P-17 Tri-lamellar mini-DSEK for repair of intractable corneal perforations

Introduction- Amniotic membrane is the innermost layer of placenta. It has unique properties like facilitation of epithelial cell migration, the reinforcement of basal cell adhesion and the differentiation of epithelial cells which provides modulation of stromal scarring.It also has anti-inflammatory and anti-bacterial activity.Such properties make it ideal for ocular surface reconstruction. Material And Methods- A study of 61 patients with ocular surface diseases who received treatment with amniotic membrane transplantation were classified in 4 groups according to indications as follow group A- chemical injuries :24 patients,group B- non healing corneal ulcers :15 patients,group C- non traumatic corneal perforations : 10 patients,group D – conjunctival reconstruction : 12.All patients were followed up till 3 months post operatively. Results -In most of the cases of amniotic membrane transplantation, the corneal surface showed a complete and stable epithelialisation within a few weeks. Out of 61 patients, 5 patients from group A required repeat surgery, 3 patients from group B developed corneal perforation and 2 patients from group C underwent tectonic penetrating keratoplasty for re-perforation. Conclusions-Amniotic membrane transplantation can effectively reduce the inflammation of the cornea at the acute stage of burn injury,can prevent corneal ulcer and perforation and can make the stabilization process faster.It can also decrease corneal neovascularization as well as establish better conditions for successful keratoplasty.

Background: Corneal perforation is a leading cause of ocular morbidity around the world. It may occur due to trauma to the eye, keratitis, and many other conditions. Any corneal perforation should be treated immediately and promptly to avoid complications and subsequently corneal blindness.Objective: To describe effectiveness of using autologous Tenon’s tissue along with bandage contact lens to manage corneal perforations less than 3 mm in size.Methods: Tenon’s patch graft was done in five cases of corneal perforation. Informed consent was obtained from the subjects after explanation of the nature and possible consequences of the study and this study was approved by ethical committee.Results: Of the five patients the first patient she showed good integration of the Tenon’s Patch Graft (TPG). She had a vision of Perception of Light+ and accurate projection of rays after a period of 5 months post procedure. The wound healed with a glaucomatous scar. Case two had a vision of counting fingers close to face after five months. Case three showed good integration of the TPG. He had a vision of 6/60 accurate after a period of three months post procedure. In case four anterior chamber was shallow, post patch integrity was not maintained. Patient was later considered for penetrating keratoplasty. Case five showed integration of TPG after one week postop with vision counting fingers at 6 meters.Conclusion: We conclude that Tenon's Patch Graft with bandage contact lens is an effective technique in the treatment of corneal perforations. Using this, the integrity of the eyeball can be maintained without any danger of graft rejection since the tissue is autologous. This technique can be used effectively in places where resources are scant.

Objective To evaluate the clinical effectiveness of application of lamellar keratectomy combined with multilayer amniotic membrane transplantation and bandage contact lens, systemic antiviral and topical corticosteroid therapy to eyes with necrotizing HSK. Methods Data were retrospectively analyzed of 15 patients (15 eyes) with necrotizing HSK that could not heal or aggravated after 7 days of antiviral therapy. Lamellar keratectomy combined with multilayer amniotic membrane transplantation and bandage contact lens wear with local corticosteroid eye drops and systemic antiviral medications were performed on the eyes; follow up was at least 6 months for postoperative cornea. Results Fourteen eyes achieved inflammation remission within 7 to 30 days. Corneal epithelium healing time under bandage contact lens was within 7 and 21 days. Vision was improved. Numbers of eyes with corneal haze grading as 1, 2 and 3 were 2, 7 and 5 in each group respectively. No other complications were observed except thinning of cornea and keratectasia in 1 eye. Enucleation was performed in 1 eye that had corneal self-resolution and perforation combined with retinal detachment. Conclusions In this observational study, early lamellar keratectomy combined with multilayer amniotic membrane transplantation and bandage contact lens, systemic antiviral and topical corticosteroid therapy to eyes with necrotizing HSK may preserve the intact eye and effective vision, in addition it avoids corneal transplantation at all or at least delayed corneal transplantation during the acute phase of inflammation. Key words: Lamellar keratectomy; Bandage contact lens; Amniotic membrane transplantation; HSK

Rationale:Ocular cicatricial pemphigoid (OCP) is a potentially blinding, rare systemic autoimmune disease. The definite etiology of OCP remains under debate, early diagnosis is important to prevent rapid deterioration. The majority of the discussion has been focused on its medical therapeutic strategy, while little effort has been made to study the role of amniotic membrane transplantation (AMT). We describe the first case of OCP with minimal immunosuppressant and initial ocular surface reconstruction procedure using double layer AMT.Patient concerns:A 66-year-old female patient presented to our outpatient department with right eye pain for several days.Diagnosis:Slit lamp examination revealed the right eye cornea perforation with iris incarceration and total collapse of anterior chamber. Symblepharon formation and severe fornix shortening was also noted. While bulbi phthisis with ankyloblepharon and ocular surface keratinization was observed in the left eye. The final diagnosis was right eye stage III ocular cicatricial pemphigoid complicated with corneal perforation and iris prolapsed.Interventions:The patient underwent ocular surface reconstruction with the aid of amniotic membrane. The first layer of the amniotic membrane was attached with tissue adhesive and fibrin glue while the second layer amniotic membrane came with a conformer ring which supported the fornix space that was recreated. Postoperative care included topical medications for inflammation alleviation. Systemic immunosuppressive agents were not administered except for oral prednisolone.Outcomes:No recurrence of symblepharon was noted during the one year follow-up.Lessons:We aim at highlighting the possible important role of AMT in advance OCP. Further investigation is still needed for providing evidence to incorporate the procedure into treatment protocol.

The Effect of a Novel Strategy in Treating Primary Pterygium: A Prospective Randomized Clinical Study

AIMSTo evaluate the efficacy of amniotic membrane transplantation (AMT) in persistent corneal epithelial defect with or without stromal thinning and corneal perforation.METHODS28 patients (28 eyes) with persistent corneal epithelial defect...

Comparison of Amniotic Membrane Transplantation and Umbilical Cord Serum in Acute Ocular Chemical Burns: A Randomized Controlled Trial

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

The present study reports the case of a superficial limbal dermoid surgically treated without suture by using a new technique of lamellar keratoplasty with allogenic lenticule from small incision lenticule extraction. The limbal lesion area was circumscribed by a trephine marker and lamellae were peeled off the anterior corneal stroma and sclera. After excision of the dermoid, the liquid on the bed was dried as much as possible and an appropriate stromal lenticule was attached to the implant bed without fibrin glue or suture. A bandage contact lens was applied to fix the graft. During postoperative follow-ups, the anterior segment optical coherence tomography, corneal refractive power, corneal topography and best-corrected visual acuity were examined to evaluate the surgical results. On the first day after the operation, the patient reported tearing and pain at the site. At one week after the operation, the patient reported no discomfort and conjunctival sutures were removed. At one month after the operation, the thickness of the lesion area was similar to that of the adjacent cornea, and the corneal curvature and refractive power of the lesion area were higher than that of the adjacent cornea. At three months after the operation, the patient was satisfied with the cosmetic outcome and no sign of corneal neovascularization, graft rejection or pseudo-pterygium formation was observed. The astigmatic error remained at 2.50 D. The present case provides insights into a potential treatment option for patients who need lamellar keratoplasty and may provide its benefit in contrast to conventional lamellar keratoplasty.

Purpose :To present complications of using fibrin glue in conjunctival-limbal autografting in pterygiumsurgeries other than recurrences and discuss their prevention and management strategies.Materials and Methodology:The charts of all patients who underwent fibrin glue assisted pterygium excision surgery withconjunctival-limbal autograft transplantation from 2010 to 2013 were reviewed. Patients who developed complicationsexcept recurrence postoperatively were included in this study.Results :Sixteen (17.39%) of the 92 patients were detected with a complication. Graft dehiscence was diagnosed in 7(7.6%) patients with 5 of them treated conservatively and 2 patients requiring suturing. Five (5.43%) patients werediagnosed with cyst formation between the graft and conjunctiva or in the graft-removal area; these cysts were primarilyexcised and no additional problems occurred. Corneal dellen developed in 3 (3.26%) patients and 2 of them regressedafter cessation of topical steroids and application of lubricant therapy while one was treated with amniotic membranetransplantation. Residual fibrin glue particles had stiffened on the ocular surface, which resulted in intensive pain andirritation in one (1.08%) patient on the same day of the surgery. The patient’s complaints were reduced by removing theseparticles from the ocular surface under topical anesthesia.Conclusion :Complications in fibrin glue assisted pterygium surgery are relatively different from other techniques. Toavoid potential complications of fibrin glue in pterygium surgery, peroperatively ophthalmologists should ensure theconjunctival autograft and conjunctiva are properly adhered, fibrin glue remnants are completely removed from the ocularsurface, and no Tenon’s capsule remains between the graft and the conjunctiva.

To describe a technique to manage corneal perforations between 3 and 6 mm in size using autologous Tenons tissue with cyanoacrylate glue and a bandage contact lens. A thin layer of Tenons capsule harvested from the patient's own eye is used to seal the perforation and act as a scaffold. The Tenons patch graft is spread over the perforation and held in place by the application of cyanoacrylate glue. A bandage contact lens is then placed on the eye. A 6-year retrospective review of 28 patients who underwent this procedure was performed. One patient was lost to follow-up. Of the 27 patients who were followed up, 20 healed completely, with an adherent leucoma and preservation of the anterior chamber. The condition of one patient (with a perforated Pseudomonas corneal ulcer) progressively worsened despite maximum medical therapy and had to undergo evisceration. This procedure makes use of easily available autologous Tenons tissue in patients with corneal perforations too large to be managed with cyanoacrylate glue alone, to preserve eyeball morphology. A corneal transplant can then be done when the cornea has healed.

Background Fungal keratitis is an extremely rare complication of laser vision correction resulting in poor visual outcomes. Amniotic membrane transplantation should be kept in mind in eyes with corneal perforation prior to penetrating keratoplasty. Aim To assess the outcomes of multilayered fresh amniotic membrane transplantation (MLF-AMT) in patients with severe keratomycosis after laser-assisted in situ keratomileusis (LASIK). Study design. Hospital-based prospective interventional case series. Methods Five eyes of 5 patients were included in the study. All cases underwent microbiological scrapings from residual bed and intrastromal injections of amphotericin (50 mcg/mL), with flap amputation if needed, followed by topical 5% natamycin and 0.15% amphotericin. MLF-AMT was performed after corneal perforation. Later, penetrating keratoplasty (PK) was performed when corneal opacity compromised visual acuity. The outcome measures were complete resolution of infection, corneal graft survival, and best-corrected visual acuity (BCVA). Results The mean age of patients was 22 ± 1.2 years with 4/5 (80%) were females. The mean interval between LASIK and symptom onset was 8.8 ± 1 day, and the mean interval between symptom onset and referral was 14 ± 1.4 days. Potassium hydroxide (KOH) smears showed filamentous fungi, and Sabouraud's medium grew Aspergillus in all cases. Melted flaps were amputated in 4 (80%) cases. MLF-AMT was performed in all cases due to corneal perforation after a mean time of 12.4 ± 1.2 days of antifungals. In all cases, complete resolution of infection was seen 26 ± 1.8 days after MLF-AMT, and optical PK was done at a mean of 2.4 months later. No postoperative complications after MLF-AMT or PK were observed, with a 0% incidence of corneal graft rejection, and a final BCVA ranged from 20/20 to 20/80 after a mean follow-up of 14 ± 1.1 months. Conclusion MLF-AMT is a safe and valid option to manage corneal perforation during keratmycosis treatment to avoid emergency therapeutic keratoplasty.

PurposeCongenital aniridia is a challenge not only for the corneal surgeon. Persisting epithelial defects, suture loosening, and an increased risk of graft rejection are typical postoperative complications in high risk keratoplasty such as in congenital aniridia.MethodsBetween 2012 and 2018, 20 keratoplasties were performed in 13 patients with congenital aniridia at our Department. Visual acuity and intraocular pressure before and after keratoplasty, corneal graft size, suture technique (interrupted or double running), use of amniotic membrane transplantation and serum eye drops, size of bandage contact lens as well as morphological and functional status during follow‐up were analysed retrospectively.ResultsSix keratoplasties were performed using continuous double running suture, 14 using interrupted sutures. Amnion membrane transplantation as a patch with a 17 mm bandage contact lens was applied 18 times to promote postoperative corneal wound healing. In 10 cases, a simultaneous temporary lateral tarsorrhaphy was performed to support corneal wound closure. All patients received systemic immunosuppression. Visual acuity improved in 14 eyes at 6 months follow‐up, in 6 eyes visual acuity remained stable, no eye showed a decrease in visual acuity.ConclusionsKeratoplasty in congenital aniridia must be considered a high risk keratoplasty. A modified keratoplasty scheme combining a small corneal graft size, interrupted sutures, simultaneous AMT Patch, large bandage contact lens, temporary lateral tarsorrhaphy, postoperative autologous serum eye drops, and systemic immunosuppression seems to be appropriate to reduce the postoperative complication rate in these most difficult eyes.

The aim of this study was to report a case of sterile corneal ulcer leading to perforation, which was treated effectively with autologous serum eye drops, topical regenerative agent (poly-carboxymethylglucose sulfate), steroids, and systemic immunosuppression in a patient with undiagnosed primary Sjögren's syndrome. A 74-year-old female presented with a month's history of gradually worsening blurry vision in her left eye. Ophthalmic examination revealed a central descemetocele with excessive corneal stromal melting and absence of signs of infection. A bandage contact lens was applied for tectonic support along with topical corticosteroid and antibiotic drops. Autoimmune screen disclosed a diagnosis of Sjögren's syndrome, and the patient was commenced on systemic immunosuppression. Forty-eight hours after presentation, the patient developed a localized corneal perforation, presenting with a flat anterior chamber. Urgent amniotic membrane transplantation was arranged while topical dexamethasone, moxifloxacin, and autologous serum eye drops were administered. After 24 h of intensive topical treatment, a significant reforming of the anterior chamber and subsequent gradual regeneration of the corneal stroma were noted, thus postponing amniotic grafting. The patient remained under close monitoring, showing progressive clinical improvement. Regenerating agent eye drops (Cacicol20®) were also applied over the next month, with careful and slow tapering of topical dexamethasone. Further improvement of corneal thickness was observed, and visual acuity increased to 20/80. This case report demonstrates the successful medical treatment of an autoimmune-related sterile corneal perforation without surgical intervention, highlighting the fact that early diagnosis and rigorous medical treatment with autologous serum and regenerating agent eye drops can effectively aid tissue regeneration and favorable visual rehabilitation.

Management of Conjunctival Cicatrizing Diseases and Severe Ocular Surface Dysfunction