CHALLENGES OF OCULAR SURFACE DISEASE IN A PATIENT WITH CHEMICAL BURN SEQULEA AND PENETRATING KERATOPLASTY

Presenting the clinical features, preoperative evaluation, surgical approach, and postoperative challenges in a patient with ocular surface disease after an alkali burn, who undergoes penetrating keratoplasty and several oculoplastic surgeries to promote optimal graft integration and obtain the best possible visual result. The patient is a 30 year-old male who suffered an ocular chemical burn after contact with white wash. The accident left him with severe visual impairment in one eye due to a complete vascularized leucoma and an inferior symblepharon. In our clinic the patient underwent a penetrating keratoplasty and two forniceal reconstruction procedures.

Saint Spiridon University Hospital, Iasi, Romania 

The patient presented in our clinic with a severely affected right eye, with very low visual acuity (BCVA= hand movement) due to a series of sequelae after an alkali burn from early childhood. The cornea had a complete, adherent, vascularized leucoma. The ocular fundus could not be visualized, but because the echography was normal, the decision was made to perform a penetrating keratoplasty as a solution of visual acuity improvement. A dry eye examination was also performed and suggested severe dry eye with a TBUT of 2 sec and a Schirmer test of 2.5 mm. The surgeon decided as right approach to resolve the symblepharon before the penetrating keratoplasty. A series of two surgeries were done to remove tractions and adherences from the symblepharon and reconstruct the fornix with an oral mucosa graft.  The postoperative evolution was good and two months later a penetrating keratoplasty was performed.

The early postoperative slit lamp examination revealed a transparent graft, with continent sutures, a medium anterior chamber, a patent superior iridectomy and a transparent lens. The BCVA was 0.06, and the palpatory ocular tonus was normal. The fundus examination showed a normal optic disc and no macular lesions. The patient was discharged with a good overall visual and clinical status but returned shortly with a reduction in visual acuity due to a central erosion on the graft. A therapeutic contact lens was applied and intensive treatment with antibiotic, autologous serum and artificial tears was initiated with a good visual outcome.

Poorly managed ocular chemical burns often lead to serious complications. Because of their lipophilic proprieties which facilitate profound corneal and conjunctival lesions, alkali burns are the most invalidating. Our patient was managed by a team of two surgeons- and anterior segment specialist and an oculoplastic surgeon. Although the forniceal shortening was resolved, graft failure rate is high in such cases because of severe dry eye and limbal stem cell deficiency. Chemical burn sequelae need a complex and patient approach to ensure complete recovery after surgery and minimize postoperative complications.