From the Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Hyo-Myung Kim, Department of Ophthalmology, Korea University College of Medicine, 126-1 Anam-dong 5-ga, Sungbuk-gu, Seoul 136-705, Korea.
Corneal perforation can be repaired with patching, soft contact lenses, cyanoacrylate application, tarsorrhaphy, conjunctival flap, amniotic membrane transplantation (AMT), or penetrating keratoplasty (PKP).1–4 In case of a large-sized corneal perforation, PKP is the definite therapy. However, a donor cornea may not always be available for an urgent PKP. A tectonic graft with a scleral or corneal patch (unusable for PKP) needs to be performed to avoid the possible complications that may arise during the waiting period.3
A Tutoplast®-processed pericardium (Innovative Ophthalmic Products, CA), which has been effectively utilized to cover the tubes of glaucoma drainage implants, orbital implants, and scleral defects, may be a good option to fulfill such a temporary tectonic need when a donor sclera or cornea is unavailable.5,6 We describe a case of corneal perforation refractory to AMT and fibrin glue application, which was finally treated with a pericardium graft while waiting for the subsequent PKP.
A 38-year-old woman presented complaining of left ocular pain after having experienced blunt trauma 2 weeks earlier. She had a history of long-standing poor vision of her left eye after having sustained blunt trauma in her early childhood. Best-corrected visual acuity was hand motion in her left eye. Slit-lamp biomicroscopy revealed a central corneal ulcer with impending perforation and surrounding corneal stromal thinning. The site of impending perforation (2.5 × 2.5-mm sized) was sealed by iris tissue with a visible overlying thin epithelial sheet. The anterior chamber was absent centrally and was of half to one corneal thickness peripherally (Fig. 1). An eye patch was placed on the left eye with 0.3% ofloxacin ophthalmic ointment (Tarivid, Santen, Japan). However, the Seidel test was positive the next day. A double-layered AMT and tissue glue application were performed. Several days later, she complained of epiphora and pain in her left eye. Aqueous leak recurred at the site of previous perforation. She received two additional AMTs combined with tissue glue application that failed to stop the corneal thinning. Therefore, PKP was planned. Unfortunately, a donor cornea was not available immediately. We decided to use a Tutoplast®-processed pericardium to repair the corneal perforation (3.0 × 3.0 mm sized) for the purpose of temporary closure while waiting for the arrival of a donor cornea. Under topical anesthesia with 0.5% proparacaine (Alcaine, Alcon), a Tutoplast®-processed pericardium (4 × 4 mm), which had been soaked in antibiotic solution for 1 min and later rinsed with balanced salt solution, was placed over the perforation lesion. The edges of the pericardium graft were secured to the corneal surface with interrupted 10-0 nylon sutures (Fig. 2). Postoperatively, a soft contact lens was applied on the eye with a prescription of 0.5% moxifloxacin (Vigamox, Alcon Laboratories, Fort Worth, TX) and 1% prednisolone acetate (Pred forte, Alcon Laboratories) eyedrops four times a day. Three days later, a donor cornea arrived and a PKP was performed uneventfully (Fig. 3). During the waiting period, the pericardium graft remained in place.
Figure 1. Central Corneal Ulcer with Impending Perforation and Surrounding Corneal Stromal Thinning.
Figure 2. A Pericardium Graft Was Secured with 10-0 Nylon Interrupted Sutures over the Perforation Area.
Figure 3. Two Weeks After Penetrating Keratoplasty was Performed.
AMT and tissue glue application play a limited role in maintaining corneal stability in eyes with severe corneal thinning, although they have been well-known to be effective solely or in combination in treating small corneal perforations.3,4 Rodriguez-Ares et al. showed that the success rate of multiplayer AMT was lower in larger-sized perforations (40% in 1.5-mm or larger perforations vs 75% in 0.5 to 1.5-mm sized perforations).7 Hick et al. reported a high success rate (92.9%, 13/14 eyes) of the combined use of fibrin glue and AMT in corneal perforations and suggested that corneal perforations up to 3 mm can be safely managed by fibrin glue and AMT.8 Recently, Kim and Park demonstrated the favorable outcome of fibrin glue-assisted augmented AMT in large corneal perforations whose diameter ranged from 2 to 5 mm.9 However, PKP seems necessary when the aforementioned procedures do not work.
A patch graft with a donor sclera or a cornea unsuitable for PKP may be used to provide a temporary structural support if a donor cornea is not readily available for an urgent PKP.10–12 However, even a scleral or corneal patch may not also be available from the eye bank. A Tutoplast®-processed pericardium, although it is costly compared with the donor sclera or cornea that is free of charge in Korea, may be a good alternative to substitute such materials. The advantages of Tutoplast®-processed pericardium include uniform size and tissue quality, easy handling, commercial availability without dependence on an eye bank, and potentially enhanced sterility.13,14 Its processing in a multi-step manner enhances immunologic safety and reduces the risk of viral transmission. The dehydration process leaves the graft cell free and without antigenic stimuli. Tissue sterilization with organic solvents as well as low-dose irradiation leads to the inactivation of the pathogens such as human immunodeficiency virus or Creutzfeld-Jakob virus.13–15
The effectiveness and stability of a Tutoplast®-processed pericardium has been proved through its uses in various kinds of ophthalmologic surgeries.5,6 Recently, Khannah and Mokhtar first reported the use of bovine-processed pericardium for the treatment of a case of a large corneal perforation secondary to alkali injury.16 They demonstrated the successful outcome at their 9-month follow-up. However, thinning of the pericardium graft has been reported from some studies of glaucoma drainage implants.14,17 The mechanisms of its development remain unclear but mechanical or immunologic ones have been presumed to be its possible causes.14,17 A pericardium graft for corneal perforation may be relatively less influenced by the mechanical factors because it merely acts as a seal to fill the empty space, whereas a pericardial graft used for glaucoma tube works as an external cover-up, which means being farther away from the original contour of an eyeball. However, their short-term outcome of a single case seems insufficient to advocate its use as a permanent graft if the possibility of thinning development is considered. Moreover, the opaque nature of the pericardium may preclude its use as a permanent graft if the lesion is located in or near the visual axis in an eye with good visual potential. Therefore, its use as a permanent graft may be reserved for eyes with no or little visual potential or conditions where donor corneas are not available for keratoplasty. However, its temporary use as in our case avoids such potential problems that its use as a permanent graft may lead to.
In conclusion, the use of a Tutoplast®-processed pericardium graft seems to be an effective method to cover the corneal perforation for temporary tectonic support.
- Webster RG, Slansky HH, Refojo MF, Dohlman CH. The use of adhesive for closure of corneal perforations. Arch Ophthalmol. 1968;80:705–709.
- Azuara-Blanco A, Pillai CT, Dua HS. Amniotic membrane transplantation for ocular surface reconstruction. Br J Ophthalmol. 1999;83:399–402. doi:10.1136/bjo.83.4.399 [CrossRef]
- Prabhasawat P, Tesavibul N, Komolsuradej W. Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation. Br J Ophthalmol. 2001;85:1455–1463. doi:10.1136/bjo.85.12.1455 [CrossRef]
- Su CY, Lin CP. Combined use of an amniotic membrane and tissue adhesive in treating corneal perforation: a case report. Ophthalmic Surg Lasers. 2000;31:151–155.
- DeBacker CM, Dutton JJ, Proia AD, Holck DE, Stone T. Bovine pericardium versus homologous sclera as wrapping materials for hydroxyapatite ocular implants: an animal study. Ophthalmic Plastic Reconstr Surg. 1999;15:312–316.
- Smith MF, Doyle JW, Ticrney JW. A comparison of glaucoma drainage implant tube coverage. J Glaucoma. 2001;11:143–147. doi:10.1097/00061198-200204000-00010 [CrossRef]
- Rodriguez-Ares T, Tourino R, Lopez-Valladares J, et al. Multilayer amniotic membrane transplantation in the treatment of corneal perforations. Cornea. 2004;23:577–583. doi:10.1097/01.ico.0000121709.58571.12 [CrossRef]
- Hicks S, Demers PE, Brunette I, La C, Mabon M, Duchesne B. Amniotic membrane transplantation and fibrin glue in the management of corneal ulcers and perforations: a review of 33 cases. Cornea. 2005;24:369–377. doi:10.1097/01.ico.0000151547.08113.d1 [CrossRef]
- Kim HK, Park HS. Fibrin glue-assisted augmented amniotic membrane transplantation for the treatment of large noninfectious corneal perforations. Cornea. 2009;28:170–176. doi:10.1097/ICO.0b013e3181861c54 [CrossRef]
- Stilma JS. Conjunctival excision or lamellar scleral autograft in 38 Mooren’s ulcers from Sierra Leone. Br J Ophthalmol. 1983;67:475–478. doi:10.1136/bjo.67.7.475 [CrossRef]
- Prydal JI. Use of an autologous lamellar scleral graft to repair a corneal perforation. Br J Ophthalmol. 2006;90:924–925. doi:10.1136/bjo.2006.092726 [CrossRef]
- Levartovsky S, Springer A, Leiba H, Marcovich AL, Pollack A. Homologous scleral graft for corneal perforation in a child. Cornea. 2008;27:230–231. doi:10.1097/ICO.0b013e31815a510e [CrossRef]
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- Lama PJ, Fechtner RD. Tube erosion following insertion of a glaucoma drainage device with a pericardial patch graft. Arch Ophthalmol. 1999;117:1243–1244.
- Sattar SA, Springthorpe VS. Survival and disinfectant inactivation of the human immunodeficiency virus: a critical review. Rev Infect Dis. 1991;13:430–447.
- Kannah RK, Mokhtar EM. Bovine pericardium in treating large corneal perforation secondary to alkali injury: a case report. Indian J Ophthalmol. 2008;56:429–430. doi:10.4103/0301-4738.42426 [CrossRef]
- Heuer DK, Budenz D, Coleman A. Aqueous shunt tube erosion. J Glaucoma. 2001;10:493–496. doi:10.1097/00061198-200112000-00010 [CrossRef]