Tectonic Eccentric Penetrating Sclerokeratoplasty à chaud as Treatment for Peripheral Perforated or Predescemetal Corneal Ulceration

Abstract

Background Tectonic eccentric sclerokeratoplasty à chaud is a very complex corneal operation and aims to preserve the eyeball and possibly to improve visual acuity in patients with peripheral corneal ulcerations or perforating corneal trauma. Methods 1650 eyes received corneal transplants in our clinic between 2006 and 2019. 14 of these 1650 eyes (0.8%) had a perforated or predescemetal peripheral corneal ulceration and these were treated between 2006 and 2019 with a tectonic eccentric sclerokeratoplasty à chaud. The mean age of the 8 women and 6 men included in this case series was 63 years (22 – 91 years). Results In the postoperative follow-up period, most complications and reoperations occurred in the first 6 months. Re-ulceration was observed in 2 cases as well as early suture loosening in 12 patients. These 2 cases were treated with a partial conjunctival flap. Additionally, prolonged superficial wound healing process was shown in 12 patients. Therefore 27 amniotic membrane transplantations, 12 suture replacements, and 6 partial conjunctival flaps were performed in total. No re-keratoplasties were required in this case series. All eyes could be stabilised through the sclerokeratoplasty as well as subsequent operations and intensive local or even systemic treatment. After removal of the corneal suture, the best-corrected visual acuity improved only insignificantly to hand movement in 1 case, finger counting in 3 cases, 0.1 in 5 cases, 0.2 in 4 cases and 0.5 in 1 case. Preservation of the eyeball with pain relief was achieved in all 14 eyes. Conclusions Eccentric sclerokeratoplasty is a very demanding surgical procedure and is extremely rarely performed. The goal is to preserve the eye.

Indications, techniques, and graft survival of mini and corneo-scleral tectonic keratoplasties: A retrospective single-center case series

“…Several other studies primarily focused on inflammatory ocular surface disease as indications of tectonic eccentric keratoplasties [11,27]. In our study 42.4% of cases were non-inflammatory eye diseases.…”

“…In a study from India, patients were considerably younger with a mean age of 38 years at surgery [21]. Ang et al from Singapore report a mean age of 51 years, Vo ¨lcker and Naumann from Germany of 54 years and Kohlhaas et al from Germany of 63 years [9,11,20]. Interestingly, anatomical success was significantly better in the oldest third of patients than in the youngest third of patients although the prevalence of non-inflammatory and inflammatory conditions was similar in these groups (Fig 4 and S1 Fig).…”

“…Indications, outcomes, and risk factors for graft failure in TK have been described in Caucasian populations [9][10][11]. However, these analyses were conducted before the introduction of non-corticosteroid immunomodulatory therapy (NCSIT) in high-risk keratoplasties [12][13][14][15][16][17][18][19].…”

“…Newer publications in this context have described TK in Asian populations [20,21]. One more recent study in a Caucasian population evaluated the outcome of tectonic eccentric penetrating sclerokeratoplasty à chaud of more than 6 mm diameter as a treatment option for peripheral perforated as well as pre-descemetal corneal ulcerations [11]. Further studies evaluated tectonic keratoplasties using glycerin-cryopreserved grafts [21,22].…”

The Use of Corneoscleral Grafts to Maintain Tectonic Stability in Severe Keratolysis

“…In another study with 14 grafts, tectonic stability was observed in all included patients. However, only ulcers with a rheumatologic etiology were included, whereas the vast majority of ulcers included in our study were of infectious origin, which may contribute to different results [ 10 ]. The differences in clinical outcomes between infectious and sterile perforated ulcers have also been demonstrated elsewhere [ 11 ].…”