Closure of microperforation during deep anterior lamellar keratoplasty with a corneal tissue fragment.

We present a case of intraoperative microperforation during routine deep anterior lamellar keratoplasty, managed with sealing the leak with the help of corneal tissue fragment and fibrin glue. Post operatively the graft was clear with complete closure of the perforation and without any further complications.

Introduction

A 20-year-old male reported with complaints of blurring of distant vision in both eyes for 4 years, which was gradually progressive. Best-corrected visual acuity was 6/60 in the right eye (RE) and 6/36 in the left eye (LE). Slit-lamp and topography evaluation was done [Figure 1]. The patient was diagnosed with keratoconus in both eyes. He underwent deep anterior lamellar keratoplasty (DALK) in the RE. A type 2 big bubble was achieved, and after removing the anterior stromal tissue, during careful dissection, there was a small microperforation. Intraoperatively, this microperforation was sealed using a small corneal tissue fragment from the already dissected anterior host corneal tissue with the help of fibrin glue. Postoperatively, the microperforation sealed well which was examined on slit lamp [Figure 2a and b] and confirmed on anterior-segment optical coherence tomography (OCT) [Figure 2c and d]. There was no communication between the anterior chamber and the perforation. At 1-week, 1-month, and 3-month postoperative visits, the graft remained clear, and the visual acuity improved to 6/12. As the tissue fragment was away from the visual axis, it did not cause any disturbance to the quality of the vision [Figure 3].

Figure 1

(a) Preoperative slit-lamp diffuse image showing keratoconus. (b) Preoperative topography showing central severe keratoconus

Figure 2

(a) A clear graft with sutures in place with small opacity (arrowhead) on the paracentral region indicating the corneal tissue fragment used to seal the microperforation with the help of fibrin glue. (b) Slit section image showing the tissue fragment. (c) Anterior-segment optical coherence tomography image showing the small corneal tissue fragment between the recipient anterior lamellar tissue and host pre-Descemetic layer (arrowhead). (d) Anterior-segment optical coherence tomography image showing the well-attached lamellar graft to host pre-Descemetic layer

Figure 3

Postoperative corneal topography

Discussion

Microperforations of Descemet's membrane are the most common intraoperative complication during DALK surgery.[12] Intraoperative micro- and macro-perforations are the risk factors for causing a double anterior chamber postoperatively. Various techniques have been mentioned in literature to deal with microperforations. Using fibrin glue to seal the microperforation is one important technique in these conditions.[3] In this case, we used a fragment of the dissected host corneal tissue and sealed the microperforation using fibrin glue. Anterior-segment OCT in such cases can be useful to image the seal and confirm the apposition of the perforation with the tissue fragment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.