Ab Interno Approach To Sealing Corneal Perforations Using An Off-The-Shelf Human Cornea

Corneal perforations necessitate prompt surgical intervention to restore globe integrity and mitigate the risk of irreversible vision loss. While techniques such as corneal gluing represent effective treatment options, larger corneal perforations particularly those situated peripherally or on steep corneal surfaces often require complex surgical strategies, including tectonic patch grafting. However, the limited availability of donor tissue can present significant challenges in meeting the urgency of these cases. An alternative approach involves using readily accessible tissue for repair. Here, we describe a novel ab interno technique for corneal perforation repair, utilizing an off-the-shelf human cornea as a viable surgical treatment

The surgery was performed at Norfolk and Norwich University Hospital, United Kingdom (UK), where Halo® (VisionGift, Portland, Oregon) cornea, made from preserved human corneal tissue, was used for repair. The tissue meets Food and Drug Administration and UK regulatory standards. The Halo® grafts are sterilized and stored at room temperature in recombinant human serum albumin. They have a shelf life of up to two years making them suitable for use in emergency situations.

An 89-year-old Caucasian female presented with a painful, red left eye associated with significant vision loss. She had previous herpes zoster ophthalmicus keratitis with corneal thinning. She also had a history of left lower lid entropion, treated with botox and lid taping.

On examination, the left eye visual acuity was reduced to hand movements with corneal perforation in the area of prior corneal thinning. Initial management included corneal gluing. Despite initial stabilization, one week postoperatively, the glue dislodged necessitating further surgical intervention.

Due to the peripheral location and size of the corneal defect, coupled with the availability of Halo® cornea tissue, a decision was made to proceed with an ab-interno approach to tamponade the defect. The corneal defect was measured, and a 5mm disc of Halo® cornea was excised to adequately cover the defect. The anterior chamber was reformed, and an inferior peripheral iridotomy was performed. The Halo® disc was then positioned internally over the defect, and air injected to facilitate its attachment. SF6 gas was subsequently injected, achieving a >90% fill followed by suture closure of wounds. Simultaneously, a Jones procedure was performed to correct the left lower lid entropion.

At one week, the patient's left eye vision had improved to 6/24, with intraocular pressure of 10mmHg. Two months post-surgery, the left eye's visual acuity improved to 6/15 with no leak and lower lid in the correct anatomical position.

This case highlights the successful use of a Halo® cornea graft for the management of a large peripheral corneal perforation in a patient with complex ocular pathology. In an emergency, corneal stroma is readily abundant with a shelf life of up to 2 years. Using an ab-interno stromal graft requires no sutures to secure the graft, and no potential for irregular astigmatism or poor vision. The combination of surgical approaches, including corneal grafting and entropion repair, resulted in significant visual recovery, demonstrating the potential for multifaceted surgical management in elderly patients with combined corneal and lid pathology. This technique would be of particular interest to ophthalmologists who manage corneal perforations.