Modified Split-Thickness Corneal Patch Graft for Conjunctival Erosions in Patients With the Port Delivery System Implant: Surgical Technique and Long-Term Outcomes.

Purpose: To describe the surgical technique and long-term outcomes of a modified split-thickness corneal patch grafting for conjunctival erosions that can be seen in patients with the Port Delivery System (PDS) implant. Methods: By way of retrospective review of medical records, this interventional case series identified 2 cases in which modified split-thickness corneal patch grafting was used to repair conjunctival erosion in patients with the PDS implant. Results: The surgical approach involved creating a small opening in the corneal graft over the center of the PDS implant to improve visibility and allow for easier access during subsequent refill-exchange procedures. At the last follow-up of 6.9 years and 5.6 years, there was no recurrence of conjunctival erosions in either patient. The PDS implants remained well covered with the split-thickness corneal graft and had undergone multiple implant refills without complication or difficulty. Conclusions: Modified split-thickness corneal patch grafting with central graft aperture offers another option for long-term successful management of conjunctival erosions in patients with a PDS, especially those who have failed prior repair, by allowing sufficient visibility and access for subsequent refill-exchange procedures.

Comparison of conjunctiva-related complications between scleral and corneal patch grafts in Ahmed glaucoma valve implantation.

Purpose: Comparison of the conjunctiva related complication rates and success rates among eyes with Ahmed glaucoma valve (AGV) implantation in which eye bank derived scleral and corneal patch grafts had been used to cover the tube. Methods: Retrospective comparative study. Patients who underwent AGV implantation between January 2000 to December 2016 were included. Demographic, clinical data, intra and post operative data was obtained from electronic medical records. Conjunctiva related complications were divided into two groups: with and without implant exposure. Conjunctiva related complication rates, success rate, risk factors among eyes with corneal and scleral patch graft were compared. Results: Three hundred and twenty three eyes of 316 patients underwent AGV implantation. Scleral patch graft was used in 214 eyes of 210 patients (65.9%) and corneal patch graft was used in 109 eyes of 107 patients (34%). Median follow up was 14 months. There was no significant difference in the conjunctiva related complication rate (7.3 % in corneal patch graft versus 7.0% in scleral patch graft;p=0.5) and conjunctival dehiscence rate (3.7% versus 4.6%, P = 0.7) among the two groups. Success rate was significantly higher in the corneal patch graft group versus the scleral patch graft group (98% versus 72%; p=0.001). Eyes with corneal patch graft had a higher survival rate (P = 0.01). Conclusion: There was no significant difference in the rate of conjunctiva related complications following corneal and scleral patch grafts used to cover the AGV tube. Eyes with corneal patch graft had a higher success rate and survival rate.

A "T.E.S.T." hydrogel bioadhesive assisted by corneal cross-linking for in situ sutureless corneal repair.

Corneal transplantation is an effective clinical treatment for corneal diseases, which, however, is limited by donor corneas. It is of great clinical value to develop bioadhesive corneal patches with functions of "Transparency" and "Epithelium & Stroma generation", as well as "Suturelessness" and "Toughness". To simultaneously meet the "T.E.S.T." requirements, a light-curable hydrogel is designed based on methacryloylated gelatin (GelMA), Pluronic F127 diacrylate (F127DA) & Aldehyded Pluronic F127 (AF127) co-assembled bi-functional micelles and collagen type I (COL I), combined with clinically applied corneal cross-linking (CXL) technology for repairing damaged cornea. The patch formed after 5 min of ultraviolet irradiation possesses transparent, highly tough, and strongly bio-adhesive performance. Multiple cross-linking makes the patch withstand deformation near 600% and exhibit a burst pressure larger than 400 mmHg, significantly higher than normal intraocular pressure (10-21 mmHg). Besides, the slower degradation than GelMA-F127DA&AF127 hydrogel without COL I makes hydrogel patch stable on stromal beds in vivo, supporting the regrowth of corneal epithelium and stroma. The hydrogel patch can replace deep corneal stromal defects and well bio-integrate into the corneal tissue in rabbit models within 4 weeks, showing great potential in surgeries for keratoconus and other corneal diseases by combining with CXL.

Tissue Adhesives for the Management of Corneal Perforations and Challenging Corneal Conditions.

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.

Microneedle scleral patch for minimally invasive delivery of triamcinolone to the posterior segment of eye.

The delivery of therapeutics to the posterior segment of the eye is achieved by invasive procedures, including intravitreal injections and implants. The topically applied formulations would not permeate through different tissue barriers of the eye to reach the posterior segment. Here, we demonstrate the effectiveness of microneedle scleral patch in delivering the model molecule, triamcinolone acetonide, to the posterior segment of the eye. Microneedle scleral patch (MSP) and microneedle corneal patch (MCP) were fabricated through the micromolding technique using rapidly dissolvable polyvinylpyrrolidone. The patches containing 25 microneedles were characterized for physical and mechanical properties, drug loading and release behavior in vitro and ex vivo porcine eye globe model. The distribution of TA administered using MSP and MCP in different ocular tissues was evaluated in the rabbit eye model. The results showed that microneedles with 545 ± 8 µm length and 279 ± 26 µm width at the base in MSP penetrate the scleral membrane with the application of 0.35 ± 0.06 N force. The needles dissolved within 60 s after insertion in the corneal and scleral tissue. The 5 min application of MSP showed a significantly (p < 0.05) greater TA disposition in the vitreous humor and choroid-retinal complex in excised porcine eye globe compared with MCP and TA nanosuspension eye drops. In rabbit model studies, the TA concentration was greatest in the choroid-retinal complex and sclera after administration through intravitreal injection and MSP, respectively. The TA disposition in the sclera was significantly (p < 0.05) greater after MSP application compared with intravitreal injection and MCP application for up to 24 h. MSP application provided a greater safety score compared with intravitreal injection. In conclusion, MSP can be developed as a minimally invasive drug delivery system to target the posterior segment of the eye.

Tenon's Patch Graft: A Review of Indications, Surgical Technique, Outcomes and Complications.

PURPOSE: Corneal perforations are common corneal emergencies faced by ophthalmologists across the globe. There are multiple modalities of management, most of which require an eye bank support or availability of tissue adhesives. Tenon's patch graft (TPG) is a technique that does not depend on these factors as the graft is harvested from the same eye of the patient. The aim of this review is to provide an overview of the indications, technique, normal postoperative course, and management of complications. METHODS: After carrying out a literature search on "tenon's capsule", "corneal patch graft", "tenon's patch graft", "multilayered amniotic membrane" and "corneal perforations", 28 articles were included for this review. RESULTS: TPG graft can be performed in cases of small to moderate perforations without active suppuration. The procedure can also be combined with amniotic membrane grafting or tissue adhesives to provide additional tectonic support. Postoperatively, the epithelium heals over a course 2-3 weeks and restoration of a stable ocular surface with a corneal scar is completed by the third postoperative month. Complications following the surgical procedure are rare but can include graft displacement, melt and pseudoectasia. Subsequent visual rehabilitation with contact lenses or keratoplasties can be planned in these eyes that yields good visual outcomes. CONCLUSIONS: Tenon's patch graft is a simple yet viable option in management of small to moderate corneal perforations. The procedure does not necessitate the prior availability of specialized products and can be performed with routine equipment of an ophthalmic theatre, making it an attractive option in low resource settings.

Spontaneous corneal perforation complicating ocular rosacea: Case report.

INTRODUCTION: Ocular rosacea is a multifactorial disease. Its pathophysiology remains unclear. The ocular manifestations of rosacea are not specific and can range from simple blepharoconjunctivitis to sight-threatening such as corneal perforation. CASE REPORT: We report the case of a 10-year-old child who presented with a red painful right eye. Based on the clinical findings, we concluded that she had a corneal perforation on ocular rosacea. She benefited from an ipsilateral lamellar autokeratoplasty by lamellar autograft. The evolution was marked by a good healing and a good visual recovery despite a corneal scar. DISCUSSION: Ocular rosacea is a multifactorial disease, with an unclear physiopathology. Corneal involvement remains the least common, but the most challenging since serious complications can occur. Corneal perforation is the most severe. Several techniques have been reported and used in the management of corneal perforations such as conjunctival flap, amniotic membrane grafting, and the use of a corneal patch. The later, corneal autografting, remains a simple and effective technique with satisfactory anatomical results. CONCLUSION: Ocular rosacea is a pathology that is still poorly understood and of delayed diagnosis. It can lead to serious vision-threatening complications such as corneal perforation. The corneal patch is a simple, effective and efficient technique that has given good results in our case.

Comparison of Locally Sourced Pericardium and Other Conventional Patch Graft Materials in a Glaucoma Drainage Device Surgery.

PURPOSE: Our study aimed to compare the outcomes and costs of various patch graft materials used in the setting of glaucoma drainage device (GDD) surgeries: conventional Tutoplast® pericardium (TP), locally-obtained Lifenet® pericardium (LP), and tissue-banked corneal (CP) and scleral (SP) patches. DESIGN: Retrospective observational study. SUBJECTS: One hundred and ninety-five eyes of 185 patients who underwent glaucoma device surgery with patch grafts were included. MATERIALS AND METHODS: Patient records were reviewed for demographics and surgical data including age at the time of GDD surgery, race, sex, eye, history of diabetes or immunologic disease, glaucoma diagnosis, length of follow-up, pre- and postoperative intraocular pressure (IOP), type and location of GDD, patch type, and tube-related complications. MAIN OUTCOME MEASURES: The primary outcome measures were rates of patch graft-related complications including conjunctival dehiscence with and without tube exposure. Secondary outcome measures were IOP control achieved and cost of patch graft materials. RESULTS: Mean follow-up for all eyes was 17.1 months. Overall, conjunctival dehiscence without tube exposure occurred in four eyes (2.1%); tube exposure was seen in six eyes (3.1%). The mean time to exposure was 3.3 months (range 1-8 months). The rate of tube exposure was 2.3% of eyes with TP grafts, 10.7% of eyes with CP grafts, 2.8% of eyes with SP grafts, and 0% of eyes with LP grafts. There was no significant difference in rates of tube exposure rates by graft material (p = 0.26). Multivariate logistic regression analysis with adjustment for patch type, age, sex, implant type, and location revealed no significant risk factors for tube exposure. Univariate logistic regression was then performed on the same risk factors as well as diabetes, prior and concurrent ocular surgery, and showed no significance. CONCLUSION: Our preliminary, short-term results show that locally sourced patch graft material can be a cost-effective alternative to traditionally used patch grafts without an increase in tube exposure rates. To further determine the efficacy of the different patch graft materials, longer-term comparative prospective trials are needed. Longer prospective studies are needed to compare the long-term safety and rate of tube exposures in these locally obtained patch graft materials. HOW TO CITE THIS ARTICLE: Aggarwal S, Kremer C, Engelhard S, et al. Comparison of Locally Sourced Pericardium and Other Conventional Patch Graft Materials in a Glaucoma Drainage Device Surgery. J Curr Glaucoma Pract 2021;15(1):14-18.

Propolis-Based Nanofiber Patches to Repair Corneal Microbial Keratitis.

In this research, polyvinyl-alcohol (PVA)/gelatin (GEL)/propolis (Ps) biocompatible nanofiber patches were fabricated via electrospinning technique. The controlled release of Propolis, surface wettability behaviors, antimicrobial activities against the S. aureus and P. aeruginosa, and biocompatibility properties with the mesenchymal stem cells (MSCs) were investigated in detail. By adding 0.5, 1, and 3 wt.% GEL into the 13 wt.% PVA, the morphological and mechanical results suggested that 13 wt.% PVA/0.5 wt.% GEL patch can be an ideal matrix for 3 and 5 wt.% propolis addition. Morphological results revealed that the diameters of the electrospun nanofiber patches were increased with GEL (from 290 nm to 400 nm) and Ps addition and crosslinking process cause the formation of thicker nanofibers. The tensile strength and elongation at break enhancement were also determined for 13 wt.% PVA/0.5 wt.% GEL/3 wt.% Ps patch. Propolis was released quickly in the first hour and arrived at a plateau. Cell culture and contact angle results confirmed that the 3 wt.% addition of propolis reinforced mesenchymal stem cell proliferation and wettability properties of the patches. The antimicrobial activity demonstrated that propolis loaded patches had antibacterial activity against the S. aureus, but for P. aeruginosa, more studies should be performed.

A Case Series Demonstrating a Novel Technique for Reversal of Trabeculectomy Using Lamellar Sclerectomy and Corneal Graft.

AIM AND OBJECTIVE: We describe two cases demonstrating a new technique to permanently reverse a problematic trabeculectomy. BACKGROUND: Trabeculectomy-related complications are typically treated in a manner that preserves the initial surgical outcome; however, in certain cases a complete reversal of the trabeculectomy is preferable to revision. TECHNIQUE: Our technique involves seating a lamellar corneal graft into a partial thickness sclerectomy. CONCLUSION: This method achieves permanent closure of large ostomies or areas of scleromalacia. CLINICAL SIGNIFICANCE: This technique can be used on very anterior ostomies while still providing an excellent seal, patient comfort, and cosmesis without inducing astigmatism. HOW TO CITE THIS ARTICLE: Bakhsh SR, Rooney D, Goldman BA, et al. A Case Series Demonstrating a Novel Technique for Reversal of Trabeculectomy Using Lamellar Sclerectomy and Corneal Graft. J Curr Glaucoma Pract 2020;14(2):61-63.

Severe bilateral descemetoceles in Alpha-1 antitrypsin deficiency.

PURPOSE: To report a case of severe bilateral descemetoceles in a patient with alpha-1 antitrypsin (A1AT) deficiency during intensive care unit hospitalization. OBSERVATIONS: A 42-year-old male presented with sub-acute bilateral vision loss during an intensive care unit hospitalization following liver and kidney transplantations. On exam, this patient's best-corrected visual acuity was 20/80 in both eyes. There were bilateral descemetoceles inferotemporally in both eyes with overlying epithelial defects and dense surrounding punctate epithelial staining. The patient was initially treated with gatifloxacin drops and frequent lubricating ointment. Given the concern for impending perforation, cyanoacrylate glue with bandage contact lens was applied to both eyes. His best corrected visual acuity remained unchanged in the right eye and improved to 20/30 in the left eye. Upon medical stabilization, anterior lamellar graft was performed in the right eye, with plans for the same treatment in the left eye in the future. CONCLUSIONS: As A1AT is found in the tear film and is believed to play a role in regulating protease activity in the cornea, we hypothesize that this patient's A1AT deficiency exacerbated the progression of corneal ulceration leading to severe descemetocele formation.

Electron Beam Irradiated Corneal Versus Gamma-Irradiated Scleral Patch Graft Erosion Rates in Glaucoma Drainage Device Surgery.

INTRODUCTION: Patch graft erosion and implant exposure is a known complication of glaucoma drainage device (GDD) surgery. Recently, electron beam (e-beam) irradiated corneal tissue ha s become available; however, limited data exist on the rates of erosion for e-beam irradiated corneal grafts compared to traditional scleral grafts after GDD surgery. METHODS: This retrospective study examines the records of 253 eyes from 225 adult subjects who underwent GDD surgery with either e-beam irradiated corneal or scleral grafts at the Casey Eye Institute by five surgeons between April 22, 2014 and October 11, 2017. Surgical procedures and the occurrence of graft erosion were determined using billing codes and verified by manual review of electronic health records. RESULTS: The average age at the time of surgery was 61.3 ± 17.5 years (n = 200) and 60.8 ± 16.8 years (n = 53) for the e-beam irradiated cornea and sclera groups, respectively. The average follow-up time post-surgery was 416 ± 345 days and 495 ± 343 days for the e-beam irradiated cornea and sclera groups, respectively. There were no statistically significant differences in sex, age, follow-up time, and glaucoma diagnosis between the groups; however, the e-beam irradiated cornea group was statistically more likely to have an Ahmed implant as compared to the sclera group. No erosion events were noted in either group. CONCLUSION: e-Beam irradiated corneal grafts were used 3.8 times more frequently relative to scleral grafts, yet there were no cases of graft erosion in either group during the follow-up period.

A comparison between the efficacy of human corneal lenticule with single blood donor fibrin glue versus sutures for sealing induced corneal penetrating wounds in porcine eyes

Objective@#To determine the efficacy of human corneal lenticule from small incision lenticule extraction (SMILE) with single blood donor fibrin glue as corneal patch for sealing induced corneal penetrating wounds in cadaveric porcine eyes compared to suturing using 2 simple interrupted nylon 10-0 sutures. @*Methodology@#This is an in vitro comparative experimental study using cadaveric porcine eyes. Twenty (20) porcine eyes were randomized into control and treatment groups. A 3-mm metal keratome was used to create a fullthickness incision with the keratome angled perpendicular to the central cornea. Seidel’s test was done to confirm leakage. An anterior chamber maintainer connected to the Centurion® Vision System (Alcon, USA) was inserted into a peripheral corneal incision with the infusion turned off. Induced corneal penetrating wounds were sealed by application of single blood donor fibrin glue and human corneal lenticule obtained from SMILE in the treatment group. In the control group, 2 simple interrupted nylon 10-0 sutures were used for wound closure. Intraocular pressure (IOP) was set at 30 mmHg using the Centurion® Vision System and IOP was increased by increments of 5 mmHg until leakage is documented. @*Results@#All porcine eyes in the control group showed no leakage immediately after sealing. One out of 10 eyes in the experimental group showed positive Seidel’s test after application of lenticule patch graft (odds ratio = 1.11 [0.904-1.336]). The mean leakage pressure for the suture group was significantly higher at 87.00 ± 4.83 mmHg compared to the lenticule group at 30.00 + 0.00 mmHg (p-value <0.001).@*Conclusion@#Human corneal lenticule from SMILE with single blood donor fibrin glue as cornel patch is less effective in sealing induced corneal penetrating wounds in cadaveric porcine eyes at IOP equal to or greater than 30 mmHg as compared to suturing using 2 simple interrupted nylon 10-0 sutures.

Use of Gamma-Irradiated Cornea to Plug Sclerostomy Site During Tube Shunt Revision.

Tube shunt implantation is a common procedure for control of intraocular pressure (IOP). However, tube revision and repositioning must sometimes be performed, and this involves removing the tube from its sclerostomy site. This site is prone to leaking and this may cause postoperative hypotony. We describe a novel and cosmetically acceptable technique of plugging and covering the sclerostomy site with gamma-irradiated corneal tissue.

[Non-traumatic corneal perforations: Therapeutic modalities]. / Perforations cornéennes non traumatiques : modalités thérapeutiques.

INTRODUCTION: The treatment of non-traumatic perforations of the cornea is a real challenge for the choice of surgical technique as well as for management of the causal pathology. The goal of our study is to determine the anatomical and functional results of the management of non-traumatic perforation of the cornea in the absence of ready access to a corneal graft. MATERIALS AND METHODS: This is a retrospective, non-comparative monocentric study of 23 consecutive cases diagnosed and treated between January 2011 and January 2013. We included 23 eyes with non-traumatic corneal perforation. Various surgical techniques were used depending on the size and location of the corneal perforation. RESULTS: The predominant etiology of the corneal perforations in our series was corneal abscess, found in 30.4% of cases (7 eyes). A conjunctival flap was performed in 43.5% of cases (10 eyes) followed by tarsorrhaphy in 21.7% of cases (5 eyes), autologous corneal patch in 17.4% of cases (4 eyes), amniotic membrane in 13% of cases (3 eyes) and finally cyanoacrylate glue in one case. Mean follow-up was 12.4 ± 2.1 months. Anatomical closure of the corneal perforation was achieved in 91.3% of cases (21 eyes), while the final visual acuity was not improved due to secondary opacities. DISCUSSION: The choice of surgical technique depends on the size of the corneal perforation, its location, its etiology and the resources available for emergencies. When amniotic membrane and corneal donor tissue are unavailable, conjunctival flap is an easy and effective technique, which is a good alternative to close corneal perforations less than 3mm. It improves ocular surface quality and prepares the eye for later penetrating keratoplasty. CONCLUSION: Conjunctival flap is a good technique that is still relevant today, especially in the absence of corneal donor tissue or amniotic membrane. The anatomical success rate is very satisfactory, but sometimes several interventions are needed to improve the visual prognosis.

New Technique of Exposed Glaucoma Drainage Tube Repair: Report of a Case.

We present the case of successful repair of an exposed glaucoma drainage tube by cornea graft fixation with tissue adhesive, and without subsequent coverage by adjacent conjunctiva or donor tissues. Patient with history of keratoglobus with thin cornea and sclera, and phthisical contralateral eye, underwent three unsuccessful corneal grafts followed by Boston type 1 keratoprosthesis in the right eye. Ahmed drainage device with sclera patch graft was implanted to control the intraocular pressure. Two years later the tube eroded through sclera graft and conjunctiva. Repair was performed by covering the tube with a corneal patch graft secured by tissue adhesive after the conjunctiva in this area was dissected away. The cornea graft was left uncovered due to fragility of adjacent conjunctiva. The healing of ocular and graft surfaces was complete prior to the 1 month follow-up. Conjunctival epithelium covered the corneal patch graft. At 12 months follow-up, the graft and the tube remained stable. Our report suggests that corneal patch graft fixation to the sclera by means of tissue adhesive, without closing the conjunctiva, can be considered as an effective alternative surgical approach for managing exposed glaucoma drainage tube, accompanied by adjacent conjunctiva tissue deficiency. How to cite this article: Berezina TL, Fechtner RD, Cohen A, Kim EE, Chu DS. New Technique of Exposed Glaucoma Drainage Tube Repair: Report of a Case. J Curr Glaucoma Pract 2015;9(2):62-64.

Corneal Perforation in Phlyctenular Keratitis

PURPOSE: Corneal perforation from phlyctenular keratoconjunctivitis is rarely reported worldwide and no case has been reported in Korea. We report a case of corneal perforation in a patient with phlyctenular keratoconjunctivitis along with a literature review. CASE SUMMARY: A 15-year-old female presented to our clinic with repetitive tears, conjunctival injection, and discomfort in her right eye for several months. Slit-lamp examination revealed oily plugs at the meibomian gland orifices with collarettes, conjunctival injection and a round, whitish elevated lesion accompanying neovascularization of the inferotemporal side of the cornea. As an initial treatment, topical antibiotic was given but no signs of improvement were observed. Hence, topical steroid was applied on suspicion of phlyctenular keratitis and the patient's symptoms and corneal lesion improved. Two months later, the patient's symptoms relapsed and the lesion was found progressing towards the central cornea. The treatment was restarted and the symptoms improved but the corneal lesion continuously progressed towards the center, thinning the central cornea. Seventeen months from the time of initial diagnosis, the patient revisited prior to the scheduled appointment complaining of abrupt tears in her right eye. Slit-lamp examination revealed a corneal perforation at the center of the thinned cornea. Hence, we performed an emergent tectonic corneal patch graft. After the operation, opacity remained covering the visual axis at the central cornea, thus penetrating keratoplasty was performed 10 months later. Henceforth, the patient has remained free of symptoms and visual acuity has been recovered. CONCLUSIONS: Usually phlyctenular keratoconjunctivitis responds well to treatment and does not have a significant influence on vision. However, occasionally phlyctenular keratoconjunctivitis may not respond to treatment and may spread to the central cornea causing loss of visual acuity and even corneal perforation in rare occasions. Therefore, in order to prevent such complications, prompt diagnosis and treatment are essential.