here we report the successful management of simultaneous bilateral peripheral ulcerative keratitis presenting with corneal perforation with surgical intervention and systemic immunosuppression. A 41-year-old female presented with similarly located super-nasal peripheral ulcerative keratitis (PUK) in both eyes and focal area of adjoining scleritis in the left eye. Serological investigations for systemic immune-mediated conditions showed positive rheumatoid factor test. She underwent cyanoacrylate glue application in both eyes, and was started on topical and oral corticosteroids and oral immunomodulators, and the right eye stabilized. The left eye required a second surgical intervention with a corneal patch graft following which the condition stabilized. This case highlights the importance of investigating for an underlying systemic etiology in PUK and the role of systemic immunosuppression prior to and after surgical intervention in order to arrest the disease and prevent recurrences.