Management Of Diabetic Corneal Melt And Perforation With Split Anterior And Posterior Lamellar Tectonic Grafts From A Single Donor Cornea

To report a case of diabetic corneal melt and perforation managed with split anterior and posterior lamellar tectonic grafts from a single donor cornea

Tertiary referral centre at King's College Hospital NHS Foundation Trust, London 

The 73 year old male presented with bilateral peripheral corneal ulcers with a hypopyon in the left eye. He was managed initially with oral doxycycline, prednisolone and topical moxifloxacin. However, he developed a perforation in the left eye 2 weeks later which was glued and was found to have uncontrolled diabetes with HbA1c of 134mmol/mol. His autoimmune screening bloods were negative. He was then referred to a diabetic consultant for urgent optimisation of his diabetic control and to facilitate general anaesthesia for a planned tectonic graft. Intraoperatively, a pre-cut DSAEK donor with the anterior lamellar cap was used. The posterior lamellar graft was first divided into 2 halves to treat the inferior nasal perforation and add tissue to the inferior temporal quadrant with significant peripheral corneal melt. The anterior lamellar cap was then positioned centrally and inferior nasally to cover the areas of corneal thinning and sutured in place with interrupted nylon sutures. The split tectonic grafts in the left eye remain viable 9 months postoperatively with a visual acuity of 6/48 unaided and 6/18 pinhole.

Our case demonstrates effective management of corneal perforation using a novel technique with split anterior and posterior lamellar grafts from a single donor cornea. Our technique can be adopted in patients with multiple areas of perforation or melts requiring tissue addition with the benefit of fully utilising donor cornea tissue and avoiding the need for multiple donor corneas.