Emergency Penetrating Keratoplasty Research Articles

Five years of emergency keratoplasty at a tertiary eye hospital.

The aim of this study is to present the results of patients who underwent emergency keratoplasty for tectonic or therapeutic reasons. Medical records of 33 patients who underwent tectonic or therapeutic keratoplasty at Ege University Department of Ophthalmology between January 2019 and January 2024 were retrospectively evaluated. Demographic characteristics, ocular and systemic findings, indications of keratoplasty, size of grafts, need for re-keratoplasty, preoperative treatment modalities, need for additional surgical interventions, and prognosis of the patients were investigated. During this period, 450 penetrating keratoplasty (PK) surgeries were performed and 34 (7.55%) were emergency PK (34 eyes of 33 patients). The mean age of the patients was 65.30 ± 15.40 (40-91). Female to male ratio was 18/15. 17 (50.00%) emergency PKs were performed for tectonic and 17 (50.00%) were performed for therapeutic purposes. Mean follow up time was 24.85 ± 26.62 (2-120) months. A total of 20 (58.82%) eyes required additional surgery, 9 (26.47%) of which required re-keratoplasty with different indications during follow-up. Graft rejection or failure developed in 17 (50.00%) of the eyes in an average of 12.05 (1-45) months. Evisceration was needed in 2 (5.88%) eyes. Despite limited access to donor cornea and high complication rate, emergency keratoplasty is one of the most important options that retain ocular integrity in the treatment of corneal infections and non-traumatic corneal perforations unresponsive to conventional treatment.

Management of corneal melting after collagen cross-linking for keratoconus: a case report and a review of the literature

PurposeWe describe the management of a case of severe corneal melting after corneal cross-linking (CXL) treated with a staged approach using a conjunctival flap followed by deep anterior lamellar keratoplasty (DALK).MethodsA 12-year-old male developed severe corneal melting with pending perforation after an accelerated epithelium-off CXL protocol. We initially treated the patient with a conjunctival flap to prevent perforation. Three months later, we performed DALK to restore vision.ResultsConjunctival flap surgery allowed us to avoid corneal perforation and penetrating keratoplasty (PK) à chaud. Once the inflammation had resolved, we recessed the conjunctiva and performed DALK for optical purposes. Twelve months later, the graft was clear and the corrected visual acuity was 20/25 (Snellen). No complications occurred after surgery.ConclusionsAlthough CXL is considered a safe procedure, in rare cases it can lead to serious complications, such as corneal haze, infectious and non-infectious keratitis, stromal melting and perforation. Corneal melting and perforation are usually managed by emergency PK. Herein we suggest a staged approach involving an emergency conjunctival flap followed by DALK at a later time that allowed us to avoid PK à chaud.

Efficacy of Emergency Penetrating Keratoplasty with Cryopreserved Human Donor Corneas.

To investigate the long-term outcomes of emergency penetrating keratoplasty using cryopreserved human donor corneas in the management of actual or imminent corneal perforation. 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. 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). 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.

Outcome of conjunctival flap surgery in case of non-healing corneal ulcer in a multi-specialty eye hospital of Northern Bangladesh

Background: This retrospective study evaluates the outcomes of conjunctival flap surgery for non-healing corneal ulcers at a tertiary eye hospital that were resistant to medical treatment. Methods: The study included 47 eyes of 47 patients with deep corneal ulcers who underwent conjunctival flap surgery in a multi-specialty eye hospital between April 2020 and January 2022. The follow-up period was 12 months. Primary outcome measures included the restoration of ocular surface integrity, while secondary outcomes assessed improvements in visual acuity and postoperative complications. Results: Among the 47 patients, 30 (63.82%) were male, and 17 (36.17%) were female, with a mean age of 52.13±14.91 years. The mean ulcer diameter was 4.52±2.02 mm, and the mean ulcer depth was 65±22.20% of the corneal thickness. An anatomic cure was achieved in 34 (72.34%) of the 47 eyes. Three eyes that failed to respond to conjunctival flap surgery required evisceration. Postoperative visual acuity improved in 15 eyes with peripheral ulcers. Common postoperative complications included flap retraction, flap necrosis, granuloma formation, and perforation. Conclusions: Conjunctival flap surgery is an effective treatment for non-healing corneal ulcers, providing ocular surface integrity and supporting corneal healing. It can potentially eliminate the need for emergency penetrating keratoplasty or prepare the eye for future optical keratoplasty.

Реабилитация пациента с субтотальным расплавлением роговицы, ассоциированным с ношением контактных линз, на основе сквозной кератопластики с использованием криоконсервированного трансплантата и последующей пересадкой жизнеспособного эндотелия: 3 года наблюдения

Purpose. To evaluate the clinical and functional results of transplantation of viable endothelium after penetrating keratoplasty with cryopreserved cornea subjected to the cross-linking procedure for the treatment of a patient with subtotal corneal melting associated with contact lenses. Material and methods. The patient B., 33 years old. Diagnosis at admission: OS – purulent corneal ulcer with perforation. From the anamnesis: she used soft contact lenses that were not daily replaced, for a month she underwent treatment in one of the Moscow clinics for keratitis, where she underwent epikeratoplasty. Treatment was performed without positive effect. Upon admission to the Fyodorov Institution, an emergency penetrating keratoplasty with a cryopreserved cornea and subsequent conservative treatment was performed. One year after penetrating keratoplasty, the phacoemulsification with intraocular lens implantation + DSAEK was performed, followed by conservative treatment. Results. Transparent engraftment was observed, no corneal edema was identified. best spectacle-corrected visual acuity was 0,4. Endothelial cell density – 1047 cells/mm2. Astigmatism was 4,25 D. Conclusion. Cryopreserved cornea subjected to the cross-linking procedure allows to preserve the structural properties of its stroma. Subsequent transplantation of viable endothelium by DSAEK allows to restore the optical properties of the cornea and to achieve visual rehabilitation of the patient. Key words: penetrating keratoplasty, cryopreserved cornea, posterior keratoplasty, DSAEK

Indications and Results of Emergency Penetrating Keratoplasty With Simultaneous Cataract Surgery ("Triple-PKP à Chaud").

The purpose of this study was to analyze the indications and clinical results of emergency penetrating keratoplasty with simultaneous cataract surgery ("Triple-PKP à chaud"). This study included all subjects who underwent Triple-PKP à chaud between 2006 and 2020 at the Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar in Germany. Data obtained from patient records were retrospectively analyzed. Triple-PKP à chaud was successfully performed in 27 of 29 eyes with a mean age of 66.0 ± 19.9 years. Previous surgery was performed in 20 eyes (69.0%), most frequently amniotic membrane transplantation in 11 eyes (37.9%) and previous keratoplasty in 9 eyes (31.0%). The most common indication was infectious keratitis (62.1%). In 27 subjects (93.1%), capsulorhexis was performed using the open-sky technique. The most frequent intraoperative complication was positive vitreous pressure (24.1%). In 2 eyes (6.9%), no intraocular lens implantation was performed because of posterior capsule rupture. The preoperative uncorrected visual acuity improved from 2.2 ± 0.6 logMAR (range = 3.0-0.7 logMAR) to 1.3 ± 0.7 logMAR (range = 3.0-0.18 logMAR) postoperatively ( P < 0.001). Common postoperative complications were suture loosening (44.4%) and corneal epithelial defects (33.3%). Repeat keratoplasty was necessary in 14 eyes (51.9%), including 9 eyes (64.2%) within 12 months postoperatively. The mean graft survival was 12.2 ± 17.9 months (range = 1-69 mo). Triple-PKP is also feasible in emergency conditions. Nevertheless, the surgery is associated with an increased risk of intraoperative and postoperative complications. Combined surgery should, therefore, only be performed in severely diseased eyes with progressed stage of cataract.

Efficacy of conjunctival flap surgery for deep corneal ulcers.

Aim: To evaluate the clinical efficacy of a selective, partial, pedicle conjunctival flap in the treatment of deep corneal ulcers with or without perforation, resistant to medical treatment.Method: This interventional self-controlled retrospective study included 31 eyes of 31 patients with deep corneal ulcers who underwent conjunctival flap surgery in a tertiary eye care unit between 2017 and 2019. Of these, 9 eyes exhibited corneal perforation. The follow-up period was 12 months. The primary outcome measures were restoring ocular surface integrity and secondary outcome measures were improvement in visual acuity and postoperative complications encountered. Results: Out of the total of 31 patients, 17 patients (55%) were males and 14 patients (45%) were females. The mean age was 56.03 ± 15.46 years. The mean disease duration was 64.10 ± 35.01 days, the mean diameter of the ulcer was 3.61 ± 1.02 mm and the mean depth of the ulcer was 70.65 ± 20.28% of the thickness of the cornea. The etiology was extensive and the corneal ulcers were categorized as infectious (12), noninfectious (16), and unknown (3). An anatomic cure was obtained in 29 (94%) of 31 eyes. Conjunctival flap surgery was unsuccessful in 2 eyes that required evisceration. The postoperative visual acuity (BCVA) improved in 13 (42%) of the 31 eyes, decreased in 9 eyes (29%) and remained unchanged in 9 eyes (29%). The most frequent complications after conjunctival flap surgery were pseudopterygium, cataract and corneal opacity and less frequent complications were glaucoma, astigmatism, flap retraction, corneal perforation and endophthalmitis.Conclusions: Conjunctival flap surgery can successfully treat refractory deep corneal ulcers. It can restore ocular surface integrity and provide metabolic and mechanical support for corneal healing. Also, it can avoid emergency penetrating keratoplasty or create appropriate conditions for a future optic keratoplasty.

Early Penetrating Keratoplasty À Chaud May Improve Outcome in Therapy-Resistant Acanthamoeba Keratitis.

Long-standing acanthamoeba keratitis (AK) may result in corneal neovascularization, extension of the infiltrate to the limbus or sclera, broad peripheral synechiae, mature cataract or ischemic posterior segment inflammation. We investigated the impact of early emergency penetrating keratoplasty (PKP) in therapy-resistant cases among the patients of a highly specialized tertiary care center. In this retrospective, observational cohort within a single institution, we collected data on best-corrected visual acuity (BCVA), epithelial wound healing, graft survival and secondary complications of AK patients who underwent PKP. A total of 23 eyes of 23 patients diagnosed with acute, therapy-resistant AK between 2006 and 2015 were enrolled. Postoperative combined topical treatment was tapered for 6-9months. Eyes were grouped based on preoperative disease duration as shorter (group 1) or longer (group 2) than the median. The median was 5.3 (0.66-36) months. The BCVA in group 1 (20/44 ± 20/18; 0.32 ± 0.18 logMAR) was significantly better than in group 2 (20/1200 ± 20/1133; 1.28 ± 0.89; logMAR); p = 0.015. Persisting epithelial defects occurred in 5 patients (50%) of group 1 and in 10 patients (77%) of group 2. In 5 eyes (group 2), no epithelial healing could be achieved. After 36months, graft survival (Kaplan-Meier) was 78% (18 grafts) for all patients (90% in group 1 and 44% in group 2). PKP à chaud within 5.3months after first symptoms of therapy-resistant AK seems to result in better final BCVA than delayed graft surgery if the disease is resistant to a classical topical triple therapy. In addition, early PKP may have a favorable impact on epithelial healing and graft survival. We thank the Alexander von Humboldt Foundation for supporting the work of Prof. N. Szentmáry at the Department of Ophthalmology of Saarland University Medical Center in Homburg/Saar, Germany. We thank the University of Saarland for funding the medical writing assistance and the Rapid Service Fees. The funding organisation had no role in the design or conduct of this research.

Emergency penetrating keratoplasty in corneal perforations

Corneal perforations represent an ophthalmological emergency due to their devastating consequences. Emergency treatment is mandatory to try to restore the anatomical integrity of the globe, to salvage useful vision as much as possible and to reduce the possible complications to a minimum. The underlying conditions or disorders responsible for corneal ulcerations, and subsequently for corneal perforations are numerous, and can be either isolated or superimposed. Emergency penetrating keratoplasty is a difficult surgical procedure that is associated with various complications, which can jeopardize the outcome of the eye.

Does PACK-CXL Change the Prognosis of Resistant Infectious Keratitis?

To examine the clinical characteristics, treatments, and prognosis of all cases of infectious keratitis resistant to conventional therapy and treated by photo-activated chromophore for keratitis corneal cross-linking (PACK-CXL) in one institution between 2012 and 2016. A database search of patients who underwent PACK-CXL (ultraviolet-A for 10 minutes for irradiance of 9 mW/cm2) for infectious keratitis unresponsive to medical treatment at a tertiary care hospital was conducted. The following parameters were documented: patient demographic information, corrected distance visual acuity (CDVA) before the procedure and at the end of follow-up, characteristics of the ulcer, antibiotic treatment prior to CXL, culture results, and long-term complications. Cases with less than 1 year of follow-up were excluded. PACK-CXL was performed in 18 consecutive eyes. CDVA at the time of presentation was 1.47 logMAR (mean 1.47 ± 0.72 logMAR, range: 0.00 to 2.79 logMAR). Culture results were positive in 72% of eyes (13 of 18 patients) and no pathogens were identified in 28% of eyes (5 of 18 patients). All patients were treated with more than one antibiotic. The mean CDVA at the end of follow-up was 1.22 logMAR (mean: 1.22 ± 0.89 logMAR, range: 0 to 2.07 logMAR). There was no significant change between CDVA at presentation to CDVA at the end of follow-up (matched pair, P = .126). One eye underwent an emergency therapeutic penetrating keratoplasty. Patients with large, central corneal ulcer and poor CDVA who were resistant to conventional treatment underwent PACK-CXL. At the end of follow-up, only one eye required emergency penetrating keratoplasty. This low rate might be attributed to a good response to CXL. [J Refract Surg. 2018;34(8):559-563.].

Amniotic Membrane Transplantation for the Treatment of Infectious Ulcerative Keratitis Before Elective Penetrating Keratoplasty

Emergency keratoplasties for inflamed eyes are considered to have a worse prognosis because of immunologic graft rejection. Amniotic membranes have antiinflammatory and antiangiogenic abilities. Therefore, amniotic membrane transplantation (AMT) was performed to stabilize the situation of eyes with severe infectious keratitis before elective penetrating keratoplasty (PK). Retrospective, nonrandomized observational case series. Seven to 41 days (median, 20 days) after the onset of intensive antiinfectious medication, an AMT (6 multigrafts and 6 sandwich) was performed in 12 patients [8 men and 4 women; age 46-80 years (median, 66 years)] with herpetic (n = 5), bacterial keratitis (n = 3), or combinations (n = 4). Three to 12 months (median, 5 months) after cessation of the inflammatory status of the eye, a central elective PK (diameter, 7-8 mm) became feasible in 10 eyes. Follow-up ranged from 4 to 38 months (median, 20 months) after PK. The primary success rate of AMT was 11/12 (92%). Five recurrences (41%) were treated successfully 4 times by repeat AMT (sandwich) and 1 time by emergency PK. In 2 of the 12 eyes, an irreversible endothelial immunologic graft reaction appeared 18 and 21 months after PK. One eye suffered from reversible recurrence of herpetic keratitis on the corneal graft. At the end of the follow-up, 10 of 12 grafts (83%) were clear. A rapid decrease in the inflammatory reaction and a fast reepithelialization because of AMT after intensive antiinfectious medication in case of severe ulcerative keratitis may help to avoid an emergency keratoplasty and improves the prognosis of the elective keratoplasty.

Scleral Patch Graft Augmented Cyanoacrylate Tissue Adhesive for Treatment of Moderate-Sized Noninfectious Corneal Perforations (3.5–4.5 mm)

To describe a new technique of scleral tissue augmented cyanoacrylate tissue adhesive (CTA) application and to evaluate its efficacy in noninfectious corneal perforations that measure between 3.5 and 4.5 mm. Retrospective noncomparative case series included 16 consecutive patients diagnosed with moderate-sized corneal perforations measuring 3.5 to 4.5 mm who were treated with scleral patch graft augmented glue application. A partial-thickness scleral patch equal to the size of corneal perforation was placed in the corneal perforation site. After the area was sufficiently dried, CTA was applied on the interface of the host cornea and scleral patch. The ability of the scleral patch graft with CTA to seal the perforation and allow complete wound healing was considered a successful outcome. The corneal perforation healed in 14 eyes (87.5%), with a mean of 5.65 weeks (range, 5-9 weeks). One eye (6.25%) developed microperforation that required additional CTA to seal the wound. Three eyes (18.75%) required reapplication of the scleral patch graft and CTA. The 2 eyes (12.50%) that failed scleral patch with CTA were successfully treated with tectonic penetrating keratoplasties. In all 5 eyes (100%), the corneal perforations as a result of Mooren ulcer healed in a mean 5.80 weeks (range, 5-7 weeks). One patient developed retinal detachment with proliferative vitreoretinopathy and cataract after trauma. Scleral patch graft augmented CTA technique is a successful alternative treatment method to emergent penetrating keratoplasty for corneal perforations that measure 3.5 to 4.5 mm.

Alternaria and Paecilomyces Keratitis Associated With Soft Contact Lens Wear

To report a series of 5 patients with soft contact lens (SCL) related fungal keratitis caused by unusual organisms diagnosed at the Wills Eye Institute, Cornea Service in 2008. Chart review of patients with SCL related Alternaria and Paecilomyces keratitis diagnosed in 2008 was performed. Causes of these fungal infections were compared to previous years. During a period from 1999 to 2007, among 64 patients with fungal keratitis, Alternaria was isolated from one case after corneal foreign body removal in 2004, and Paecilomyces was not isolated in any of these patients. In 2008, however, 5 patients with SCL-related atypical fungal keratitis were diagnosed. Alternaria was isolated from 2 cases and Paecilomyces from 3 cases. All patients wore Acuvue SCL (Johnson & Johnson Vision Care): Acuvue Oasys, Acuvue Advance, and Acuvue 2 (1 case each) and Acuvue unspecified (2 cases). A total of 2 patients with Alternaria and 1 patient with Paecilomyces used ReNu or a generic-brand solution manufactured by Bausch & Lomb; 2 with Paecilomyces keratitis used Opti-free Replenish solution. A total of 3 patients wore lenses for daily wear and 2 wore them occasionally for overnight wear. The patients were treated with either voriconazole drops alone or combined with voriconazole 200 mg pills or Natamycin 5% drops. Three patients responded well to treatment. One patient with Paecilomyces keratitis developed a corneal perforation managed with tissue adhesive. One Paecilomyces keratitis patient required an emergency penetrating keratoplasty because of a perforated corneal ulcer present at the initial examination. We report 2 cases of Alternaria and 3 cases of Paecilomyces keratitis in patients wearing frequent replacement lenses and using multipurpose solutions diagnosed during 2008. We want to raise awareness of fungal keratitis caused by unusual organisms associated with SCL wear.

Amnionmembrantransplantation bei gesicherter ulzerativer Herpeskeratitis: Erfolgreiche Entzündungshemmung zum richtigen Zeitpunkt

In active herpetic keratitis, treatment with systemic and topical aciclovir together with low dosed-out steroids has been successful for few decades. However, in cases with severe herpetic ulcer and melting inflammation, emergency penetrating keratoplasty is necessary, which carries high risk for recurrent herpetic keratitis and rejection. The anti-inflammatory effect of amniotic membrane transplantation can be used as a first surgical step in order to gain time for planned penetrating keratoplasty. The results are analysed in this retrospective case series. Twelve eyes of 12 patients with clinically highly active herpetic ulcer without healing despite topical and systemic aciclovir were treated with amniotic membrane transplantation. Ten of 12 eyes (83 %) showed positive PCR testing for HSV-1. In one case, the molecular genetic result was negative, one analysis for HSV was not done. For surgery, debridement of the margins and the ground of the ulcer was done with steam heated cauterization. Afterwards, an amniotic membrane was made to cover the defect and fixed with single sutures. Peri- and postoperatively, the patients were treated with systemic aciclovir (4000 mg daily one week, 2000 mg daily 2 weeks) and gentamicin ointment topically. Mean follow-up was 6.8 months (1-12.5). After 25 days in the mean (11-34), nine of 12 patients experienced an intact epithelial corneal surface together with a clinically clear reduction of the inflammation. Three other patients did not recover and were treated with emergency penetrating keratoplasty after 31 days in mean (25-35). Visual acuity did not improve after amniotic membrane transplantation except in one case. The known anti-inflammatory potential of amniotic membrane causes a reduction of the inflammatory process in herpetic ulcer. A precondition is a sufficient antiherpetic and anti-inflammatory therapy and a decision for amniotic membrane transplantation in time in order to avoid an emergency penetrating keratoplasty. This gives the opportunity to perform planned penetrating keratoplasty with optimal HLA-match and postoperative immunosuppression.

An Outbreak of Fusarium Keratitis Associated With Contact Lens Use in the Northeastern United States

To report an outbreak of Fusarium keratitis in contact lens (CL) wearers in the northeastern United States. Over a 41-month period, all cases with culture-proven corneal ulceration secondary to Fusarium at 2 tertiary care eye centers were identified through the microbiology departments of each institution, and a retrospective review of charts was performed. Statistical analyses were performed to evaluate a possible association of Fusarium keratitis with specific CL and CL solution brands. Fifteen cases of Fusarium keratitis were reported at the 2 tertiary centers between July 2005 and May 2006 (16.4 cases/yr) compared with 6 cases over the previous 30 months from January 2003 to June 2005 (2.4 cases/yr). All 15 of the more recent cases were CL users, and none had a history of trauma. All 15 patients claimed use of ReNu brand contact lens solution when they developed keratitis. Twelve (80.0%) of 15 patients were Acuvue soft contact lens users. Ten (66.7%) of 15 patients used tap water to rinse their contact lens cases. Six (40.0%) of 15 cases have thus far required corneal transplantation. The incidence of corneal ulceration secondary to Fusarium has increased sevenfold over the reported 11-month period at 2 tertiary eye care centers in the northeastern United States compared with the previous 30 months. There seems to be an association between the recent outbreak of Fusarium keratitis among CL users and the use of ReNu contact lens solution. Medical treatment of Fusarium keratitis may be ineffective, and emergent penetrating keratoplasty (PKP) may be required in some patients. CL users and their physicians should reconsider the risks of CL use and discuss proper lens care techniques.

Acute corneal hydrops with perforation after LASIK‐associated keratectasia

Herein a case of acute corneal hydrops with perforation in keratectasia 9 years after bilateral laser in situ keratomileusis is presented. A 27-year-old man presented with right eye sudden loss of vision. Right eye best-corrected visual acuity was counting fingers. Left eye best-corrected visual acuity was 6/9. Right eye slit-lamp examination revealed diffuse corneal oedema with central epithelial cystic change. The interface between the flap and residual stroma was open and filled with fluid. This separation extended nearly to the flap margin. Shallow anterior chamber and aqueous leakage were noted the following day. An emergency penetrating keratoplasty was performed to the right eye. Histopathology of corneal button revealed reactive keratocytes with irregular, wrinkled collagen formation over ablated stroma. Marked stromal oedema was observed. Twelve months after corneal transplantation, vision improved to 6/6 with correction in the right eye.

Clear graft survival and immune reactions following emergency keratoplasty

Emergency penetrating keratoplasty is said to have a poorer outcome than conventional keratoplasty. We performed a retrospective analysis of 272 cases of emergency keratoplasty to evaluate this hypothesis. We analysed 272 cases of emergency keratoplasty and compared the results with a control group of 1,257 scheduled normal-risk keratoplasties and 407 scheduled high-risk keratoplasties. Kaplan-Meier estimations were performed to estimate the percentage of clear graft survival and development of immune reactions. Indications for emergency keratoplasty were microbial diseases (n=109, acanthamoeba, bacteria, fungi), herpes simplex virus infections (n=83), ulcers due to immunological diseases (n=63), and 17 cases of ulcers of unknown origin. Within 1,500 postoperative days, grafts following emergency keratoplasty suffered statistically significantly more graft failures (clear graft survival, 67.9 vs. 86.9%, P<0.01) and immune reactions (grafts free from immune reactions, 62.8 vs. 78.6%, P<0.01) than grafts following scheduled, normal-risk keratoplasty. There was no statistically significant difference between emergency and scheduled high-risk keratoplasties (clear graft survival, 67.9 vs. 70.2%, and grafts free from immune reactions, 62.8 vs. 66.8%). For emergency keratoplasties, systemic immunosuppression (with cyclosporin A and/or mycophenolatmophetil) had a statistically significant positive effect on clear graft survival (77.4 vs. 63.5%, P=0.01), but not on the development of immune reactions (62.8 vs. 62.3%). A sub-group analysis showed that the effect on clear graft survival was mainly an effect on the underlying systemic immunological disease that had lead to emergency keratoplasty. This retrospective analysis revealed that clear graft survival is limited following emergency keratoplasty. As in high-risk situations, systemic immunosuppression may be the key to improving prognosis following emergency keratoplasty in the long run.

Prise en charge chirurgicale des perforations cornéennes non traumatiques : étude rétrospective sur 8 ans

Treatment of nontraumatic corneal perforation is a difficult task. The aim of our study was to retrospectively analyze predisposing conditions leading to perforation, surgical treatments, and visual outcomes. Fifty-six patients were admitted in our department for a nontraumatic corneal perforation between 1997 and 2004. Mean patient age was 69 years (range, 16-95 years) and the mean follow-up was 20.5 months (range, 6-96 months). The diseases associated with perforations were neurotrophic ulcer in 24 cases (43%), peripheral immunologic ulcer in ten cases (18%), dry eye in six cases (11%), and infectious keratitis in seven cases (13%). All patients had specific adapted medical treatment before surgery. As a first procedure, we used cyanoacrylate glue in 14 cases (50% anatomic success), multilayer amniotic membrane transplantation in 23 cases (100% anatomic success), conjunctival flap in six cases, peripheral lamellar graft in three cases (33% anatomic success), emergency penetrating keratoplasty in 13 cases (31% anatomic success), and one patient's eye had to be eviscerated. Several surgical procedures were necessary in 16 cases (28%), nine patients needing total conjunctival flap at the end. We were able to achieve tectonic stability in 91% of eyes and 32% of patients recovered useful visual acuity between 20/400 and 20/50. Amniotic membrane transplantation is an effective method for managing corneal perforations and usually does not need a further reconstructive procedure. Visual outcome is poor when peripheral or central keratoplasty are needed. We recommend a conjunctival flap when descemetocele or perforation recurs despite previous surgical management.

Fibrin glue in the management of corneal melt

Human fibrin glue aids physiological healing thereby reducing corneal vascularization and scarring compared with cyanoacrylate tissue adhesive. A 40-year-old intellectually disabled man with a corneal melt is reported who was managed successfully using human fibrin glue, alleviating the need for emergency penetrating keratoplasty.

Corneal and conjunctival toxicity from hydrogen peroxide: A patient with chronic self-induced injury

Purpose To report a patient with severe corneal and conjunctival toxicity from long-term, habitual use of hydrogen peroxide as an eye wash. Design Observational case report. Intervention and testing Serial examinations of the cornea, conjunctiva, and ocular adnexa were done. Penetrating keratoplasty with amniotic membrane transplantation was performed. Main outcome measures Ocular inflammation, pain, and visual acuity outcome. Results Bilateral corneal and conjunctival inflammation and scarring mimicking ocular-cicatricial pemphigoid were noted. Formation of a descemetocele after starting treatment with low-dose topical steroids required emergent penetrating keratoplasty with amniotic membrane transplantation. Conclusions This is the first reported case of ocular surface toxicity in a patient after deliberate chronic use of high-dose hydrogen peroxide. It highlights the value of obtaining a thorough medical and social history and the importance of direct questioning about the use of any medications or agents on the eyes before making a diagnosis or initiating therapy.