Modified tectonic keratoplasty with minimal corneal graft for corneal perforation in severe Stevens--Johnson syndrome: a case series study

Abstract

Background: Corneal perforation in severe Stevens-Johnson syndrome (SJS) presenting great therapeutic difficulties, the imperative corneal transplantation always result in graft failure and repeated recurrence of perforation. The aim of this study was to evaluate the effectiveness of a modified small tectonic keratoplasty (MSTK) with minimal corneal graft in the management of refractory corneal perforation in severe SJS.

Methods: Refractory corneal perforations in ten patients (10 eyes) with severe SJS were mended with a minimal corneal patch graft, under the guidance of anterior chamber optical coherence tomography, combined with conjunctival flap covering. The outcome measures included healing of the corneal perforation, survival of the corneal graft and conjunctival flap, relevant complications, and improvement in visual acuity.

Results: Corneal perforation healed, and global integrity was achieved in all eyes. No immune rejection or graft melting was detected. Retraction of conjunctival flap occurred in one eye, which was treated with additional procedure. Visual acuity improved in six eyes (60%), unchanged in three eyes (30%) and declined in one eye (10%).

Conclusions: The MSTK combined with conjunctival flap covering seems to be effective for refractory corneal perforation in severe SJS.

Figure 1

Determination of trephine diameter. (A) The appearance of the corneal ulcer and perforation on HD-OCT examination. (B and C) Shape of the corneal ulcer (*) and the area with the remaining stroma more than two-thirds of the cornea in thickness (†) in the corneal section and overall appearance. The diameter of the trephine should equal to that of “†”.

Figure 2

The procedure of modified small tectonic keratoplasty and conjunctival flap covering. (A and A’) Corneal ulcer after clearing of necrotic tissues and restoring of synechia. (B and B’) A selected trephine was used to mark around the perforation. (C and C’) The recipient bed with the posterior stroma and Descemet’s membrane reserved. (D and D’) The corneal button was placed in the bed and sutured with interrupted 10–0 nylon sutures. (E and E’) A bridge-like conjunctival flap, 0.5 mm larger than the ulcer, was obtained. (F and F’) conjunctival flap was secured tightly using 10–0 monofilament nylon sutures.

Figure 3

Preoperative and postoperative corneal perforation in patient 2. (A) Preoperatively, the size of the maximum diameter(blue) of the corneal ulcer was much larger than that of the minimum diameter(yellow) of the area that a corneal transplantation could be easily performed. (B) The corneal perforation healed and the conjunctival flap presented significant regression 6 months after surgery.

Figure 4

Postoperative corneal perforation in patient 2. (A) The corneal perforation healed yielding a visual acuity of 20/200 at 6 months after surgery. But a clean, paranasal corneal ulcer, 2 mm in diameter, occurred just beside the conjunctival flap. (B) Both the corneal ulcer and the perforation healed with good survival of the corneal graft and conjunctival flap at 32 months after the second surgery.