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Anterior lamellar keratoplasty an option for treating corneal melt with perforation
The extraocular procedure avoids the risk of intraocular infection posed by open-sky techniques.
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 Thomas John |
Corneal melt with focal perforation is an ocular emergency that usually requires surgical intervention to stabilize the globe and retain ocular integrity. Therapeutic keratoplasty is a potential treatment option, but this is an intraocular procedure. In addition to increasing ocular inflammation due to surgical trauma, therapeutic keratoplasty poses the risk of intraocular infection because it is an open-sky technique. Also, performing a full-thickness graft in a soft eye secondary to perforation may be challenging.
An alternative procedure to consider is anterior lamellar keratoplasty (ALK), an extraocular procedure. ALK may be a preferred procedure, especially because the eye is often inflamed at the time of corneal perforation.
In this column, I describe ALK with the use of fibrin glue to surgically treat sterile corneal melt with focal perforation. Other materials have been used to seal such corneal perforations, including amniotic membrane as well as scleral and pericardial grafts.
Surgical technique
The preferred anesthesia for ALK is monitored anesthesia care, but peribulbar or general anesthesia may also be used, according to surgeon preference.
It is important not to exert any undue pressure on the globe during the surgical procedure. In addition, 2% lidocaine jelly is applied to the ocular surface (Figure 1, top left). The margins of the area of corneal melt may be demarcated with a sterile surgical marking pen. A straight crescent blade is used to remove the epithelium in the affected area and the surrounding cornea (Figure 1, top right and bottom left).
 Figure 1. Top left: 2% lidocaine jelly is applied to the ocular surface. Top right and bottom left: Using a straight crescent blade, the corneal bed and the surrounding area are prepared by gently scraping the epithelium off the corneal surface. Bottom right and insert: Donor lamellar corneal disc is prepared by using an artificial anterior chamber and a microkeratome. |
 Figure 2. The outer boundaries are marked on the recipient cornea, and the lamellar donor corneal disc is cut to the desired size freehand using curved Vannas scissors. Insert: Donor lamellar corneal disc in profile. Images: John T |
 Figure 3. The edges of the donor lamellar graft need to be shaped appropriately to fit the recipient cornea bed before it is anchored to the recipient cornea with interrupted 10-0 nylon sutures. The undersurface of the graft should be beveled at the margins for proper seating on the recipient cornea. |
 Figure 4. The donor disc is folded back to expose the recipient bed and the stromal surface of the donor disc, and fibrin glue is applied (components 1 and 2) to the stromal surfaces of the donor and recipient corneas. |
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The donor corneal graft is prepared by using an artificial anterior chamber and a microkeratome. The donor disc is shown in Figure 1 (insert). The outer boundaries are marked on the recipient cornea, and the lamellar donor corneal disc is cut to the desired size freehand using curved Vannas scissors (Figure 2). The edges of the donor lamellar graft need to be shaped appropriately to fit the recipient corneal bed before the graft is anchored to the recipient cornea with interrupted 10-0 nylon sutures (Figure 3). The undersurface of the graft should be beveled at the margins for proper seating on the recipient cornea. The surface of the cornea should be uniform, because a good donor-recipient bed fit is important.
The donor disc is folded back to expose the recipient bed and the stromal surface of the donor disc, and fibrin glue is applied (components 1 and 2) to the stromal surfaces of the donor and recipient corneas (Figure 4). Gentle pressure is applied to the donor graft for uniform adhesion of the graft to the recipient corneal bed (Figure 5). Both slit view and full view of the completed procedure are shown in Figure 5.
References:
- Kim HK, Park HS. Fibrin glue-assisted augmented amniotic membrane transplantation for the treatment of large noninfectious corneal perforations. Cornea. 2009;28(2):170-176.
- Panda A, Agarwal A, Kumar S. Therapeutic keratoplasty for corneal perforation. Cornea. 2008;27(10):1218-1219.
- Siatiri H, Moghimi S, Malihi M, Khodabande A. Use of sealant (HFG) in corneal perforations. Cornea. 2008;27(9):988-991.
- Turner SJ, Johnson Z, Corbett M, Prydal J. Scleral autoplasty for the repair of corneal perforations: a case series. Br J Ophthalmol. 2010;94(5):669-670.
- Yoo C, Kang SY, Eom YS, Kim HM. Temporary repair of corneal perforation using Tutoplast-processed pericardium graft. Ophthalmic Surg Lasers Imaging. 2010;9:1-3.
- Thomas John, MD, OSN Cornea/External Disease Board Member, is a clinical associate professor at Loyola University Chicago and is in private practice in Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com.
