EARLY ENDOTHELIALIZATION OF AB INTERNO LAMELLAR STROMAL TECTONIC PATCH IN THE MANAGEMENT OF CORNEAL PERFORATION SECONDARY TO BACTERIAL KERATITIS.

To describe a novel surgical technique using an ab interno lamellar stromal patch to treat corneal perforation, and to present the histological findings of the patch following its removal during subsequent mushroom keratoplasty.

Various technical permutations of Descemet stripping (automated) endothelial keratoplasty (DS(A)EK) have recently been proposed in sealing corneal perforations from within the anterior chamber. This approach avoids potential suture-related complications induced via the conventional anterior or full thickness approach. In tectonic DSAEK, the pressure gradient across a large corneal perforation may be more important in promoting graft adherence than the pump function of donor endothelium. We recently had the opportunity to test this hypothesis via a case in which stromal material without endothelium was used as an ab interno patch to seal a corneal perforation.

The patient was managed successfully with a sutureless ab interno stromal tectonic patch, prepared from tissue that had already been used to harvest an endothelial graft on the same day. 2 months later, definitive mushroom keratoplasty was performed and the patch was sent for histological examination. Immunohistochemistry revealed a reactive endothelium covering the posterior surface of the graft. Nine months later her best corrected visual acuity was 6/9.

This is the first case to our knowledge demonstrating that stromal tectonic grafts without endothelium can successfully attach to host tissue and seal a perforation. The use of leftover graft material for this indication may reduce pressure on tissue bank supply. Stroma may undergo re-endotheliazation and begin to restore vision, even prior to PK.