Seminars in Ophthalmology

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Lamellar corneal patch grafts in the management

of corneal thinning and perforations without using
extra corneas

Umit Calli, Selim Genc, Osman Şalkacı & Asena Ömeroğlu

To cite this article: Umit Calli, Selim Genc, Osman Şalkacı & Asena Ömeroğlu (2021): Lamellar
corneal patch grafts in the management of corneal thinning and perforations without using extra
corneas, Seminars in Ophthalmology, DOI: 10.1080/08820538.2021.1896754

To link to this article: https://doi.org/10.1080/08820538.2021.1896754

Published online: 06 Apr 2021.

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SEMINARS IN OPHTHALMOLOGY
https://doi.org/10.1080/08820538.2021.1896754

Lamellar corneal patch grafts in the management of corneal thinning and

perforations without using extra corneas
a b
Umit Calli , Selim Genc , Osman Şalkacıc, and Asena Ömeroğlub
a
Fatih Sultan Mehmet Research and Training Hospital, Ophthalmology Department, Istanbul, Turkey; bBeyoglu Research and Training Hospital,
Ophtalmology Department, Istanbul, Turkey; cKartal Dr. Lütfi Kırdar Research and Training Hospital, Ophtalmology Department, Istanbul, Turkey

ABSTRACT ARTICLE HISTORY

Objectives: To report the tectonic role of circular and square-shaped lamellar grafts without using extra Received 27 January 2021
corneas. Revised 16 February 2021
Materials and Methods: We retrospectively reviewed 23 lamellar patch grafts performed over a six-year Accepted 18 February 2021
period for various tectonic indications in corneal thinning and perforations. The anterior stroma of corneal Keywords
endothelium peeled for Descemet Membrane Endothelial Keratoplasty were used to prepare circular Corneal donor; corneal
lamellar corneal grafts. After punch trepanation of donor corneas for penetrating keratoplasty, the melting; patch graft; tectonic
remaining rim of the cornea was used to prepare square-shaped grafts. lamellar keratoplasty
Results: Circular lamellar grafts were used in 13 eyes that had paracentral or central corneal thinning or
perforations. Square-shaped grafts were used in 10 eyes, nine of which had peripheral corneal thinning or
perforations, and one, limbal. Anatomical success after tectonic grafts was achieved in 22 of 23 eyes
(95.6%) at a mean follow-up of 9.83 ± 6.27 months. The mean of the best-corrected visual acuity improved
from logMAR 2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 postoperatively, at the final follow-up.
Conclusions: The main disadvantage of patch grafts is the shortage in corneal supply due to insufficient
cornea donation in developing countries like Turkey. By evaluating unused corneal rims, extra corneas will
not be required.

Introduction
December 2020. The inclusion criteria were central, paracentral,
Tectonic lamellar keratoplasties (LKP), also known as “patch or peripheral perforations or thinning. Cases of perforation with
grafts”, are mainly used to repair corneal thinning, perfora­ a bandage contact lens and primary suturation failures were also
tions, or descemetoceles. Reconstructive LKP allows for the included. The following parameters were analyzed: age, sex, initial
subsidence of inflamed and unstable eyes, such as those with diagnosis, preoperative visual acuity, location of the lesion (cen­
corneal perforation or descemetoceles, before vision- tral, paracentral, peripheral, or limbal), type of lamellar graft
rehabilitating penetrating keratoplasty (PKP), which is per­ (circular or square-shaped), postoperative visual, clinical out­
formed later.1,2 In this period, systemic immunosuppressive come, and complications. The patients also underwent anterior
medical treatment has a chance to halt collagenolytic corneal segment optical coherence tomography preoperatively and
breakdown in rheumatologic patients.3 postoperatively.
We retrospectively reviewed 23 lamellar patch grafts per­
formed over a six-year period for various tectonic indications in
Circular Lamellar Corneal Graft
severe corneal melting with or without perforation. The main
disadvantage of patch grafts is the provision of the cornea due to Trypan blue solution was used to stain the edges of the Descemet
insufficient cornea donations in developing countries like Turkey. membrane (DM). With a balanced salt solution, a liftable edge
We evaluated the reconstructive role of two types of tectonic was created using a Sinskey hook anterior to Schwalbe’s line, and
lamellar grafts without using extra corneas: circular grafts a 360° circumference DM edge was separated. A free area of the
obtained from the anterior stroma of donor corneas used for DM edge was grasped with tying forceps and peeled away from
Descemet Membrane Endothelial Keratoplasty (DMEK)s surgery the stroma. When the DM was stripped partially, the graft was
(Figure 1) and square-shaped grafts obtained from the rim of re-stained and replaced over the stroma. Superficial partial-
donor corneas used for PKP (Figure 2). thickness trephination was performed from the endothelial
side with the previously determined diameter, and the entire
endothelium was peeled from the donor stroma. The circular
Materials And Methods
lamellar corneal graft was prepared from this stroma, and the
We performed tectonic grafts in 23 eyes of 23 patients with remaining endothelial graft was transferred to an Optisol corneal
corneal thinning and perforations from January 2014 to storage medium.

CONTACT Umit Calli [email protected] Fatih Sultan Mehmet Research and Training Hospital, Ophthalmology Department, Yaprak Street No: 4/21
Umraniye, Istanbul, Turkey.
The manuscript has been read and approved by all the authors.
© 2021 Taylor & Francis
2 U. CALLI ET AL.

formed by cutting the cornea approximately 1–2 mm outside

the lesion borders in a rectangular or square shape in partial
thickness by a crescent knife.
In circular or square-shaped grafts, the donor corneal
button was sized 0.25–0.50 mm or larger than the recipient
bed. The externalized or incarcerated iris was either reposi­
tioned or excised. Grafts were sutured with interrupted
10–0 nylon sutures. All eyes received topical antibiotic
drops, and some eyes received an additional subconjuncti­
val antibiotic injection. The eyes were covered with a patch
and metal shield.
Topical moxifloxacin and preservan-free artificial tears were
used four times daily for the first four weeks postoperatively.
Topical preservan-free steroid drops (Dexasine SE, LİBA) were
used four times daily and gradually tapered. Systemic immu­
nosuppression, either with corticosteroids or cytotoxic agents,
was continued in cases of rheumatoid arthritis and systemic
lupus erythematosus, as advised by the rheumatologist, for
Figure 1. Square-shaped lamellar patch graft in a peripheral corneal perforation systemic control of the disease.
due to trauma. Statistical analyses were performed using SPSS version 19.0
(IBM Corp., Armonk, NY, USA). Snellen visual acuity mea­
surements were converted to logMAR equivalents to allow for
quantification of the numerous visual acuity values that were in
the counting fingers (logMAR 2), hand motions (logMAR 2.3),
and light perception (logMAR 2.8) range. The Wilcoxon
signed-rank test and Mann-Whitney U test were performed
to assess statistical differences. Statistical significance was
defined as p < .05.

Results
Twenty-three eyes of 23 patients underwent tectonic lamellar
grafts. The mean age of the patients was 53.04 ± 19.96 years.
There were 13 female and 10 male patients. The indications for
tectonic lamellar grafts were immunologic disease in 10 eyes,
bacterial infectious keratitis in 7 eyes, trauma in 2 eyes, expo­
sure keratopathy in 2 eyes, and neurotrophic keratitis in two
eyes. Circular lamellar grafts were used for 13 eyes with para­
central or central corneal thinning or perforation. Square-
Figure 2. Circular lamellar patch graft in a paracentral/central corneal melting shaped lamellar grafts were used for nine eyes with peripheral
case secondary to rheumatoid arthritis.
and one eye with limbal corneal thinning or perforation.
Anatomical success after tectonic grafts was achieved in 22 of
Donor stroma was cut by a trephine to punch out a circular 23 eyes (95.6%) at a mean follow-up of 9.83 ± 6.27 months. The
button. characteristics and outcomes of patients are summarized in
The recipient cornea was trephined to a partial stromal depth Table 1.
using a disposable trephine with the obturator set for the requi­ The mean of the best-corrected visual acuity improved from
site depth, or alternatively, cut in a freehand fashion. Lamellar logMAR 2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 post­
dissection was performed with either a spatulate, lamellar inci­ operatively, at the final follow-up. While preoperative visual
sional blade, or a sharp-point blade. Viscoelastic material was acuity was not significantly different, postoperative visual
injected into the anterior chamber through either the perforation acuity was significantly better in eyes with peripheral corneal
or through a separate paracentesis to improve global turgor and ulcerations than in eyes with central ulcerations (logMAR
to reduce anterior chamber collapse during dissection. 1.16 ± 0.24 and logMAR 1.51 ± 0.21, respectively).
Remelting of the graft was seen in three eyes, which then
underwent a second lamellar patch graft. One patient under­
Square-shaped Corneal Lamellar Graft went PKP after failure of the second LKP. Corneal abscess was
After punch trepanation of the donor cornea used for kerato­ seen in two eyes, which were then treated with topical fortified
plasty, the remaining rim of the cornea was cut to 50% thick­ antibiotic drops. Pseudochamber formation at the interface
ness and suitably sized for the lesion. The recipient bed was was detected in six patients (Figure 3).
 SEMINARS IN OPHTHALMOLOGY 3

Table 1. Characteristics and outcomes of patients. the globes in all 80 eyes of 64 patients.4 In the present study, we
Female/male 13/10 evaluated the effects of tectonic LKP on the integrity of the
Age, years 53.04 ± 19.96 globe and visual rehabilitation in patients with corneal melting
İndications; 10
İmmunologic diseas 7
and perforations. Tectonic or anatomical success was achieved
İnfectious keratitis 2 in 22 of 23 eyes (95.6%). This high success rate was similar to
Trauma 4 that reported in previous studies.3,4
Other
Sites of perforation/thining 13
Although tectonic LKP applied in cases of active corneal
Paracentral/central 9 melting or perforation is a successful method for maintaining
Peripheral 1 globe integrity, its effect on visual acuity is limited due to the
Limbal
Anatomic success 22/23 (95.6%)
underlying disease’s destructive process .4,9 The fact that some
Visual improvement 19/23 (82.6%) patients we evaluated in our study reached ambulatory vision
Functional success (with visual acuity of 20/100 or better) 6/23 (%26,1) levels support this. Soong et al. reported that the visual acuity
improved in 34 cases (42% of the eyes) after tectonic LKP, even
though only 14 (17.5%) cases resulted in visual acuities of 20/100
Discussion or better. The mean logMAR acuity preoperatively was 1.831
Corneal thinning or perforations (impending or recent) can and postoperatively was 1.653 in their study.4 In another study,
occur secondary to inflammatory diseases, trauma, or micro­ the mean of the best corrected visual acuity (expressed in deci­
bial keratitis. Small perforations may be treated effectively with mals) improved from 0.2 ± 0.26 preoperatively to 0.34 ± 0.26
cyanoacrylate tissue adhesives, but in more extensive lesions or postoperatively at the final follow-up.9 In our study, the mean of
in cases of cyanoacrylate tissue-adhesive failure, lamellar cor­ the best-corrected visual acuity improved from logMAR
neal patch grafts are effective in providing tectonic support and 2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 postoperatively
in stabilizing the eye while systemic immunosuppression takes at the final follow-up. The visual acuity improved in 19 (95.6%)
effect.4 Lamellar patch grafting is also useful in the removal of of 23 eyes after tectonic LKP, even though only 6 (26.1%) cases
necrotic stroma, which is a source of collagenase.5,6 The ana­ resulted in visual acuities of 20/100 or better.
tomical success in cases of PKP in corneal melting is generally In the present study, the postoperative visual acuities were
inferior7,8 to that described in cases of LKP.3,4 In a study by significantly better in the peripheral square-shaped LKP
Bernauer et al., the application of tissue adhesive as a definitive patients than in the central circular LKP patients. Soong et al.
repair failed in all five eyes, lamellar grafting was anatomically similarly reported that postoperative visual acuity was signifi­
successful in three of four eyes, and PKP was successful in 10 cantly better in eyes with peripheral corneal ulcerations than in
(45%) of 22 eyes. The most common cause of early failure of eyes with central ulcerations.4 However, the effect of the shape
penetrating grafts was recurrent melting.2 In a study by Nobe of the corneal lamellar graft on final visual acuity is still vague.
et al., all six PKPs performed for corneal melting secondary to Peripheral square shaped-LKP cases should be compared with
immunologic diseases failed.7 Palay et al. reported an 87% peripheral circular LKP cases to clarify the effects of square-
success rate in preserving global integrity with PKP in patients shaped lamellar grafts on visual acuity.
with rheumatoid arthritis; however, after five years, PKP sur­ Postoperative bacterial keratitis occurred in two eyes in our
vival decreased to 48%.8 study. Soong et al. reported three bacterial keratitis cases in 80
Tectonic LKPs are effective in providing tectonic support eyes; all three keratitis cases occurred in previously uninfected
and in stabilizing the eye while systemic immunosuppression eyes. Vanathi et al. reported microbial keratitis in 41 eyes after
treatment takes effect. In a study by Raizman et al., the PKP LKP in a patient with traumatic limbal perforation with iris
success rate was 88% and the LKP success rate was 92% in incarceration. In our study, bacterial keratitis on the graft
corneal melting.3 Soong et al. reported that tectonic LKP for cornea after LKP was seen in patients with corneal perforation
active corneal melting was effective in saving the integrity of secondary to bacterial keratitis.

Figure 3. Pseudochamber formation after patch graft.

4 U. CALLI ET AL.

Tectonic grafts of varying size, shapes, and positions are DISCLOSURE STATEMENT
used in the treatment of refractory corneal diseases that
The authors report no conflicts of interest.
endanger the integrity of the globe.10 Twenty-four full-
thickness tectonic grafts, nine mushroom grafts, and nine
lamellar patch grafts were performed in the study of
Funding
Vanathi et al.9 In our study, if the patient had
a peripheral thinning or perforation, we used a square- None.
shaped lamellar patch graft obtained from the remaining
rim of a corneal graft used for PKP. We also performed two
transplants from a single cornea by obtaining a circular REFERENCES
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