Tectonic Penetrating Keratoplasty Research Articles

Simultaneous tectonic Descemet stripping endothelial keratoplasty and tectonic Bowman layer transplant for the management of corneal perforation.

To report the outcomes of three cases of corneal perforation managed with simultaneous tectonic Descemet stripping endothelial keratoplasty (t-DSEK) and tectonic Bowman layer transplant (t-BLT) as an alternative to tectonic penetrating keratoplasty (t-PKP). Three eyes of three patients receiving simultaneous t-DSEK and t-BLT for corneal perforation were included. The technique for DSEK was modified depending on individual requirements. The t-BLT technique was standardised using an 8 mm graft and fixated with a running suture. Success was measured by the ability of this procedure to close a corneal perforation. All three cases achieved tectonic eye globe restoration and remained stable during the minimum 3-month observation period. Reinterventions were relatively common: 2 cases required amniotic membrane transplant for persistent epithelial defects. One case required DSEK rebubbling. One case developed angle closure glaucoma requiring surgical peripheral iridectomy. Simultaneous t-DSEK and t-BLT may be a useful strategy for the management of corneal perforation as an alternative management to t-PKP for selected cases.

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.

Spontaneous corneal perforation in treatment‐resistant MPO‐ANCA‐associated small vessel vasculitis

AbstractPurpose: Spontaneous corneal perforation is a rare complication in peripheral ulcerative keratitis (PUK). Identifying the systemic cause of PUK is essential for optimal treatment. MPO‐ANCA‐associated small vessel vasculitis is a potential cause of PUK. Being an autoimmune disorder, immunosuppressive therapy is indicated. Besides steroids, biologicals such as rituximab can be used with excellent results.Methods: In this case report, we would like to present a 83‐year‐old male patient with PUK caused by MPO‐ANCA‐positive small vessel vasculitis.Results: In this patient with PUK due to small vessel vasculitis, a spontaneous corneal perforation could not be prevented despite maximal immunosuppressive therapy. Thus, a tectonic penetrating keratoplasty à chaud was inevitable.Conclusions: Ophthalmologists should be aware of the rare complication of corneal perforation secondary to PUK caused by vasculitis.

A rare ophthalmic complication: Expulsive suprachoroidal hemorrhage.

Expulsive suprachoroidal hemorrhage is a rare but dreadful complication of any ophthalmic surgery. Hence an ophthalmologist should know about the various risk factors, methods for preventing such a situation, and be aware of the various options for timely management to tackle the situation. To discuss the risk factors, intraoperative signs, and ways of managing expulsive choroidal hemorrhage. We discuss two cases having multiple risk factors, where the patients underwent tectonic penetrating keratoplasty. In view of extensive involvement of ocular structures, the patients were clearly explained about the guarded visual prognosis and the risk of auto-evisceration. Following trephination of host cornea, rise in intraocular pressure was identified by the increasing size of the vitreous seen prolapsing through the wound and markedly visible pulsations, along with subconjunctival bleeding. Suprachoroidal hemorrhage was suspected and immediate tamponade was given. However, bleeding was not controlled, and eventually, expulsion of all the intraocular contents occurred. A surgeon must be aware of the risk factors, be prompt to identify the signs, and must take immediate actions for the management of expulsive choroidal hemorrhage, a rare but dreadful complication of intraocular procedures. https://youtu.be/UnCH-lWGzwU.

Trends in the epidemiological and microbiological profiles of infectious keratitis in southeastern Brazil.

To investigate the antibiotic susceptibility as well as the clinical, epidemiological, and microbiological profiles of microbial keratitis. This was a longitudinal retrospective study, and we retrospectively reviewed medical and laboratory records from 2015 to 2019. In total, 380 pathogens (321 bacteria and 59 fungi) were isolated from the corneas of 352 patients. Staphylococcus species (45%) were most abundant within the organisms that were isolated, followed by Pseudomonas (18.4%), fungi (15.5%), Streptococcus (7.9%), and Serratia species (3.2%). The isolated gram-positive bacteria were not resistant to amikacin or vancomycin, although 14.8% of the gram-positive isolates were resistant to ciprofloxacin (p<0.05). All the gram-negative isolates were susceptible to amikacin. Male patients represented 62.8% of the 129 cases with accessible clinical data. The mean age of the patients was 53.17 ± 21 years. The time to presentation (from onset of symptoms) was 14.9 ± 19.4 days (median: 7 days). Large ulcers (>5 mm in any dimension) were present in 49.6% (64 eyes) of the cases. The duration of treatment was 49 ± 45.9 days (median: 38 days). Direct ocular trauma was reported by 48 (37.2%) patients, and 15 patients (11.6%) reported using contact lenses. For 72 (55.8%) patients, topical treatment had been previously prescribed, and 16 (12.4%) patients reported using other classes of drugs. Hospitalizations were required for 79 (61.2%) patients, and in terms of major complications, 53 (41.1%) patients had corneal perforations. A total of 40 patients (31%) underwent tectonic penetrating keratoplasty, and 28 (21.7%) developed secondary glaucoma. A progression to endophthalmitis occurred in 8 (6.2%) patients, with 50% of those patients' (3.1% of the total) endophthalmitis evolving to evisceration. The patients' microbial keratitis was largely treated empirically, with 94 (72.9%) patients prescribed moxifloxacin and 56 (43.4%) prescribed ciprofloxacin before receiving their culture results. For the most part, our hospital treated patients with severe microbial keratitis. Despite identifying gram-positive bacteria in most of the isolates, we also frequently identified gram-negative rods and fungi. Our susceptibility results support prescribing a combination of vancomycin and amikacin as an effective empirical therapeutic regimen to treat microbial keratitis.

Mycotic Keratitis in a Tertiary Hospital in Northeastern Malaysia

Objectives:To identify the clinical profile, etiology, and outcome of culture-positive mycotic keratitis in a tertiary referral centre in the northeastern part of Malaysia.Materials and Methods:A retrospective review of all patients with culture-positive mycotic keratitis in Hospital Universiti Sains Malaysia over a 3-year period, from January 2015 to December 2017.Results:This study included 27 eyes of 27 patients treated for mycotic keratitis based on a positive fungal culture. The most common predisposing factor was ocular trauma, in 22 patients (81.5%). Eleven patients (40.7%) had a presenting visual acuity worse than 6/60, due to central ulcer involvement. Approximately half of these (6 patients) experienced visual improvement post-treatment. Fusarium spp. was the most common fungus isolated (37%), followed by non-sporulating fungi and Curvularia spp. Three patients (7.4%) had corneal microperforations, which healed after gluing and bandage contact lens application. One patient (3.7%) required tectonic penetrating keratoplasty and 1 patient (3.7%) underwent evisceration. The final visual acuity was 6/18 or better in approximately half (14 patients) of our cohort and worse than 3/60 in approximately 20% (5 patients).Conclusion:Mycotic keratitis occurred mainly in males and secondary to ocular trauma. The most common organism isolated was Fusarium spp. Although treatment may improve vision, the visual outcome is guarded.

Tectonic Keratoplasty in Patients with Non-traumatic, Non-infectious Corneal Perforations

Introduction:The study aims to report clinical results of tectonic keratoplasty for non-traumatic, non-infectious corneal perforations.Materials and Methods:The medical records of 12 patients who underwent tectonic penetrating keratoplasty between October 2014 and August 2018 at Ege University Ophthalmology Department were retrospectively reviewed.Results:The mean age of the patients was 52.92±30.34 (range, 2-82) years. The causes of corneal perforation were dry eye (neurotrophic keratopathy (n=4), limbal stem cell deficiency (n=2), exposure keratopathy (n=2) and graft versus host disease (n=1)) in 9 patients. In the remaining 3 patients, the etiology of perforation was not determined. The mean Visual Acuity (VA) was 2.98±0.39 (range, 1.8-3.1) LogMAR before the surgery. Despite conservative treatment, tectonic penetrating keratoplasty had to be performed in all patients in order to manage the perforation. Mean time in between initial examination and surgery was 10.75±12.04 (1-41) days. In 2 patients, allogenic limbal stem cell transplantation; in one patient, lateral tarsorrhaphy and in one patient symblepharon release with amniotic membrane transplantation were performed additional to tectonic keratoplasty. Mean follow-up time was 57.88±55.47 (4-141) weeks. Grafts were clear in 6 eyes and opaque in 5 eyes. The main causes of graft failure among opaque grafts were ocular surface disease (3), allograft rejection (1) and glaucoma-related endothelial failure (1). Phthisis bulbi was detected in one patient with congenital glaucoma due to vitreous loss at the time of perforation. The mean final VA in patients who had clear grafts was 1.83±1.03 (range, 0.8-3.1) LogMAR.Conclusion:To prevent serious complications in non-traumatic, non-infectious corneal perforations, providing anatomic integrity immediately is a must. If conservative treatment is inadequate or the perforation area is extensive, tectonic penetrating keratoplasty is indicated. Besides, it is important to manage the etiological risk factors in order to obtain successful clinical follow up.

Clinical indications of penetrating keratoplasty in a tertiary care centre of North India

Background: Corneal diseases are one of the major causes of blindness and visual impairment in developing countries. Penetrating keratoplasty is a surgical procedure where a damaged or diseased cornea is replaced by donor corneal tissue. Aim was to determine the indications of penetrating keratoplasty (PK) in a tertiary health care centre of North India.Methods: A retrospective analysis of the records of 288 patients, who underwent penetrating keratoplasty (PK) from January 2016 to December 2018 at Regional Institute of Ophthalmology, PGIMS Rohtak were included in this study. All patients who underwent PK during this time period were included in our study except those who underwent regrafting.Results: A total of 288 patients who underwent penetrating keratoplasty (PK) surgery were included in our study. Out of 288, 184 (63.88%) were males and 104 (36.11%) were females. In our study, 162 (56.25%) patients underwent optical PK, 76 (26.38%) had tectonic PK and 50 (17.36%) underwent therapeutic PK. Most common indication for optical PK was bullous keratopathy followed by corneal opacity. Most common reason for tectonic PK was found to be corneal perforation while for therapeutic PK was sloughing corneal ulcer followed by recalcitrant fungal keratitis.Conclusions: Though bullous keratopathy (BK) was the most common indication for penetrating keratoplasty in North India, but in our study 27% patients had tectonic PK and 17% patients underwent therapeutic PK which is significantly higher than documented data from South India and developed countries. It can be because of low literacy level, lack of awareness and late presentation to ophthalmologist in North India.

Corneal transplantation and eye banking practices during COVID-19-related lockdown period in India from a network of tertiary eye care centers.

Purpose:The purpose of this study was to discuss the guidelines and modification of practices with respect to corneal transplantation and eye banking during the COVID-19 pandemic lockdown period and beyond, at a network of tertiary care centers in India.Methods:Descriptive study of the challenges faced in eye banking during the lockdown, and practices adopted to overcome the critical aspects in the clinical care of patients who presented with emergency corneal diseases requiring keratoplasty.Results:Complete lockdown orders from the Indian government, as a strategy to control the Coronavirus pandemic, resulted in drastic reduction of all types of elective corneal transplants and eye banking activities from March 24, 2020 to May 31, 2020. The sudden cessation of eye banking resulted in an acute demand and supply imbalance of fresh donor corneas for transplants during this time. Our network of eye banks addressed this issue by adopting glycerol preservation of donor corneas, which were subsequently utilized for tectonic penetrating keratoplasty. The donor cornea retrieval was resumed in a strategized manner 3 weeks prior to the date of exit of the lockdown, with modified guidelines on donor suitability, screening, retrieval, processing, and harvesting from various sources. A triage of keratoplasty priority was formulated to tide over the post lockdown shortage of corneas. We performed 31 therapeutic keratoplasties during the nationwide lockdown among our network of tertiary eye care centers.Conclusion:The study highlights the approach and strategies to manage and tide over an unprecedented crisis situation faced by corneal surgeons in general and, specifically, the eye banking community.

A new trepanation technique for penetrating keratoplasty in cases of large corneal perforation

Abstract Aim/objective Tectonic penetrating keratoplasty is technically difficult to perform in cases of large corneal perforations. Indeed, severe ocular hypotonia makes it difficult to achieve high-quality trephination. Therefore, it is essential to create a normotensive eye. We investigated the use of a piece of sterile cardboard to seal the globe before recipient trephination. Methods This is a retrospective case series. Patients treated with a new technique of tectonic keratoplasty for the management of large corneal perforations were studied. Main outcome measures were achievement of recipient trephination, preservation of globe integrity preservation and visual acuities. Results This case series included 6 eyes of 6 patients, with a mean age of 51 years (range, 21–79 years). The perforations were 4–7 mm in diameter. Five out of the 6 patients had undergone unsuccessful prior multilayer amniotic membrane transplantations. Mean follow-up period was 14 months (range, 6–24 months). The use of a piece of sterile cardboard to seal the globe made it possible to carry out a circular recipient trephination with a diameter identical to that of the donor corneal graft in all cases. Conjunctival flap and partial tarsorrhaphy were used in three patients and in one patient, respectively. Preservation of globe integrity was achieved in all cases. Visual acuity had improved at the end of follow-up in four patients. Conclusions We describe here a new surgical technique allowing achievement of a circular recipient trephination with a diameter identical to that of the donor corneal graft.

Candida dubliniensis: A novel cause of fungal keratitis.

A 45-year-old female with history of contact lens wear presented with a persistent corneal ulcer that was unresponsive to topical moxifloxacin. The patient’s exam was concerning for fungal keratitis. Cultures were obtained, and the patient was started on fortified amphotericin B drops and oral voriconazole. The cultures identified Candida dubliniensis as the causative organism. The patient’s exam worsened despite treatment, and the decision was made for surgery. At the time of surgery, her cornea was found to have unexpectedly perforated. She underwent cryotherapy; tectonic penetrating keratoplasty; anterior chamber tap; intracameral voriconazole, amphotericin B, and cefuroxime; and a partial conjunctival flap. Pathology from the cornea showed GMS and PAS stains positive for fungal forms.C. dubliniensis is a yeast closely related to Candida albicans that was first described in 1995 as a cause of oral candidiasis in patients with AIDS. There are a few published cases of endophthalmitis due to C. dubliniensis in the ophthalmology literature, but to our knowledge, no cases of fungal keratitis due to this organism have been reported. C. dubliniensis is a novel cause of fungal keratitis that can be difficult to identify and treat but is felt to be less virulent than C. albicans and generally susceptible to available anti-fungal therapies.

Non-traumatic corneal perforations: aetiology, treatment and outcomes

PurposeTo report aetiology, characteristics, treatment and main outcomes of non-traumatic corneal perforations in a single referral centre.MethodsA retrospective review of clinical records of patients diagnosed with non-traumatic corneal perforation. The...

Tectonic lamellar keratoplasty: simplified management of corneal perforations with an automated microkeratome

ObjectiveTo describe a simplified tectonic lamellar keratoplasty (LK) technique, which can be used to manage full-thickness corneal perforations. DesignCase series demonstrating a new surgical technique. ParticipantsA 69-year-old female with rosacea keratitis and peripheral corneal perforation; a 49-year-old male with keratoconus, ipsilateral herpes simplex keratitis and an inferonasal corneal perforation; and a 12-year-old female with an apparently spontaneous central corneal perforation. ResultsThese 3 patients with full-thickness corneal perforations were successfully managed with this automated tectonic LK technique. ConclusionsTectonic LK has benefits relative to tectonic penetrating keratoplasty but remains unpopular because it is technically difficult to prepare the host and donor corneas. This tectonic LK technique negates the need for challenging free-hand dissection and gives an excellent donor fit to the host bed. This provides an easier and more effective way to manage corneal perforations.

Risk Factors, Microbiological Profile, and Treatment Outcomes of Pediatric Microbial Keratitis in a Tertiary Care Hospital in Hong Kong

To report the risk factors and microbiological profile of pediatric microbial keratitis cases in a tertiary care hospital in Hong Kong. Retrospective study. Case records of patients <18 years old with microbial keratitis were reviewed over a period of 10 years, between January 2001 and December 2010. Risk factors, microbiological profile, and treatment outcomes were analyzed. Overall, 18 patients (13 female, 5 male) with unilateral microbial keratitis were included. The mean age was 12.4 years (range: 3-17 years). The most commonly associated risk factor was contact lens wear (15, 83.3%). Seven cases (38.8%) were associated with orthokeratology lenses. Two cases (11.1%) were related to intrinsic keratopathy and 1 case (5.5%) was infected secondary to trauma. Microbiological culture was positive in 16 cases (88.8%). Overall, Pseudomonas sp. was the most commonly isolated organism (10/16, 62.5%), followed by coagulase-negative Staphylococcus (5/16, 31.2%) and Corynebacterium sp. (2/16, 12.5%). All cases responded to intensive medical management with topical antibiotics. One case with posttraumatic keratitis required stepped surgeries with initial tectonic penetrating keratoplasty followed by lens aspiration and retinal detachment repair. At the last follow-up, 13 out of 17 eyes (76.5%) had best-corrected visual acuity ≥20/40. Contact lens wear was the most commonly encountered risk factor for the occurrence of microbial keratitis in the pediatric age group in our setting. Orthokeratology remains one of the leading causes of contact lens-related infections. The majority of the cases responded to medical management.).

Contact-lens related keratitis caused by an atypical organism

This is a case report of contact-lens related, infectious keratitis with a subsequentperforation. A tectonic penetrating keratoplasty was performed and Sphingomonas paucimobiliswas cultured from the corneal button. One week post surgery, the patient developed are-infection involving the donor button. This was treated based on culture and sensitivity of thecorneal button and the infection resolved. Two months post surgery, the patient’s vision wascounting fingers in the affected eye. The corneal infection had completely resolved, but the grafthad failed despite the use of topical steroids.

La kératoprothèse Alphacor™ : dispositif, technique chirurgicale et résultats cliniques

Clinical evaluation of Alphacor keratoprosthesis in patients at high risk of corneal allograft rejection. Retrospective case series. Alphacor implantation was performed via a two-step procedure with intrastromal insertion followed by secondary exposure of the optic after 6 months. Visual acuity and occurrence of postoperative complications were evaluated. Fourteen eyes of 14 patients underwent Alphacor keratoprosthesis implantation. Mean follow-up was 15.6 ± 5.6 months (from 2 to 24 months). Postoperative mean visual acuity gain was 2.5 ± 3.1 lines (from 0 to +11 lines). Visual acuity was superior or equal to 20/200 in 21% of cases. Seven cases of stromal melt (50%) occurred, of which one case (7.1%) experienced spontaneous extrusion of the implant, three cases (21.4%) required tectonic penetrating keratoplasty, and three patients underwent lamellar keratoplasty on top of the implant. Three cases (21.4%) of retroprosthetic membrane were observed and successfully managed. One patient (7.1%) developed late endophthalmitis. Alphacor is an alternative to corneal allograft in cases of corneal blindness at high risk of allograft failure. Throughout the preoperative evaluation, it is imperative to take into account the limitations of this keratoprosthesis in terms of indications, and additional studies are necessary in order to determine and refine the optimal surgical technique for implantation as well as the efficacy of postoperative treatments.

Collagen cross-linking for resistant corneal ulcer

Corneal ulcer is a devastating corneal disease which is potentially sight-threatening and conventionally is treated by topical antibiotics and in some cases with more invasive procedures such as keratoplasty. The aim of this study is to evaluate the efficacy of corneal collagen cross-linking in resistant corneal ulcers. Ten patients with resistant infectious corneal ulcers who had not responded properly to maximal treatment with topical and subconjunctival antibiotics were enrolled in the study and underwent classic corneal collagen cross-linking with riboflavin and UV-A under sterile conditions in the operating room and were followed up regularly. The result was healing and scar formation with improvement of vision in all patients except for two who underwent enucleation and tectonic penetrating keratoplasty. Corneal collagen cross-linking is a viable therapeutic option for treatment of corneal ulcers and can be used as an adjuvant for conventional treatment in resistant cases.

A Case of Fungal Keratitis Secondary to Cylindrocarpon Destructans

Purpose: To report the first human case of fungal keratitis caused by Cylindrocarpon destructans and to highlight the issues with the use of topical steroids, the duration of antifungal treatment and the potential role of topical ciclosporin. Methods: A patient presented following being injured in the left eye by a fuchsia plant. Data was collected by slit lamp examination and review of the case notes and microbiology reports. Results: No organisms were cultured from a corneal scrape however cultures from a corneal biopsy identified cylindrocarpon species morphologically resembling Cylindrocarpon destructans. The patient responded well to topical amphotericin and clotrimazole and oral voriconazole but, developed a corneal perforation, which required an urgent tectonic penetrating keratoplasty (PKP). Despite being on topical dexamethasone and natamycin, the patient presented two months post-operatively with a corneal epithelial defect and a large hypopyon. Subsequently, the patient developed a deep corneal infiltrate and corneal vascularisation with a persistent epithelial defect. Conclusion: This is the first reported case of keratitis caused by Cylindrocarpon destructans. The case highlights: the contentious issues in the use of topical steroids following PKP and the duration of antifungal treatment both in primary infection and following PKP. Furthermore, the case accentuates a potential role for ciclosporin as an alternative to steroids following PKP.

Anterior segment OCT imaging in opaque grafts with secondary glaucoma following tectonic penetrating keratoplasty for perforated corneal ulcers

Anterior segment OCT imaging in opaque grafts with secondary glaucoma following tectonic penetrating keratoplasty for perforated corneal ulcers

Spontaneous corneal melting during pregnancy: a case report

IntroductionBiomechanical changes in the cornea during pregnancy might lead to pathological conditions such as corneal perforation or melting.Case presentationA 33-year-old Asian female who underwent penetrating keratoplasty in both eyes developed corneal melting in the right eye and marginal keratitis in the left eye in her fifth month of pregnancy. Marginal keratitis in the left eye immediately subsided with topical steroid therapy. However, spontaneous corneal melting progressed in the right eye, despite oral steroid therapy and amniotic membrane transplantation. We performed tectonic penetrating keratoplasty and corneoscleral grafting in the right eye.ConclusionWe advise caution in the ophthalmologic care of pregnant patients who have preexisting corneal thinning disorders or who have undergone multiple corneal surgeries, because physiologic changes during pregnancy might contribute to corneal changes leading to spontaneous melting especially in patients with compromised cornea.