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Session Title: Cornea surgical I
Session Date/Time: Tuesday 08/10/2013 | 08:00-10:30
Paper Time: 10:24
Venue: Forum (Ground Floor)
First Author: : R.Barbara ITALY
Co Author(s): : P. Santorum C. Bovone C. Russo M. Busin
To report on a 78 year-old man with immunologically failed penetrating keratoplasty originally performed for neurotrophic ulcer and corneal scaring in the right eye (RE). The patient was previously diagnosed with fifth and seventh cranial nerve palsy causing corneal anesthesia and lagophthalmos. The left eye (LE) had no visual potential as a result of central retinal artery occlusion (CRAO). We report on the use of Autologous Descemet stripping automated endothelial keratoplasty (A-DSAEK) for RE, to eliminate the risk of repeat rejection. The donor LE underwent heterologous DSAEK to replace the endothelial tissue harvested for RE. Autologous DSAEK was complemented subsequently with a lateral tarsorrhaphy to treat a persistent epithelial defect with stromal melting and a subsequent deep anterior lamellar keratoplasty (DALK) to remove the consequent central corneal leucoma.
Eye Department of private hospital "Villa Igea" in Forli, Italy.
A 300 micron microkeratome head was used to create a superficial flap with superior hinge in LE. After lifting the flap, a full thickness trephination 8 mm in thickness was performed to harvest the donor tissue (deep stroma and endothelium). Surgery was then completed by suturing the flap back into position and replacing the excised tissue with a similar 8.0 mm button obtained from an eye bank cornea by means of microkeratome dissection. The autologous graft obtained from LE was then utilized for a standardized DSAEK procedure performed in RE. Three months later, a 7.0 mm DALK was also performed in RE to treat a stromal opacity occurring after persistent epithelial defect and partial tissue melting; the whole central part of the old PK graft was removed up to the plane of the DSAEK stromal surface, which was totally free from any adhesions. A double running 10-0 nylon suture was used to complete the procedure and was removed 1 year after surgery.
Preoperatively, visual acuity was limited to finger counting due to failed PK in RE and to light perception in LE as a consequence of CRAO. Following DSAEK, the cornea of RE cleared as early as one day postoperatively, but the central leucoma resulting from the stromal melting did not allow vision to improve beyond finger counting at 1 meter. One month after DALK in DSAEK visual acuity was 0.3 and did not change during the following 2 years of follow-up. The cornea of LE cleared as per regular postoperative DSEAK course, but vision did not improve because of CRAO.
PK with utilizing tissue from homologous donors has an extremely poor prognosis in eyes with previous immunologic graft failure and combined fifth and seventh cranial nerve palsy. Instead, a two-step surgical approach including first auto-DSAEK and then DALK was instrumental in obtaining long-lasting useful vision. Auto-DSAEK allowed elimination of the risk of immunologic rejection, while stromal changes, always possible in eyes with neurologic deficits, could then be treated with DALK. Later, possible recurrence of stromal changes could also be dealt with by simply exchanging the anterior graft, while leaving the underlying autologous tissue untouched.
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