Tectonic Descemet Stripping Endothelial Keratoplasty for the Management of Corneal Perforation: A Case Series

Abstract

Purpose: Corneal perforations pose a considerable challenge for ophthalmic surgeons. The aim remains restoring the anatomical integrity of eye while attempting to preserve as much visual function as possible. To our knowledge, we report the first case series of 4 successful tectonic Descemet stripping endothelial keratoplasty (DSEK) grafts completed for acute corneal perforation. In all cases, restoration of globe integrity was achieved. In cases where visual potential remained, deep anterior lamellar keratoplasty over DSEK was offered. Methods: Four patients presenting to Royal Gwent Hospital (Newport, Wales) with corneal perforation were included. Etiological origins included exposure keratopathy, corneal hydrops secondary to pellucid marginal degeneration with fistulization-associated aqueous leak, and herpetic keratitis. Patients were treated with initial temporary therapies, including glue patch, the use of bandage contact lenses, amniotic membrane transplant, and antibiotic cover, depending on the size and location of the perforation. Subsequent DSEK was subsequently performed under local anesthesia. Results: All patients had successful tectonic grafts (3 DSEKs and 1 hemi-DSEK) up to 4 months postoperatively. In the case involving a hemi-DSEK, the patient underwent 2 refloating attempts of the graft before anchoring suture placement because of repeated graft detachment. Successful graft placement and tectonic globe restoration was confirmed by anterior segment imaging. Conclusions: Tectonic DSEK provides corneal surgeons with a new modality of treating corneal perforations. It provides clinicians an additional tool in their armamentarium in complex cases where anterior lamellar or penetrating keratoplasty may be contraindicated or deemed high risk of complications.

Transplantation of autologous lamellar scleral graft for the treatment of corneal perforation

“…8À10 Transparency of scleral tissue embedded in cornea has also been noted and confers its advantage over other long-term solutions that do not result in corneal clarity. 4,8 Unfortunately, in our case, opacification around the suture sites did occur because the patient was lost to follow-up prior to suture removal. However, maintenance of her visual acuity and eye health suggests that this is a viable option for corneal perforation when follow-up is tenuous, as it is in countries with limited resources.…”

“…1,3 New techniques continue to advance our repertoire for corneal perforations that are too large for tissue adhesives. For instance, Tourkmani et al 4 described the use of tectonic Descemet-stripping endothelial keraoplasty grafts for acute corneal perforations. 4 Advantages over penetrating keratoplasty include shorter surgical time, quicker recovery, and no general anaesthetic needed.…”

“…For instance, Tourkmani et al 4 described the use of tectonic Descemet-stripping endothelial keraoplasty grafts for acute corneal perforations. 4 Advantages over penetrating keratoplasty include shorter surgical time, quicker recovery, and no general anaesthetic needed. More recently, Seifelnasr et al 5 have documented the use of a small-diameter tectonic Descemet-stripping automated endothelial keratoplasty graft for closure of a traumatic perforation.…”

Tectonic Descemet’s stripping automated endothelial keratoplasty for corneal perforation

“…The use of DSAEK ‘patch grafts’ for impending and frank corneal perforations in eyes with1 6 and without8 endothelial decompensation have already been shown to be effective. When attached to the posterior corneal stroma, DSAEK can successfully restore the integrity of the cornea without its further modification by sutures, thereby avoiding suture-related complications 1…”

Early Endothelialization of Ab Interno Stromal Tectonic Patch in the Management of Corneal Perforation Secondary to Bacterial Keratitis

“…For this reason, various technical permutations of Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) have recently been proposed in sealing the perforation from within the anterior chamber (AC). [2][3][4][5][6] Unlike emergency gluing with cyanoacrylate, which is often the first-line treatment for such patients, tectonic DSAEK may be a definitive rather than an often temporizing measure, and the stromal substrate of the DSAEK may promote reepithelialization across the perforation site sooner than the glue, which is cytotoxic. 4 In conventional DSAEK, it is presumed that adherence of the lenticule requires the donor endothelium to create a negative pressure across the graft-host interface.…”