Modified tectonic corneoscleral graft technique for treating devastating corneoscleral infections

Abstract

Background: This study aims to evaluate the clinical outcomes and efficacy of a modified tectonic corneoscleral graft (TCG) in patients suffering from devastating corneoscleral infections.

Methods: Thirty-eight eyes from 38 patients who underwent the modified TCG were included in this study. The outcomes measured were recurrence rates, best-corrected visual acuity (BCVA), ocular surface stability, postoperative complications, and graft survival.

Results: Among the 38 patients, 23 had fungal infections, 9 had bacterial infections and 6 had Pythium insidiosum infections. At the final follow-up, with an average duration of 25.1 ± 8.6 months, the rate of monocular blindness decreased from 100 to 58%. Significant improvements in LogMAR BCVA were observed from preoperative to postoperative measurements (P < 0.001). Thirty-two eyes (84.2%) maintained a stable ocular surface. The survival rate of ocular surface stability was 84.2%±5.9% at one year and 57.7%±9.7% at three years post-surgery. Twenty eyes (52.6%) retained a clear graft, with a survival rate for graft clarity was 81.6%±6.3% at one year and 36.0%±10.8% at three years post-surgery. The incidence of immune rejection was 36.8%. Corneal epithelial defects were observed in ten patients, and choroidal detachment occurred in four patients. No cases of elevated intraocular pressure were detected.

Conclusions: The modified TCG is effective in eradicating infections, preserving the eyeball, and maintaining useful vision in cases of devastating corneoscleral infections. Regular use of tacrolimus, timely administration of glucocorticoids, and good patient compliance can help mitigate postoperative challenges.

Keywords: Corneoscleral graft; Corneoscleral infection; Keratoplasty; Treatment.

Fig. 1

Inclusion criteria for patients. Slit-lamp image of corneoscleral infection (a); AS-OCT demonstrated involvement of the total cornea, with the yellow line indicating a corneal thickness of 516μm (b); B-scan ultrasound showed no signs of pre-operative endophthalmitis (c)

Fig. 2

The donor’s scleral ring was sutured overlapping with the recipient’s sclera

Fig. 3

Operative procedure of TCG. The conjunctival incision was made along the limbus (a); The donor graft with a 2 mm wide scleral ring was cut off (b); The diseased cornea and infected scleral tissue were removed completely (c); Scleral ring was sutured overlapped on to the recipient sclera (d); The angle was separated by viscoelastic agent (e); The bulbar conjunctiva was sutured to the corneal limbus (f)

Fig. 4

Photographs of patients with recurrent anterior chamber fungal infiltrate after TCG. Preoperative photograph of a patient (a). One month after TCG (b). After three months of treatment (c). Cataract surgery performed two years after infection control (d)

Fig. 5

Cumulative best-corrected visual acuity (BCVA) before and after TCG (a); LogMAR BCVA before and after TCG (b). Preop = preoperative; Postop = postoperative; FC = finger counting; HM = hand movement; LP = light perception

Fig. 6

Photographs of four patients before and one year after TCG. The first group of pictures (a-d) displays fungal corneoscleral infections, while the second set of pictures (e-h) with bacterial corneoscleral infections

Fig. 7

UBM examination after TCG. The picture shows closure of corneal angle, anterior synechia of iris, and filtering passage at the scleral junction of donor and recipient 2 mm behind corneal limbus (arrow)

Fig. 8

The anatomical survival curve of ocular surface stability (a) and the graft survival of corneal graft clarity (b)