Salvaging The Corynebacterium–Herpetic Melt: Stromal-Peel Dalk-On-Pk After Glued Full-Thickness Perforation Reveals Unexpected Posterior Integrity

To demonstrate that stromal-peel deep anterior lamellar keratoplasty (DALK) can be successfully performed within a previous penetrating keratoplasty (PK) after a cyanoacrylate-sealed full-thickness perforation caused by combined Corynebacterium and herpetic keratitis, showing that posterior corneal integrity may recover sufficiently to permit an endothelium-sparing alternative to redo PK without pneumatic dissection.

Norfolk and Norwich University Hospital NHS Foundation Trust, United Kingdom

A man in his early 70s with keratoconus and a history of herpes simplex keratitis had undergone left PK 9 years earlier for severe hydrops. He subsequently developed severe infectious keratitis due to Corynebacterium species with concurrent herpetic disease, complicated by a full-thickness corneal perforation, managed with cyanoacrylate glue and bandage contact lens support. Owing to the full-thickness defect, redo PK was initially planned.

Definitive surgery was undertaken once the eye had stabilised. Given the vascularised, herpetic ocular surface and high rejection risk, DALK was attempted as an endothelium-preserving strategy.

After removal of the cyanoacrylate glue, dissection initiated at the graft–host junction revealed a natural lamellar cleavage plane. The corneal stroma was then peeled en bloc in a single layer, without pneumatic dissection.

Despite the prior full-thickness perforation, the pre-Descemet layer complex was intact and the perforation had completely healed, allowing completion of DALK without entry into the anterior chamber and avoiding conversion to redo PK. Donor anterior lamellar tissue was secured in standard fashion.

A cyanoacrylate-sealed full-thickness perforation from severe bacterial and herpetic keratitis does not necessarily mandate redo PK. In selected post-perforation eyes, posterior corneal layers may recover structural integrity sufficient for lamellar reconstruction. En bloc stromal peeling can enable DALK as an endothelium-sparing alternative, reducing rejection risk while restoring tectonic stability. Importantly, a lamellar plane of separation commonly exists at the graft–host interface in eyes with prior PK, which can be exploited to access the pre-Descemet plane. This case highlights the potential for biological restoration of posterior integrity even after full-thickness corneal perforation.