Perforated Corneal Ulcer Research Articles

Frequency of reoperations after amniotic membrane transplantation

Retrospective evaluation of the frequency of reoperations after amniotic membrane transplantation for different pathologic entities. We included 81 cases of amniotic membrane transplantation (AMT), which were operated on at the university eye clinic Tübingen since 1997 and which had been followed up for at least 12 months. Patient diagnoses were subdivided as follows: conjunctival defects after tumour excision (N = 2), bullous keratopathy (N = 5), external fistula after glaucoma filtering surgery (N = 3), recurrent pterygium (N = 5), symblepharon (N = 6), corneal ulcer with descemetocele (N = 3), non-perforated corneal ulcer (N = 51), perforated corneal ulcer (N = 1), other (n = 5). The overall reoperation rate was determined to be 42 % after a follow-up period of one year. Most frequently, a second AMT (N = 16) and a perforating keratoplasty (N = 16) were performed after the initial AMT. The following reoperation rates were determined for the subgroups: Conjunctival defects after tumour excision (0 %), Bullous keratopathy (60 %), External fistula after glaucoma filtering surgery (67 %), Recurrent pterygium (60 %), Symblepharon (67 %), Corneal ulcer with descemetocele (67 %), Non-perforated corneal ulcer (49 %), Perforated corneal ulcer (100 %). Particularly in patients with conjunctival defects after tumour excision and with non-perforated corneal ulcers, stabilisation of the ocular surface homeostasis can be achieved with a single amniotic membrane transplantation for at least one year.

Role of choroidal drainage in therapeutic keratoplasty.

To discuss the role of choroidal drainage in the management of positive vitreous pressure during therapeutic keratoplasty for patients with perforated corneal ulcers. Over a 2-year period, 8 of 36 (22%) consecutive patients with therapeutic grafts presented with a shallow anterior chamber during or immediately after surgery. These patients underwent choroidal drainage for formation of the anterior chamber. In 5 of them choroidal drainage was done intraoperatively when there was significant positive vitreous pressure and the anterior chamber could not be formed. Three patients had drainage within a week postoperatively for persistent shallow anterior chamber when ultrasonogram showed choroidal detachment. Of the eight cases, seven drained fluid and the chamber could be reformed well. One was a dry tap and the chamber did not reform completely. Choroidal detachment (CD) is a previously unpublished cause for positive vitreous pressure in therapeutic keratoplasty for perforated corneal ulcers. In these situations suprachoroidal drainage can be considered as an option for the reformation of the anterior chamber. We recommend that a preoperative B-scan ultrasound be included in the workup of all corneal perforations and that intraoperative drainage of the fluid is considered in cases with significant positive vitreous pressure and confirmed CD.

Tectonic Epikeratoplasty: A Surgical Procedure for Corneal Melting

Tectonic epikeratoplasty (TEK) is a method in which a corneal button, preserved in glycerin is used as a seal over corneal perforation. The graft is sutured to the recipient sclera, upon the sick melted cornea, with silk sutures, after 360 degree peritomy of the conjunctiva. The graft is left in place for a few weeks, and by that time the cornea is completely healed. We describe our experience in TEK as a method of treatment for selected cases of melted cornea or descemetocele. We review 12 TEK operations done in our department over the period of 1992 to 1997, and describe the outcome in each case. The 12 TEK operations included 9 eyes of 9 patients. The patients, 7 males and 2 females, suffered from ocular surface disturbances including indifference to pain syndrome, Steven-Johnson syndrome, dry eye, relapsing herpetic keratitis, post-traumatic corneal thinning, and local anesthetic abuse. Six of the 9 eyes had leaking perforated corneal ulcer, and the remaining 3 had an imminent perforation caused by descemetocele or melting. All the grafts but one fell off the eyes between 10 and 21 days following surgery. In most of the cases the leakage ceased, and a scar sealing the perforation site was observed. One eye had gone through this procedure 3 times, and another eye had gone through it twice. In only 3 cases did the procedure fail to eliminate leakage, and another TEK or urgent penetrating keratoplasty (PKP) was done. TEK is an available method for saving the integrity of the globe when PKP is not possible. Although it increases corneal vascularity, PKP can be done later under optimal conditions.

Tectonic sclerokeratoplasty and tectonic penetrating keratoplasty as treatment for perforated or predescemetal corneal ulcers

PURPOSE: To report the clinical outcome of patients with perforated or predescemetal corneal ulcers treated by tectonic, centric or eccentric penetrating keratoplasty or by tectonic sclerokeratoplasty. DESIGN: Nonrandomized clinical trial. METHODS: The study included 60 patients (60 eyes) with perforated or predescemetal corneal ulcers who were consecutively operated on by the same surgeon. Fifty-two patients underwent tectonic penetrating centric or eccentric keratoplasty. Eight patients with paralimbal corneal ulcers underwent tectonic sclerokeratoplasty. A control group consisted of 76 patients (76 eyes) electively undergoing central penetrating keratoplasty for treatment of inactive central corneal scars. RESULTS: In the study group with perforated or predescemetal corneal ulcers, best-corrected postoperative visual acuity ranged from perception of light to 0.80 (median, 0.10), with 54 of 60 eyes (90%) attaining an improvement of best visual acuity. In 10 of 60 patients (16.7%), tectonic penetrating keratoplasty had to be re-performed because of a recurring corneal ulcer. Patients with sclerokeratoplasty and patients with eccentric keratoplasty did not differ in clinical outcome, despite larger trephine and corneal lesion size in the sclerokeratoplasty group. Among study patients compared with control patients, postoperative visual acuity was significantly lower ( P = .01), postoperative refractive and keratometric astigmatism were significantly higher ( P < .05), and immunologic graft reactions ( P = .02) and suture loosening ( P < .001) occurred significantly more often. CONCLUSIONS: Eyes with perforated corneal ulcers or predescemetal corneal ulcers can usually be saved by tectonic keratoplasty or sclerokeratoplasty, with a moderate to considerable amount of remaining useful vision. In case of doubt, one may prefer conservative treatment of corneal ulcers and to electively perform central keratoplasty when the ulcers have healed. For selected clinical situations, sclerokeratoplasty is an alternative to keratoplasty for surgical treatment of paralimbal corneal defects.

Impression Cytology-proven Corneal Stem Cell Deficiency in Patients After Surgeries Involving the Limbus

To report three cases of limbal stem cell deficiency (confirmed by impression cytology) that followed multiple pterygium surgeries and therapeutic penetrating keratoplasty. The first case, after multiple pterygium surgeries, presented with corneal scarring and thickened epithelium with vascularization sparing the central cornea in the right eye and involving the entire cornea in the left eye. The second case presented with superficial scarring and extensive vascularization after failed therapeutic graft performed for a large perforated corneal ulcer. The third case was a clear graft performed for a progressing fungal ulcer with signs of conjunctivalization inferotemporally. Limbal stem cell deficiency was clinically suspected in all of these cases. Goblet cells with mucin globules were found on the corneal surface by impression cytology in all three cases. We report three cases of limbal stem cell deficiency (proven by impression cytology) that followed multiple pterygium surgeries and therapeutic penetrating keratoplasty. Surgical insult to the limbus is the predisposing factor for stem cell damage in these cases. Involvement of the limbus by infection and use of intensive medications are probable contributing factors for stem cell damage in cases of therapeutic penetrating keratoplasty.

Nonmechanical excimer laser penetrating keratoplasty for perforated or predescemetal corneal ulcers

Objective To review the authors’ results using nonmechanical excimer laser trephination in penetrating keratoplasty for perforated or predescemetal corneal ulcers. Design Noncomparative, consecutive, interventional case series. Participants Thirty-two patients with perforated (17) or deep (15) corneal ulcers (9 bacterial, 5 acanthamoebal, 10 herpetic, 3 associated with rheumatoid arthritis, 5 other) necessitating immediate tectonic keratoplasty. Intervention Penetrating tectonic keratoplasty with excimer laser trephination was performed along metal aperture masks in donor and recipient corneas. Main outcome measures Clinical results including intraoperative and postoperative complications were evaluated. Results Trephination was possible in all eyes without perforation of predescemetal ulcers or extrusion of intraocular contents. No eyes with bacterial or acanthamoebal ulcers showed persistence or recurrence of infection. One eye showed recurrent epithelial herpetic keratitis. Best-corrected postoperative visual acuity ranged from 20/700 to 20/20 (median, 20/58), with 30 of 32 eyes achieving improvement of best visual acuity during follow-up (mean, 22.4 months) and with 12 of 32 eyes reaching a visual acuity of 20/40 or greater. Eyes with bacterial or acanthamoebal ulcers showed best results. Episodes of graft rejection occurred in nine eyes and resulted in irreversible opacity of the graft in seven cases. None of the eyes lost all vision, developed endophthalmitis, or had to be enucleated. Conclusions Nonmechanical trephination is a useful technical refinement of tectonic penetrating keratoplasty à chaud for perforated or deep progressive corneal ulcers. This technique greatly facilitates exact trephination under these difficult surgical conditions and might possibly improve the prognosis of this procedure.

Visual outcome and ocular survival following Iris prolapse in the horse: a review of 32 cases

The medical records of 32 horses treated for iris prolapse (IP) during an 8 year period, at the University of Florida Veterinary Medical Teaching Hospital, were reviewed. Iris prolapse was associated with perforated corneal ulcers in 15 horses (47%), ruptured stromal abscesses in 2 horses (6%), and full thickness corneal lacerations in 15 horses (47%). Initial ophthalmic examinations revealed IP with severe iridocyclitis in all eyes and keratomalacia in 8 eyes with corneal ulcers, one with a stromal abscess and 1 with a corneal laceration. Hyphema was present in 7 eyes with corneal lacerations. Thirty horses were managed with combined medical and surgical therapy. Two horses were only treated medically with topically administered antibiotics. Of the 24 perforations surgically repaired, 21 were closed primarily and 13 were then covered with a conjunctival graft. After combined therapy and a minimum of 4 months of follow-up, vision was retained in 6 of the horses (40%) with perforating corneal disease and 5 of the horses (33%) with perforating corneal lacerations. Post operatively, of the 11 (37%) horses blind at discharge, 6 (55%) subsequently developed phthisis bulbi. Enucleations were performed in 4 cases with extensive keratomalacia and/or endophthalmitis, 2 cases with limbal rupture and total hyphema, and one case with a chronic IP. One horse was subjected to euthanasia after 3 surgical treatments failed to stabilise stromal melting. Horses presented with ulcerative keratitis of fewer than 15 days duration, or horses with corneal lacerations less than 15 mm in length, tended to have a favourable visual outcome. Keratomalacia, hyphema, corneal lacerations longer than 15 mm and lacerations extending to, along, or beyond the limbus, adversely influenced visual outcome. Iridectomy did not appear clinically to exacerbate anterior uveitis or adversely affect visual outcome. Ocular survival following combined therapy was 80% (12/15) in horses with corneal lacerations and 67% (10/15) in horses with ulcerative keratitis.

Clinical and immunohistochemical correlation of herpetic keratitis with the expression of HLA-DR antigen.

The corneal buttons after corneal graft of 22 patients with herpetic keratitis were studied (16 male, 6 female; 7-87 years of age). Ten still had active inflammation, while 12 had stabilized by the time of the study. Different degrees of neovascularization were observed in 19 cases. HLA-DR antigen was detected in the corneal epithelium in 7 of 22 cases (32%), in the corneal stroma in 17 of 22 cases (77%), and in the endothelium in 9 cases (41%) by using the immunohistochemical technique. The expression of HLA-DR antigen was more common and more marked in active herpetic keratitis (90%) and in neovascularized corneas (84%). The frequency and density of HLA-DR expression in perforating corneal ulcers were no higher than in other cases, but anterior synechia was accompanied by strong expression of HLA-DR antigen in the corneas. The expression of HLA-DR antigen was not only detected in the peripheral, but also in the central area of the specimens. The cells expressing HLA-DR antigen in corneas were mainly corneal cells. The results showed a close relationship between HSV-keratitis and the expression of HLA-DR antigen, which may be induced during the clinical course of the disease. The expression of HLA-DR might be one of the factors in the recurrent onset of the disease and a significant sign of the prognosis of corneal transplantation for these patients.

Paracentral Rheumatoid Corneal Ulceration: Clihical Features and Cyclosporine Therapy

Six patients with rheumatoid arthritis (eight eyes) presented with small paracentral perforating corneal ulcers in otherwise quiet eyes. Initial management in five patients (seven eyes) consisted of systemic immunosuppression and therapeutic tissue adhesive with a bandage contact lens or tectonic keratoplasty. Ulceration recurred in all of these eyes, and recurrent ulcers treated with repeat tectonic keratoplasty or therapeutic tissue adhesive and a bandage contact lens all developed recurrent ulceration. The introduction of topical cyclosporine therapy in five eyes with recurrent corneal ulceration was associated with arrest of keratolysis and rapid re-epithelialization of the ulcer in all cases. One corneal ulcer was successfully treated initially with topical cyclosporine, tissue adhesive, and a bandage contact lens. In patients with rheumatoid arthritis and small paracentral corneal ulcerations or perforations, application of tissue adhesive and a bandage contact lens and introduction of topical cyclosporine may be the preferred initial treatment.

Determination of resistance and antibiotic therapy in bacterial eye diseases of childhood

From June 1982 to December 1983 children aged between 3 days and 5 years (average 2-1/2 years) with bacterial conjunctivitis, blennorrhea or perforated corneal ulcers were examined microbiologically. The results of 30 antibiotic susceptibility tests were compared with those of adults. Prevalence of Escherichia coli (6%) and Staphylococcus aureus haemolyticus (17%) was observed; Candida species was not found in the young children. Pediatric diseases revealed themselves to be more pronounced in general. The authors diagnosed 3 chlamydial blennorrheas in newborn aged 7, 8 and 10 days. Mixed infections were found significantly less often in children (21%) than in adults (64%). The authors point out the need for epidemiologic antibiotic susceptibility studies to facilitate decision making for ad hoc therapeutic measures that are sometimes indicated in endophthalmitis or severe blennorrhea. The possible complications of antibiotic polypragmasia and the use of fixed combinations are discussed.

Serum antiproteases and polymorphonuclear leucocyte neutral collagenolytic protease in the tear fluid of patients with corneal ulcers treated with n-butylcyano acrylate glue.

Four patients with central melting perforating corneal ulcers were treated by n-butylcyano acrylate gluing of the ulcer region. The glue facilitated healing of the eyes, and when the glue scaled off weeks later the corneas were left with stable leucomas. The glue membrane appears to prevent tear-borne polymorphonuclear leucocytes (PML) from reaching the ulcer region and to diminish activation of PML, with the consequent dramatic fall in tear fluid polymorphonuclear leucocyte neutral collagenolytic protease (PML-c-ase). After gluing, the tear fluid content of serum antiproteases returns to normal levels within days. This might indicate a decreased leakage of proteins from conjunctival vessels.

Malignant Melanoma of the Choroid Associated with Spontaneous Expulsive Choroidal Hemorrhage

A 79-year-old man initially had a perforated corneal ulcer of his blind right eye. The next day a spontaneous expulsive choroidal hemorrhage occurred just before scheduled enucleation. Histopathologic examination of the enucleated eye revealed a severe necrosis of several posterior ciliary arteries in the expulsive choroidal hemorrhage, as well as a large occult spindle B malignant melanoma of the choroid. The necrosis of the posterior ciliary arteries may have been the cause of the choroidal hemorrhage. The finding of an occult malignant melanoma may be more than a chance occurrence of two unrelated events, inasmuch as both are associated with necrosis of the posterior ciliary arteries.

Comparison of eye patching with cyanoacrylate glue application for anterior chamber reformation in infected perforated corneal ulcers

Objectives: This study was designed with the primary objective to compare between eye patching and cyanoacrylate glue application for anterior chamber (AC) reformation in infected perforated corneal ulcers. Subjects and Methods: This is a nonrandomized prospective comparative study conducted in a tertiary eye hospital. Patients with perforated keratitis were offered either eye patching (Group 1) or cyanoacrylate gluing (Group 2) under hospital admission and medical treatment to reform the AC. Success was defined as a formed AC at the time of discharge from the hospital. Patients were followed up to 1 month after discharge. Normally distributed data were expressed as mean ± standard deviation and skewed data as median. Nominal data between the two groups were compared using Chi-square test or Fisher's exact test. Results: Forty eyes underwent eye patching and 38 eyes cyanoacrylate gluing to reform the AC. The number of eyes with formed AC was more in Group 2 (92%) compared to Group 1 (70%) (P = 0.020). Subgroup analysis on the basis of the size of perforation and size of ulcer showed that AC reformation was better in Group 2 compared to Group 1 in all aspects [Table 1]. In intragroup analysis, success in Group 1 was significantly better in small perforations (P = 0.001) and in small ulcers (P = 0.032) and ulcer in central location (P = 0.004). In Group 2, there was no significant difference in AC reformation between small and large perforation or ulcer. In both groups, AC reformation in peripheral perforations was poor compared to central and paracentral perforations (P = 0.004, 0.032). Conclusions: Cyanoacrylate glue is better than eye patching to restore ocular integrity. However, eye patching showed promising results in subgroup of patients with small perforated ulcers.{Table 1}

Recent advances in the use of alloplastic materials in ocular surgery.

This report briefly reviews the use of alloplastic materials in ocular surgery. Among the materials employed, silicone and methyl methacrylate dominate, but acrylate hydrogels are attracting increasing interest. The following alloplastic devices are most commonly used or show promise: Splints of silicone rubber are used in the treatment of perforated corneal ulcers. Replacement of a corneal graft endothelium with a membrane of silicone rubber or hydrogel (artificial endothelium) shows considerable promise in otherwise hopeless cases. Through-and-through corneal implants, mostly of methyl methacrylate, are sometimes successful but leaks and extrusion are not uncommon. Intraocular lenses of methyl methacrylate as replacement of cataractous lenses are used little due to their complications. Drainage tubes for glaucoma are still experimental. Alloplastic materials are routinely employed more in retinal detachment surgery than in any other type of ocular surgery. Encircling bands, tubes and implants of various shapes, mostly of silicone rubber, are used to indent the sclera. Intravitreal injections of silicone oil have a high rate of complications.

A technique for the repair of perforated corneal ulcers.

A simple but effective technique for restoring the anterior chamber in cases of perforated corneal ulcer is reported. It consists of placing a thin slice of corneal tissue on the ulcer, covering it with a transparent membrane of silicone rubber, and holding the membrane and the tissue in place with tight overlying sutures. This technique, and modifications thereof, has been used in 16 patients, resulting in permanent reforming of the anterior chamber in all cases. With this procedure, penetrating keratoplasty can be postponed until absence of active inflammation will permit a more favorable prognosis.

Ocular involvement in erythema multiforme.

WHEN INVOLVEMENT of the mucous membrane accompanies erythema multiforme bullosum, serious ocular sequelae may occur. Of 162 previously reported cases of erythema multiforme with mucosal involvement, the eyes were affected in 148. The ocular picture varied from mild mucopurulent conjunctivitis to perforating corneal ulcers destroying the globe. The striking increase in the number of cases reported recently and the high percentage with ocular lesions make it important for the ophthalmologist to be aware of the ocular implications of erythema multiforme. <h3>NOMENCLATURE</h3> Unfortunately, the literature has been cluttered with many cumbersome names for mucosal involvement accompanying erythema multiforme of the skin. A brief survey of titles used is presented in an attempt to clarify the current nomenclature. In 1866 Hebra¹proposed the name "erythema exudativum multiforme" for a cutaneous disease identified by variously shaped erythematous lesions of the skin. He cited a rare variant of erythema multiforme with accompanying severe

A Note on the Treatment of the Sequelae of Perforated Corneal Ulcer

Although uncommon in private and in­ stitutional practice in the U.S.A., the perforated corneal ulcer and its sequelae are deemed to be subjects of sufficient interest to warrant the publication of sev­ eral related experiences gained at the Peiping Union Medical College (or, in brief, the P.U.M.C). There is a great difference in the rela­ tive incidence of eye diseases between the material seen in the P.U.M.C. hospital and clinics and the material of, let us say, the Illinois Eye and Ear Infirmary in Chicago. With regard to the latter place it is not far from Correct to say that one third of the time of the attending staff is taken up by refraction work, one third by work on cataract cases, and the remain­ ing one third by work on cases of various kinds. In Peking an altogether different situation prevails. Taking, as an example, the intraocular operations performed at the P.U.M.C. one finds that 29 percent are for the relief of senile and other forms of cataract, 28 percent for the treatment of secondary and IS percent for the treatment of primary glaucoma, whereas the remaining 28 percent repre­ sent optic iridectomies. In most of the operations for secondary glaucoma the latter is due to an anterior synechia which is the outcome of a perforated corneal ulcer. Since the optic iridectomies also concern themselves with the aftereffects of perforated corneal ulcers it may be said that two thirds of all intraocular oper­ ations are performed for the correction of

Glaucoma secondary to perforating corneal ulcer

Glaucoma secondary to perforating corneal ulcer