A novel technique of penetrating keratoplasty to prevent intraocular contents extrusion for infectious keratitis

Abstract

Purpose: To evaluate the safety and the effectiveness of our novel penetrating keratoplasty for infectious keratitis.

Methods: Retrospective, noncomparative, interventional case series of patients with infectious keratitis who received the novel penetrating keratoplasty technique were analyzed. A prepared plastic sheet was located between the diseased cornea and iris-lens diaphragm. After the diseased lesions were removed, the graft was positioned on the plastic sheet and sutured to the recipient bed. The plastic sheet was pulled out from the anterior chamber before the all interrupted sutures were placed. The intra- and post-operative complications, the outcome of the graft and the number of corneal endothelial cells were analyzed.

Results: A total of 82 eyes of 82 patients was included. The mean follow-up period was 29 ± 16 months (range from 13 to 45 months). No intraocular content extrusion, simultaneous cataract extraction and suprachoroidal hemorrhage occurred. Direct contact between the infectious cornea and the graft was successfully avoided. Greater than expected endothelial cell reduction or complications were not found.

Conclusions: This modified technique effectively prevents the extrusion of intraocular contents while avoiding the direct contact with donor endothelium during the procedure. The occurrence rate of complications such as endothelial cell loss is not higher than the conventional methods.

Keywords: Extrusion; Infectious keratitis; Intraocular contents; Lens-iris diaphragm; Penetrating keratoplasty; Plastic sheet.

Fig. 1

Illustration of the plastic sheet. A. Surgical film with drainage bag is used as a protective sheet for the extrusion of intraocular contents. B. The sheet is single-layered and the thickness is 0.1 mm

Fig. 2

Illustration of the PK technique. A. Preparation of the plastic sheet. B. Separation of the adhesion between ulcerated cornea and iris-lens with viscoelastic agent. C. Insertion of the sheet beneath the ulcerated cornea, fixation of the sheet with four sutures to stabilize the iris–lens diaphragm. D. Resection of the ulcerated cornea. E. Fixation of the graft with 4 sutures. F. Removal of the sutures of the sheet and pulling it out through the superior arc incision secondary by sutures of cornea button

Fig. 3

Description of the technique for protecting endothelium and preventing extrusion of intraocular contents with plastic sheet. (A) Trephination with suctionless trephine. An adequate size of hand-held trephine is used to make a circular and deep anterior incision to about 2/3 depth of the cornea. Curved corneal scissors used to make two full thickness arc incision from 10 to 2 o’clock and 4 to 8 o’clock in recipient bed. (B) Insertion of plastic sheet into anterior chamber. A sheet is cut from drainage bag with 7-7.5 mm wide and 20 mm long and is inserted into anterior chamber, just beneath the ulcerated cornea. (C) Sagittal view of plastic sheet inserted beneath the ulcerated cornea. (D) The ulcerated cornea is excised, and plastic sheet sutured to the edge of recipient bed could protect the lens-iris diaphragm from protrusion and facilitate the suturing of corneal graft. Note the iris and pupil are visible through the plastic sheet. (E) Plastic sheet is removed, and the suture of corneal button is complete