Patch Transplant in Corneal Perforations: Time, Method, and Cause.

OBJECTIVES: We present demographic data and clinical features of corneal perforations repaired with patch grafts prepared from residual donor corneal rims. MATERIALS AND METHODS: For this retrospective study, we evaluated patients who underwent corneal perforation repair with corneal or corneoscleral patch grafts. We recorded demographic data, as well as perforation cause, examination notes, tissue type-size used, follow-up time, and additional surgeries. Anterior segment photographs were also evaluated. Transplanted tissues were prepared from residual donor corneas used in penetrating keratoplasty and were manually adjusted to the precise size of the wound. RESULTS: Fifteen patients were enrolled in the study. Mean age of the patients was 64.9 ± 19.7 years (range, 15-81 years) with a female-to-male ratio of 0.85. The causes of perforation were grouped as inflammation, infection, and trauma. The main indications were inflammation (n = 7; 46.7%) and infection (n = 6; 40%), followed by trauma (n = 2; 13.3%). All patients demonstrated preservation of globe integrity during the follow-up time; however, 1 patient's eye required regrafting with limbal conjunctival excision due to melting and leakage. Three eyes required permanent tarsorrhaphy to control progressive exposure keratopathy, and 2 eyes underwent penetrating keratoplasty to cure scar-related corneal opacity. CONCLUSIONS: Patch grafts are effective surgical interventions to assure and maintain globe integrity in corneal perforations. The main advantage seems to be that patch grafting allows special preparations for wound architecture. Moreover, in clinics performing keratoplasty, these patch tissues are readily available.

Development of an in-situ forming collagen-based hydrogel as a regenerative bioadhesive for corneal perforations.

Corneal injuries play a significant role in global visual impairment, underscoring the demand for innovative biomaterials with specific attributes such as adhesion, cohesion, and regenerative potential. In this study, we have developed a biocompatible bioadhesive for corneal reconstruction. Derived from Collagen type I, naturally present in human corneal stromal tissue, the bioadhesive was cross-linked with modified polyethylene glycol diacrylate (PEGDA-DOPA), rendering it curable through visible light exposure and exhibiting superior adhesion to biological tissues even in wet conditions. The physicochemical characteristics of the proposed bioadhesive were customized by manipulating the concentration of its precursor polymers and adjusting the duration of photocrosslinking. To identify the optimal sample with maximum adhesion, mechanical strength, and biocompatibility, characterization tests were conducted. The optimal specimen, consisting of 30 % (w/v) PEGDA-DOPA and cured with visible light for 5 min, exhibited commendable adhesive strength of 783.6 kPa and shear strength of 53.7 kPa, surpassing that of commercialized eye adhesives.Additionally, biocompatibility test results indicated a notably high survival rate (>100 %) of keratocytes seeded on the hydrogel adhesive after 7 days of incubation. Consequently, this designed bioadhesive, characterized by high adhesion strength, robust mechanical strength, and excellent biocompatibility, is anticipated to enhance the spontaneous repair process of damaged corneal stromal tissue.

The incidence of severe complications in acanthamoeba keratitis: Qualitative and quantitative systematic assessment.

Acanthamoeba keratitis (AK) is a rare, sight-threating corneal infection. The disease is challenging to diagnose and treat, and the amoeba can rapidly encyst, persisting in the tissue and causing recurrences. Medical therapy is conventionally considered the first line treatment, but advanced cases could require more invasive treatments like a "chaud" corneal transplant. We review the incidence of severe complications in patients affected by AK. Of 439 reports screened, 158 met our inclusion criteria. Incidence of severe complications was low, with 2.21 % patients developing perforation, 1 % requiring evisceration/enucleation and less than 1 % developing endophthalmitis. Corneal transplantation was required in 16.68 % of the cases. According to our results, and considering the reported incidences of these complications in other infectious keratitis, AK patients have an overall low risk of developing perforation, endophthalmitis, and enucleation/evisceration. Nevertheless, data available in the literature remain poor, and further randomized control trials are needed to confirm our findings.

NSAID-induced corneal melt as the first presentation of Sjögren's syndrome.

A non-diabetic woman in her 80s presented 1 week following uncomplicated left eye cataract surgery complaining of decreased vision, gritty sensation and photophobia in the same eye. Postoperative treatment included G. Acular (Ketorolac Tromethamine 0.5%, NSAID: non-steroidal anti-inflammatory drug) and G. Tobradex (Tobramycin 0.3% and Dexamethasone 0.1%, antibiotic and steroid, respectively) each prescribed four times a day for 2 weeks. On examination, the patient had a corneal epithelial defect which progressed to a full-thickness perforation despite ceasing the NSAID drops. Cyanoacrylate glue application with a plastic drape patch failed to seal the perforation, and a full-thickness tectonic corneal transplant was performed. On investigation, the patient had positive anti-RO and anti-LA antibodies, suggesting a diagnosis of Sjögren's syndrome. We advocate for careful preoperative assessment prior to cataract surgery, patient education, close follow-up and cautious medication use postoperatively including avoiding NSAID drops in patients with risk factors for postoperative dry eye disease.

Secondary bacterial corneal infection caused by Myroides species in primary fungal keratitis.

A middle-aged male patient presented with a central corneal perforation in a deep stromal infiltrate in his left eye. An emergency therapeutic penetrating keratoplasty was performed. Microbiological evaluation of the corneal scraping specimen revealed septate fungal filaments on stains. However, culture reports after 24 hours from the scraping sample and the excised half corneal button showed growth of gram-negative bacilli. This pathogen was identified as an aerobic, non-fermentative, gram-negative, bacillus by conventional microbiology and confirmed as Myroides species by the VITEK 2 Compact system (bioMérieux, Marcy l'Etoile, France). Susceptibility to chloramphenicol was noted based on which the patient was treated with topical chloramphenicol 0.5%. No recurrence of the infection was noted. This is the first reported case of corneal infection with the Myroides species of bacteria which, heretofore, have been known to cause endocarditis and urinary tract infections.

Interface fluid syndrome caused by the corneal perforation injury after small incision lenticule extraction: a case report.

BACKGROUND: To report a case of interface fluid syndrome (IFS) following traumatic corneal perforation repair after small incision lenticule extraction (SMILE). CASE PRESENTATION: A 23-year-old woman, with a past history of SMILE, was struck in the left eye with a barbecue prod and subsequently underwent corneal perforation repair at local hospital. Primary wound repaired with a single 10 - 0 nylon suture at the area of leakage. After the surgery, her best corrected visual acuity (BCVA) was 20/30. Four days later, she presented at our hospital with blurred vision, and interface fluid syndrome (IFS) was diagnosed. Intraoperative optical coherence tomography (iOCT) was used to guide the resuturing of the corneal perforation in the left eye, followed by anterior chamber gas injection. At the first postoperative month, the BCVA was 20/25. The corneal cap adhered closely to the stroma, the surface became smooth. CONCLUSIONS: This case illustrates that any corneal perforation following lamellar surgery, including SMILE, may lead to IFS. It is crucial to consider the depth of corneal perforation, and intraoperative optical coherence tomography (iOCT) plays a unique role in the repair procedure.

Wet bio-amniotic membrane plugging combined with transplantation in the treatment of small corneal perforations.

PURPOSE: Wet bio-amniotic membrane plugging combined with transplantation is a novel option that combined amniotic membrane plugging with amniotic membrane transplantation for the treatment of small corneal perforations. This study aimed to evaluate the efficacy of wet bio-amniotic membrane plugging in the treatment of small corneal perforations and compared it with that of the penetrating keratoplasty procedure. METHODS: Forty patients (41 eyes) with small corneal perforations <3 mm in diameter treated at our hospital between July 2018 and January 2021 were retrospectively included. Among them, 21 eyes were treated with wet bio-amniotic membrane plugging (wet bio-amniotic membrane plugging group), and 20 eyes were treated with penetrating keratoplasty procedure (penetrating keratoplasty procedure group). The best-corrected visual acuity, anterior chamber formation, corneal thickness, primary disease control, postoperative complications, and graft survival rate were assessed. RESULTS: No significant difference in baseline characteristics was found between the wet bio-amniotic membrane plugging and penetrating keratoplasty procedure groups (p>0.05). The postoperative control rates of primary diseases in the wet bio-amniotic membrane plugging and penetrating keratoplasty procedure groups were 95.2% and 90.0%, respectively (p=0.481). Visual acuity was improved 6 months after the operation in the wet bio-amniotic membrane plugging group and was improved at postoperative 1 month in the penetrating keratoplasty procedure group. The formation time of the anterior chamber in the wet bio-amniotic membrane plugging group was significantly shorter than that in the penetrating keratoplasty procedure group (p=0.023). The corneal thickness of the two groups significantly increased 12 months after the operation; however, the degree of thickening in the penetrating keratoplasty procedure group was higher than that in the wet bio-amniotic membrane plugging group (p<0.001). During the follow-up, postoperative complications were not different between the two groups (p>0.999). CONCLUSION: The results suggest that wet bio-amniotic membrane plugging is effective and safe in the treatment of small corneal perforations. Thus, it can be used as an emergency treatment alternative to penetrating keratoplasty procedure for small corneal perforations.

Corneal Plug Keratoplasty for the Treatment of Small Corneal Perforation.

This case report describes the performance of corneal plug keratoplasty in a male patient aged 30 years who presented with corneal perforation secondary to metal foreign body.

Severe Corneal Damage After Minor Eyelid Surgery: A Case Series.

OBJECTIVES: To present three cases of serious corneal complications after seemingly minor and uncomplicated eyelid surgery. METHODS: These cases emphasize the real-world risk of corneal damage after oculoplastic surgery. RESULTS: The first case is a 46-year-old man referred to our department with a corneal perforation after bilateral blepharoplasty of both upper and lower eyelids. The second case concerns a 51-year-old woman who suffered an accidental coagulation of the cornea during the removal of upper eyelid papillomas, and the third case is a 55-year-old woman who had severe corneal thinning accompanied by visual loss after an upper lid blepharoplasty. All patients were stabilized without the need for corneal transplantation, although there were significant corneal scars and sequelae. CONCLUSIONS: Although complications after esthetic oculoplastic surgery are rare, the reported cases show that corneal damage can have a major impact on the patient's vision and quality of life. Strategies such as the use of a corneal shield can be used to mitigate these risks, but their use is debated. Nevertheless, diligent postoperative care is paramount. At the first postoperative visit, a basic visual acuity measurement should be performed. In cases where reduced vision is reported, particularly when accompanied by pain, patients should be urgently referred for specialized eye care.

Patch endothelial keratoplasty for corneal perforations secondary to ocular surface disease: case series.

BACKGROUND: Corneal perforation is an ophthalmic emergency. The conventional management of corneal perforation can be associated with severe complications especially in patients with ocular surface disease. Endothelial keratoplasty has been suggested as an alternative surgical technique for the management of corneal perforations. We present a case series of nine patients with corneal perforation and ocular surface disease managed with secondary patch endothelial keratoplasty. METHODS: This is a retrospective case series of nine patch endothelial keratoplasties performed between 2016 and 2022 at a quaternary eye hospital in Australia. The surgical technique is similar to conventional endothelial keratoplasty except descemetorhexis was not performed. RESULTS: A total of 9 cases were treated during the review period. Eight of the nine cases had an improvement in visual acuity. One case failed to achieve corneal tectonic objective. CONCLUSION: Patch endothelial keratoplasty is a safe secondary procedure for the management of corneal perforations in patients with ocular surface disease.

Photocurable and Temperature-Sensitive Bioadhesive Hydrogels for Sutureless Sealing of Full-Thickness Corneal Wounds.

Penetrating corneal wounds can cause severe vision impairment and require prompt intervention to restore globe integrity and minimize the risk of infection. Tissue adhesives have emerged as a promising alternative to suturing for mitigating postoperative complications. However, conventional water-soluble adhesives suffer formidable challenges in sealing penetrating corneal wounds due to dilution or loss in a moist environment. Inspired by the robust adhesion of mussels in aquatic conditions, an injectable photocurable bioadhesive hydrogel (referred to as F20HD5) composed of polyether F127 diacrylate and dopamine-modified hyaluronic acid methacrylate is developed for sutureless closure of corneal full-thickness wounds. F20HD5 exhibits high transparency, wound-sealing ability, proper viscosity, biodegradability, and excellent biocompatibility. It allows in situ cross-linking via visible light, thereby providing sufficient mechanical strength and adhesiveness. In vivo, the adhesive hydrogel effectively closed penetrating linear corneal incisions and corneal injuries with minimal tissue loss in rabbits. During the 56-day follow-up, the hydrogel facilitates the repair of the injured corneas, resulting in more symmetrical curvatures and less scarring in distinction to the untreated control. Thus, bioinspired hydrogel holds promise as an effective adhesive for sealing full-thickness corneal wounds.

Customized therapeutic deep anterior lamellar keratoplasty in perforated Mooren's ulcer: A novel technique.

We describe customized therapeutic deep anterior lamellar keratoplasty (DALK) for treating a perforated Mooren's ulcer. Slit-lamp biomicroscopy revealed corneal perforation (3.5 mm × 3.0 mm) with iris prolapse. The corneal melt extended from 9.0 o'clock to 4.0 o'clock. The peripheral edge of the ulcer was sloping, whereas the medial edge showed undermining. Immunological tests did not reveal any evidence of systemic autoimmune disease. In view of extensive peripheral corneal melt with large corneal perforation, the patient needed tectonic keratoplasty. The penetrating graft is not only technically demanding but also results in a poor visual outcome. We advised customized tectonic DALK. We used two different-sized trephines to obtain appropriate-sized donor tissue and avoided manual dissection. The post-surgery period was uneventful. He was prescribed topical steroids and oral methotrexate. He achieved 6/9 aided visual acuity at 4 months and maintained it until the last follow-up at 36 months.

Proportion and characteristics of lacrimal drainage pathway disease and keratopathy in non-infectious corneal perforation using lacrimal syringing test.

Lacrimal drainage pathway disease-associated keratopathy (LDAK) has been associated with corneal perforation, which arises from both infectious and non-infectious corneal disorders. However, patients with corneal perforation are often not routinely tested for LDAK, and the potential risk posed by LDAK in the development of corneal ulcers has not been investigated in detail. This study aimed to assess the proportion and characteristics of LDAK in patients with non-infectious corneal perforation using lacrimal syringing test. This study enrolled 56 patients with corneal perforation treated at Saitama Medical University Hospital between January 2016 and September 2022. The causes of corneal perforation were trauma (n = 17, 30%), infection (n = 19, 34%), non-infection (n = 16, 29%), and unknown (n = 4, 7%). A lacrimal syringing test was performed on 12 patients with non-infectious corneal perforation and 4 with an unknown diagnosis. Among the 16 patients with non-infectious corneal perforation, 13 (81%) had lacrimal drainage disease, but only 3 (19%) patients had lacrimal puncta, as revealed by slit-lamp examinations. The primary bacterial species identified in lacrimal obstructive disease and lacrimal canaliculitis were Staphylococcus spp. and Actinomycetes spp. respectively. Lower temporal and peripheral corneal perforations were common. All patients underwent lacrimal surgery, and 6 (38%) were treated for corneal perforation without corneal surgery. Interestingly, several patients with LDAK who did not exhibit any lacrimal duct obstruction on slit-lamp examination. The study findings demonstrate the significance of the lacrimal syringing test for assessing LDAK in patients with corneal perforation, indicating LDAK as a potential cause of corneal perforation.

DALK combined intralamellar tectonic patch graft: an alternative approach to treat frank corneal perforation.

BACKGROUND: Deep anterior lamellar keratoplasty (DALK) has gained popularity in cases of corneal thinning and leaking descemetocele. In this study, we introduced an intralamellar tectonic patch graft in addition to conventional DALK procedures to treat frank cornea perforation. METHODS: This retrospective case series included 13 patients (13 eyes) with frank corneal perforations who underwent DALK combined with intralamellar tectonic patch graft between December 2015 and December 2021. In addition to the standard DALK procedure, the perforation site was repaired with an extra intralamellar tectonic patch graft. The collected data included patient demographics, aetiology, size and location of the corneal perforation, visual acuity, surgical details, and postoperative complications. RESULTS: Seven patients underwent autologous intralamellar patch grafts, whereas six received allogeneic ones. Anatomical success was achieved in all patients. The mean postoperative follow-up was 33.31 ± 25.96 months (6-73 months). The postoperative visual acuity (0.90 ± 0.65 logMAR) was significantly improved (P = 0.003) compared to the preoperative score (1.74 ± 0.83 logMAR). Best corrected visual acuity (BCVA) improved in 12 eyes (92.3%). The mean endothelial cell density was 2028 ± 463 cells/mm2, 6-12 months postoperatively. There was no recurrence of perforation, and the anterior lamellar graft remained transparent in 12 patients (92.3%). Postoperative complications included epithelial defects (23.1%), ocular hypertension (15.4%), and cataract (7.7%). CONCLUSIONS: DALK combined with intralamellar tectonic patch graft may serve as a secure and effective alternative in treating frank corneal perforation, with reduced complications compared to conventional penetrating keratoplasty.

Corneal Perforation in a Patient Treated with Atezolizumab-Bevacizumab Combination Therapy for Unresectable Hepatocellular Carcinoma.

BACKGROUND Immune checkpoint inhibitors (ICIs) targeting the programmed cell death protein 1 (PD-1), or its ligand PD-L1, are the mainstay treatment for several metastatic malignant conditions. ICIs are associated with multiple toxic adverse events affecting various organs, known collectively as immune-related adverse events (irAEs). Dry eye, uveitis, ocular myasthenia, and cicatrizing conjunctivitis are well-recognized ocular irAEs associated with ICIs. CASE REPORT We present a case of 69-year-old man who presented with paracentral, punch-out corneal perforation in the left eye, associated with bilateral severe ocular surface disease 3 weeks after receiving the second dose of atezolizumab-bevacizumab combination therapy for the treatment of unresectable hepatocellular carcinoma. Corneal gluing using cyanoacrylate glue was performed along with bandage contact lens application and temporary tarsorrhaphy to seal the corneal perforation and improve the ocular surface. On the subsequent follow-ups, the corneal glue was unstable and dislodged. Thus, penetrating keratoplasty was performed to salvage the globe along with holding the combination therapy. At the 8-month follow-up, the graft remained clear, and the ocular surface improved substantially in both eyes. CONCLUSIONS Ocular irAEs associated with immune-modulating agents can lead to vision-threatening complications. Therefore, communications between oncologists and ophthalmologists in a multidisciplinary team would be of utmost importance for early detection and timely management of any ocular-related adverse events associated with the use of immunotherapy agents.

Pterygium combined with corneal perforation: a case report.

BACKGROUND: Pterygium is a common ocular surface disease. Pterygium combined with corneal perforation is rare. CASE PRESENTATION: A 28-year-old female patient visited our outpatient clinic due to sudden onset of blurred vision and increased tearing in her left eye. The visual acuity was 1.0 OD and intraocular pressure (IOP) of 19.5 mmHg for the right eye with no significant abnormalities found in the anterior and posterior segments. The visual acuity of her left eye was 0.06, and IOP was 6.2 mmHg. A triangular vascular membranous tissue was seen in her left eye below the nose growing into the cornea and the pupil area was not touched. Slit-lamp examination revealed a tiny round corneal perforation in 8 o'clock position of the lesion area. Hospital diagnosis was given as pterygium combined with corneal perforation. The patient was treated with levofloxacin eye drops and autologous serum-based eye drops. CONCLUSIONS: We report a rare case of pterygium combined with corneal perforation. Perforation is a very rare complication of pterygium. This patient received proper treatment and good result was seen. This article aimed to improve clinicians' understanding of pterygium.