Atypical Tectonic Lamellar Keratoplasty In A Corneal Perforation Due To Severe Dry Eye Disease

To describe the management of a corneal perforation over a large ulcerated corneal bed due to severe dry eye disease performing an atypical tectonic lamellar keratoplasty.

Referral tertiary care Centre in Ophthalmology, Ocular Surface and Cornea Department, Centro de Oftalmología Barraquer, Barcelona.

A 59-year-old patient diagnosed with severe dry eye disease underwent regular check-ups at our centre. His best corrected visual acuity (BCVA) was 0.85 in the right eye (RE) and 0.75 in the left eye (LE).

At a follow-up visit, a corneal ulcer was noted with considerable stromal thinning without infiltrates in the LE, covering the lower third of the cornea. It was decided to perform daily treatment with tobramycin ointment, 1 drop of prednisone and pressure eye patch.

The condition progressed to corneal perforation with iris incarceration and athalamia. Cyanocrylate tissue adhesive was applied. However, the perforation failed to seal and a tectonic lamellar keratoplasty covering the entire horseshoe-shaped ulcerated bed was performed.

During surgery, realizing that the sutures of the upper edge of the graft would invade the pupillary axis, it was decided to extend the graft so that it covered the pupillary area, turning it into an almond-shaped tectonic corneal graft.

One year after the procedure, the patient underwent scheduled cataract removal surgery with IOL implantation in the same eye.

The patient currently undergoes regular annual check-ups. His BCVA is 1.0 in the RE and 0.25 in the LE. He continues treatment in both eyes with artificial tears, 20% autologous serum, lubricating ophthalmic gel, N-acetylcysteine 4 times a day, 0.05% Cyclosporine A twice daily, and pilocarpine (5 mg) orally twice daily.

In conclusion, tectonic lamellar keratoplasty is a good therapeutic option in patients with corneal perforation who present extensive perilesional stromal thinning that prevents other techniques such as small-diameter eccentric penetrating keratoplasty. The lamellar technique provides a lower incidence of graft rejection thanks to the preservation of the patient's endothelium. Finally, it should be noted that morphological variants of keratoplasty, such as the almond shape in this case, allow us to adapt the graft to the anatomical conditions of the cornea in order to achieve the best structural and visual outcome for each patient.