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Chapter-38 Deep Lamellar Keratoplasty in Corneal Perforation

BOOK TITLE: Surgical Techniques in Anterior and Posterior Lamellar Corneal Surgery

Author
1. Shimmura Shigeto
ISBN
9788180616051
DOI
10.5005/jp/books/10883_38
Edition
1/e
Publishing Year
2006
Pages
5
Author Affiliations
1. Keio University School of Medicine, Tokyo, Japan
Chapter keywords

Abstract

Corneal perforation occurs following trauma, or stromal melting due to infection or autoimmune disease. Sharp, linear lacerations can be treated by direct suturing, or a therapeutic contact lens may suffice in cases without leakage of the aqueous. Small, pin-point perforations can be treated with tissue adhesives such as cyanoacrylate, or by transplanting amniotic membrane (AM) grafts to promote epithelialization. An AM alone can be used by folding multiple layers to fill small ulcers, especially in areas outside of the optical zone. However, for perforations associated with extensive thinning of the stroma, therapeutic keratoplasty is still the procedure of choice for restoring globe integrity. Penetrating keratoplasty (PKP) continues to be the primary choice for large corneal perforations involving extensive loss of Descemet’s membrane (DM) and endothelium. However, PKP is prone to immunological rejection, especially in eyes with extensive inflammation and neovascularization. Unfortunately, a large percentage of eyes with stromal melting or infection often have high risk factors that can lead to graft rejection and graft failure. Repeated PKP in such eyes are not only unsuccessful but also are often complicated with other sequelae such as secondary glaucoma and infection. Once PKP is chosen as the initial surgery, all subsequent procedures will be limited to PKP. Lamellar keratoplasty (LKP) can be done using preserved or fresh donors to patch areas of corneal perforation. Donor size and design can be modified according to the size and location of perforation. The LKP involving the optical zone cannot be avoided in paracentral lesions seen in autoimmune disease and herpetic lesions. However, if the perforation is restricted to the periphery as in Mooren’s ulcer, an arcuate lamellar graft can be designed to fit the marginal ulcer to patch the perforation. The LKP usually leaves a significant opacification of the stromal interface, which can lead to suboptimal visual quality in patients with intact visual function. This chapter describes deep LKP as a means to obtain both therapeutic results and satisfactory vision in one procedure.

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