Combined “Pull-Through” Technique And Two-Piece Microkeratome-Assisted Mushroom Keratoplasty To Manage Increased Vitreous Pressure In Pediatric Eyes

To describe a modified two-piece mushroom penetrating keratoplasty technique to manage increased vitreous pressure in pediatric eyes

All surgeries were performed at two tertiary Care Referral Centers: Ospedali Privati Forlì “Villa Igea,” Forlì, Italy, and Azienda Ospedaliero-Universitaria di Ferrara - Arcispedale Sant’Anna, Ferrara, Italy.

Using a 250µm microkeratome head, the donor cornea was split into an anterior and posterior lamella and punched to 8.5mm and 6mm respectively.

A trephination 250µm in depth was performed and the anterior stroma was dissected. A 6-mm full-thickness trephination was carried out incompletely, leaving the central button attached to the peripheral cornea in several areas.

The 8.5-mm donor anterior lamella was then fixated via 4 cardinal sutures and the underlying 6-mm trephination was completed and the recipient central button excised. Finally, the posterior lamellar graft was delivered into the anterior chamber using the pull-through technique and attached via air to the anterior lamella which was fixated with 8 additional interrupted sutures.

Modified two-piece mushroom keratoplasty was performed in 4 phakic eyes of 4 pediatric patients (mean age = 55 months) with infectious keratitis (n=2) and Peters anomaly (n=2). No complications were observed intraoperatively. In all cases, the two-piece mushroom graft remained attached and clear, with no episode of graft detachment, wound dehiscence, immune rejection, or graft failure over a 6-month follow-up.