Corneoscleral Graft Research Articles

Cystic Epithelial Ingrowth after Goniotomy for Congenital Glaucoma

To describe the clinical and histopathologic findings of a child with congenital glaucoma who developed cystic epithelial ingrowth after goniotomy. A five-month-old boy was diagnosed with congenital glaucoma due to Axenfeld syndrome. Goniotomy was performed immediately after the clinical diagnosis in his left eye. Cystic epithelial ingrowth was noted two years postoperatively. The cyst was incompletely excised elsewhere, and recurred two years later. Cystic epithelial ingrowth expanded from the 2 o'clock to the 4 o'clock position involving the chamber angle. Best corrected preoperative visual acuity was 20/600 in his left eye. Cystic epithelial ingrowth was treated by block excision (8.0 mm) and tectonic corneoscleral grafting (8.1 mm). Best corrected postoperative visual acuity was 20/200 and the intraocular pressure was 8 mmHg without antiglaucomatous medication. There was no recurrence of the cyst during the 31 months of follow-up. Histopathologic results found that cystic epithelial ingrowth consisted of nonkeratinizing squamous epithelium with goblet cells covering Descemet's membrane, the chamber angle structures, the anterior face of the ciliary body, and the iris. Cystic epithelial ingrowth is a rare complication after goniotomy. Block excision with tectonic corneoscleral grafting is the treatment of choice for cystic and diffuse sheet-like epithelial ingrowth.

Block excision with tectonic corneoscleroplasty for cystic and/or diffuse epithelial invasion of the anterior eye segment. Report of 51 consecutive patients (1980-1996)

Many surgical and nonsurgical techniques for the treatment of cystic and/or diffuse sheet-like epithelial ingrowth of the anterior chamber led to recurrences or even enucleation of the eye. There were 32 (62.7%) men and 19 (37.3%) women ranging in age from 1 month to 80 years (median, 55.5 years). Cystic epithelial ingrowth occurred in 45 patients, and diffuse sheet-like epithelial downgrowth in 6 patients. Block excision consisted of simultaneous en bloc removal of epithelial ingrowth together with adjacent iris, pars plicata of the ciliary body, and cornea and sclera in full-thickness. The resulting defect was covered with a tectonic corneoscleral graft. The median follow-up was 7.9 years. The main causes for epithelial ingrowth were trauma (41.2%) and complicated cataract extractions (27.5%). Eleven patients had undergone surgery of epithelial ingrowth before block excision, elsewhere. Epithelial ingrowth involved up to 5 clock hours of the circumference of the chamber angle (median, 3 clock hours). The median preoperative visual acuity was 0.3 (range, hand motions -1.0). The median diameter of the block excision was 8.0 mm (range, 5.5-12.0 mm). The main postoperative complications were vitreous hemorrhage (27.5%) and corneal endothelial decompensation (21.6%). The median postoperative visual acuity was 0.2. Visual acuity was > or = 0.3 in 43.1% of patients and < 0.1 in 35.3% of patients. Visual results were significantly better after simultaneous cataract extraction with intraocular lens implantation (n = 5). Histopathologically, the invading epithelium mainly consisted of nonkeratinizing squamous epithelium with goblet cells (64.7%). There was a secondary proliferation of corneal endothelium on the cyst's surface in 82.4% of patients. There was no clinical evidence of recurrence of epithelial ingrowth, and no enucleation had to be performed during follow-up. Block excision with tectonic corneoscleral grafting is the treatment of choice for cystic and/or diffuse sheet-like epithelial ingrowth of the anterior chamber or anterior uvea, retrospectively.

Block Excision of Tumors of the Anterior Uvea: Report on 68 Consecutive Patients

This study describes the authors' surgical technique and the results in 68 consecutive patients with tumors of the iris and ciliary body involving the angle removed by block excision and tectonic corneoscleral grafting between 1980 and 1995. There were 41 (60.3%) women and 27 (39.7%) men whose ages ranged from 14 to 85 years (median, 41 years). Follow-up ranged from 0.5 to 15.2 years (median, 6.3 years). Tumors of the iris and ciliary body with chamber angle involvement were removed with a modified block excision consisting of simultaneous en bloc removal of the tumor with adjacent iris and cornea and sclera in full-thickness. The resulting defect of 6 to 20 mm (median, 9.0 mm) diameter is covered with a tectonic corneoscleral graft. Forty-nine tumors (72.1%) were classified as malignant tumors of the iris and ciliary body. Twenty-one (44.7%) of 47 malignant melanomas showed histologic evidence of scleral invasion of more than one third of scleral thickness. Extrascleral extension of the tumor was present in seven (14.9%) patients with malignant melanomas and in four (21.1%) patients with benign tumors of the iris and ciliary body. The 10-year survival probability of patients with malignant melanomas was 91.4%. The main intraoperative complication was vitreous hemorrhage in 24 (35.3%) patients, and the main postoperative complication was complicated cataract, occurring in 22 (32.3%) patients. Two local tumor recurrences (2.9%) were observed. Four eyes (5.8%) had to be enucleated after block excision. Best-corrected postoperative visual acuity was better than 20/60 in 36 (52.9%) patients. The authors' results indicate that block excision with tectonic corneoscleral grafting may be the treatment of choice for progressive circumscribed tumors of the iris and ciliary body involving the anterior chamber angle up to 150 degrees of its circumference.

Corneoscleral block excision of postoperative anterior chamber cysts

To describe the clinical presentation, surgical treatment and histopathology of three cases of cystic epithelial ingrowth occurring after cataract surgery.Three patients developed anterior chamber cysts, two with an associated conjunctival bleb and fistula, following extracapsular cataract and phacoemulsification surgery. The technique of block excision and corneoscleral graft was used in the three patients.There was no evidence of recurrence twenty-six, twenty-three and seven months postoperatively. Visual acuities were 20/30, 20/20-2 and 20/25-2, with mild astigmatism and well controlled intraocular pressure. Histopathology illustrated that conjunctival and corneal epithelium invaded the anterior chamber through a wound defect.At this time, block excision with a corneoscleral graft may be the most definitive surgical treatment of cystic epithelial ingrowth.

Cystic Hydrops and Spontaneous Perforation in Fuchs' Superficial Marginal Keratitis

We studied a case of Fuchs' superficial marginal keratitis in which cystic corneal hydrops developed in one eye, and spontaneous corneal perforation occurred in the fellow eye. The patient underwent bilateral annular corneoscleral lamellar patch grafts for tectonic support. The patient had an uncomplicated postoperative course and visual acuity of 20/25 bilaterally. Stromal loss in Fuchs' superficial marginal keratitis may be severe enough to result in cystic corneal hydrops. Patients with this disorder should be counseled regarding the possibility of corneal perforation.

Donor Eyeball Holder to Reduce Contamination During Corneoscleral Graft Preparation

Donor Eyeball Holder to Reduce Contamination During Corneoscleral Graft Preparation

Donor Eyeball Holder to Reduce Contamination During Corneoscleral Graft Preparation

Donor Eyeball Holder to Reduce Contamination During Corneoscleral Graft Preparation

Perforated Bacterial Corneal Ulcer in a Radial Keratotomy Incision Secondary to Minor Trauma

The use of radial keratotomy (RK) for the treatment of myopia has increased rapidly over the past several years. Major complications, such as corneal ulcers, are relatively rare following RK. However, damaged or traumatized surface epithelium may predispose the cornea to the development of infectious keratitis. We describe a patient in whom a corneal ulcer developed secondary to minor trauma to her eye following RK who subsequently required a corneoscleral patch graft. Report of a Case. A 53-year-old woman underwent simultaneous bilateral RK on January 16,1993. The following evening she suffered minor trauma to her right eye when her cornea touched the bill of a baseball cap. She experienced pain in the eye for 2 days and then noted a white spot on her cornea. She was placed on ciprofloxacin hydrochloride and tobramycin drops every hour by the referring physician. However, the following morning, the ulcer appeared worse, and she

Surgical Intervention in Infectious Keratoscleritis

Moriarty et al1failed to address the importance of surgical treatment in patients with infectious keratoscleritis. In an article published in 1991,2we examined 28 patients with cultureproven infectious scleritis and keratoscleritis. Three patients had developed keratoscleritis following pterygium removal and application of beta radiation. An additional patient had pterygium removal alone, without the application of beta radiation. Seven of eight patients who were treated with antibiotics alone and two of 11 patients who received surgical intervention and antibiotics eventually required evisceration or enucleation of the eye. Our results suggest that cryotherapy, lamellar or penetrating corneoscleral grafts, in addition to intensive antibiotic therapy may improve the outcome of patients with infectious keratoscleritis. In infectious scleritis alone, five patients were treated with conjunctival recession and cryotherapy in addition to an intensive regimen of antibiotics, and four patients were treated with antibiotics alone. The infections of these nine patients resolved.

Surgical Intervention in Infectious Keratoscleritis-Reply

In reply We are grateful to Dr Alfonso for his comments. Reynolds and Alfonso1highlight the importance of cryotherapy, lamellar or penetrating corneoscleral grafts, in addition to antimicrobial treatment in infectious keratoscleritis. Surgery did indeed play a major role in our patients.2In 11 patients, seven had full-thickness penetrating keratoplasties either for incipient or frank perforation or to control overwhelming infection. A graft would have been performed in another patient had he not declined. Three patients required further grafts since infection failed to be eradicated. These were three fungal cases in which an initial graft was necessary for frank perforation but before adequate antifungal therapy. The chronicity of these fungal cases was particularly troublesome, and as we point out,2viable fungal elements were still present in tissue from two patients despite grafting and 3 and 6 months antifungal treatment, respectively. We received communication from several ophthalmologists with

Schwannoma of the ciliary body treated by block excision.

A 26-year-old man developed a non-pigmented ciliary body tumour of his right eye. A 7 mm block excision and tectonic corneoscleral graft were performed. The excised tissue was studied using histopathological, immunohistochemical, and electron microscopic techniques. The tumour revealed characteristic features of a Schwann cell neoplasm including Antoni A and B patterns, acid mucopolysaccharides, S-100, and vimentin positivity, and--by electron microscopy--Luse bodies. It was classified as a schwannoma. Although rare, schwannoma should be included in the clinical differential diagnosis of non-pigmented ciliary body tumours. Local excision should be considered to avoid over-treatment by enucleation.

Surgical Management of Melanocytoma of the Ciliary Body With Extrascleral Extension

We treated four white women with extrascleral extension of suspected ciliary body melanomas with a modified block excision (three patients) or enucleation (one patient). Light and transmission electron microscopy established the diagnosis of ciliary body melanocytoma with extrascleral extension in each patient. Two eyes were irradiated before block excision. Block excision involved simultaneous removal of full-thickness cornea and sclera, iris, and ciliary body with tectonic corneoscleral grafting. The postoperative visual acuity of the three patients treated with a modified block excision was 20/25, 20/50, and 20/60, respectively. No patient experienced local tumor recurrence (30 to 60 months of follow-up). The two irradiated eyes eventually developed radiation-associated complications. After three years the other block excision patient had visual acuity of 20/25. Ciliary body melanocytoma should be included in the differential diagnosis of pigmented tumors of the anterior uvea with extrascleral extension. En bloc excision with simultaneous full-thickness corneoscleral resection is indicated in circumscribed ciliary body tumors, especially when extraocular extension is present.

Congenital Nonpigmented Epithelial Iris Cyst after Amniocentesis: Clinicopathologic Report on Two Children

Congenital nonpigmented epithelial iris cysts are not common. They may arise spontaneously from developmental entrapment of surface ectodermal epithelium or from occult ocular trauma prenatally or at birth. Between 1989 and 1991, an 8-month-old child and a 6-year-old child presented with large, progressive congenital epithelial iris cysts. Both children had a maternal history of diagnostic amniocentesis after an ultrasound scan, and there was no history of postnatal ocular trauma. The cysts were successfully removed by a modified block excision and tectonic corneoscleral grafting. A dense adherence of the cyst wall to Descemet's membrane resembled old anterior synechiae after occult perforation of the globe in both patients. On histopathologic examination, the epithelial lining of the cysts consisted of non-keratinizing stratified squamous epithelium with goblet cells resembling conjunctival epithelium. A perforating limbal scar with a corresponding break in Descemet's membrane could be detected in one eye. The long-term visual acuity of both children was encouraging, and there was no evidence of recurrence of the iris cyst during the follow-up period (average, 23 months). The authors conclude that the clinical and histopathologic features of these congenital iris cysts may be consistent with an occult intrauterine limbal perforation of the anterior chamber with a needle during amniocentesis. Amniocentesis, when not guided by a real-time ultrasound scan, may be a risk factor for prenatal ocular trauma, which should be considered in the differential diagnosis of congenital ocular disorders.

Block Excision of Cystic and Diffuse Epithelial Ingrowth of the Anterior Chamber

From 1980 to 1990, 32 consecutive patients with progressive cystic or diffuse epithelial ingrowth of the anterior chamber were treated successfully with block excision. This technique consists of simultaneous removal of adjacent iris, pars plicata of ciliary body, and all layers of sclera and cornea in contact with the lesion acting as a shell. The resulting defect is covered by a tectonic corneoscleral graft. Twelve patients had suffered from perforating ocular injury, 10 patients had previously undergone cataract extraction, and 10 patients had various causes of epithelial ingrowth. Cystic epithelial ingrowth occurred in 27 patients, diffuse sheetlike epithelial ingrowth occurred in four patients, and one lesion was identified as foreign body granuloma. On histopathologic examination, all but two patients revealed epithelial involvement of the surface of the ciliary body. All patients were followed up for an average of 60.1 months (range, 1 to 120 months). Long-term visual acuity was better than 20/60 in 37.5% of the patients. No recurrence of ingrowth was noted and enucleation was not necessary. Our results indicate that block excision currently may be the treatment of choice for cystic and diffuse sheetlike epithelial ingrowth of the anterior chamber.

Treatment of Infectious Scleritis and Keratoscleritis

We reviewed 28 cases of culture-proven infectious scleritis and keratoscleritis to clarify the role of an operation in this disorder. Surgical management in 11 patients with keratoscleritis included cryotherapy, five; penetrating corneal-scleral graft, two; lamellar corneoscleral graft, two; and tectonic penetrating keratoplasty, two; in addition to intensive fortified antibiotic eyedrops. Eight patients with keratoscleritis were treated medically only with intensive fortified frequent antibiotic eyedrops, one; intensive instilled plus intravenous antibiotics, three; and instilled, intravenous, and subconjunctival antibiotics, four. Seven of eight patients treated with antibiotics alone and two of 11 patients who received surgical intervention in addition to antibiotics eventually required evisceration or enucleation of the eye. These results suggest that cryotherapy, lamellar or penetrating corneoscleral graft, in addition to intensive antibiotic therapy, may improve the outcome of patients with infectious keratoscleritis. Five eyes with isolated scleritis without corneal involvement were treated with conjunctival recession and cryotherapy in addition to aggressive antibiotics, and four were treated with antibiotics alone. The infections of these nine patients resolved.

Long-term Results of Keratoenpithelioplasty in Mooren's Ulcer

A consecutive series of 20 eyes with Mooren's ulcer was treated by a new surgical approach: keratoepithelioplasty alone or in combination with corneoscleral lamellar graft. Eighteen (90%) eyes showed complete remission promptly after surgery; the other two also healed with the administration of additional systemic and topical steroids. During the follow-up periods (mean, 3.1 years), minor recurrence was found in 5 (25%) eyes for the first 6 months, in none (0%) for the second 6 months, in 2 (12%) for the third 6 months, and none thereafter. All seven eyes with recurrence were cured by additional steroid treatment, alone or with conjunctival excision and/or keratoepithelioplasty. In the 18 (90%) eyes, the lenticules, constantly observed, remained silent on the scleras, which were free from conjunctival invasion. These results strongly support the authors' theory that keratoepithelioplasty using donor corneal lenticules can heal Mooren's ulcer via blockage of infiltrated conjunctival invasion.

Corneoscleral Freehand Lamellar Keratoplasty in Terrien's Marginal Degeneration of the Cornea-Long-Term Results

Freehand corneoscleral lamellar grafts were used in the treatment of advanced Terrien's marginal degeneration of the cornea in four eyes of three patients followed over a period of 12 to 20 years. Anatomic reconstruction of the ectatic thinned peripheral cornea was achieved and irregular astigmatism eliminated in all four eyes. Corneal astigmatism secondary to the corneal ectasia was reduced by 4.00 to 9.00 diopters. The progressive increase in against-the-rule astigmatism associated with advancing Terrien's was arrested for up to 20 years. Gradual thinning of the lamellar graft was noted in all four eyes after 10 years, but the return of corneal ectasia and increasing astigmatism has not occurred.

Corneoscleral melanosarcoma. Keratoplasty

In cases of corneoscleral melanosarcoma enucleation is generally ineritable. In the case described, the patient was treated with a corneoscleral lamellar graft after excision of the enormous tumor and of a recidive. Uneventful recovery and good anatomical and functional result in the six months since the last operation.

Scleral Ring As Template For Corneoscleral Graft

A 19-year-old woman sustained a corneal laceration in her right eye. After bacterial keratitis was treated by antibiotics and a conjunctival flap, she developed a corneoscleral ectasia. We used a 15-mm diameter scleral ring as a template for corneoscleral graft. We obtained uniform donor and host buttons by suturing the ring alternately to donor and host eyes. One year postoperatively, the patient had a retrograft fibrous membrane with corneal edema, a visual acuity of R.E.: 6/60 (20/200), and intraocular pressure of 16 mm Hg.

Corneoscleral lamellar transplant for recurrent pterygium.

The recurrent pterygium and repeated surgical operations destroy the normal Bowman's membrane which acts as a barrier to the ingrowth of conjunctival tissues. The insertion of a lamellar corneoscleral graft in the area of involvement seems to be a logical approach. Measurements are made on both the recipient and donor eye using the limbus as a point of reference. The dissections are made by hand. The 10-0 monofilament suture can be left indefinitely with little discomfort. The interrupted sutures are absorbed after the sclera has become adequately fixed by fibrous tissue.