Short Reports Traumatic wound dehiscence after deep anterior lamellar keratoplasty Sunita Chaurasia, MS, and Muralidhar Ramappa, MS
A 5-year-old boy who had undergone deep anterior lamellar keratoplasty (DALK) in the right eye 8 months earlier presented with a fullthickness graft–host junction dehiscence and iris prolapse following an injury with a rubber ball. The junction was resutured and the graft became clear within 5 weeks. To our knowledge, this is the first reported case of wound dehiscence after DALK in a child. Although Descemet’s membrane might be considered a protective barrier following DALK, the graft–host junction remains vulnerable and can rupture with blunt trauma.
Case report
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5-year-old boy presented to the LV Prasad Eye Institute, Hyderabad, India, with pain, redness, and reduced vision in the right eye, where he had been struck with a rubber ball. Eight months earlier he had undergone uncomplicated deep anterior lamellar keratoplasty (DALK) for mid- to deep stromal scar over the pupil following infectious keratitis in the same eye. The post-DALK treatment regimen included prednisolone acetate 1% 10 times daily for a week, which was tapered gradually over the next 6 weeks and maintained at twice daily. Sutures were removed serially under general anesthesia at regular 4- to 6-week intervals. At 6 months after surgery all sutures were removed and, with a refraction of plano 5.00 180, his visual acuity was 20/80. Maintenance therapy with prednisolone acetate 1% once daily was continued until the injury occurred. On examination, his visual acuity was hand movements in the right eye and 20/20 in the left eye. There was 180 fullthickness graft–host junction rupture extending from 12 o’clock to 6 o’clock nasally, with the iris prolapsed through the site of the wound and a total hyphema, which precluded assessment of the lens. The left eye was unremarkable. The graft–host junction was resutured under general anesthesia. The graft was hazy on postoperative day 1, with total hyphema. The patient was treated with tapering doses of prednisolone acetate 1% eye drops and ofloxacin 0.3% eye drops for 2 weeks. B-scan ultrasonography of the
Author affiliations: Cornea and Anterior Segment Service, LV Prasad Eye Institute, Hyderabad, India The authors have no conflicts of interest to disclose. Submitted April 30, 2011. Revision accepted June 26, 2011. Reprint requests: Sunita Chaurasia, MS, LV Prasad Eye Institute, LV Prasad Marg, Banjara Hills, Hyderabad, India 500034 (email:
[email protected]). J AAPOS 2011;15:484-485. Copyright Ó 2011 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2011.06.006
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posterior segment of right eye showed no evidence of retinal detachment, and there was no evidence of endophthalmitis. The graft edema and hyphema cleared over 5 weeks. At 2 months’ follow-up, his visual acuity in the right eye was 20/400. The graft was clear and the pupillary area showed an organized membrane. At 6 months’ follow-up all sutures were removed and a membranectomy was performed to clear the pupil. Intraocular lens implantation was deferred for lack of posterior capsular support. He was subsequently managed with an aphakic contact lens.
Discussion Traumatic wound dehiscence after penetrating keratoplasty is a well-known complication, suggesting that the graft– host interface remains weak for years after the surgery.1 DALK has emerged as a viable alternative to penetrating keratoplasty for the management of anterior stromal scarring. Compared to penetrating keratoplasty, DALK involves removal of stroma, which leaves Descemet’s membrane intact and a theoretically stronger wound. The literature on wound dehiscence after DALK is sparse, suggesting that it may occur infrequently. Lee and Mathys2 reported a case of wound dehiscence of lamellar graft 2 weeks after DALK without perforation into the anterior chamber. Prasher and colleagues3 reported a case of traumatic dislodgment of a lamellar graft after anterior lamellar keratoplasty 2 months after surgery without development of ocular perforation. One case of traumatic graft–host junction dehiscence and ultimate ocular perforation 3 months after DALK has been reported in a 20-year-old man.4 To our knowledge, this is the first report of a full-thickness graft–host junction dehiscence with Descemet’s membrane rupture after DALK in a child. The various factors affecting the healing at the graft– host junction and influencing wound integrity include presence of sutures, age,5 and frequency of steroid administration.6 Sutures afford mechanical protection until the graft–host junction is healed. The corneal wound healing response is faster in children than adults and hence suture removal is performed earlier in children.5 Our patient presented with traumatic graft–host junction rupture 8 months after surgery. All sutures were removed by 6 months after surgery, when wound healing is expected to have been completed. Subsequently, he was maintained on low-dose steroid therapy, which is unlikely to have influenced the wound integrity. Although Descemet’s membrane is presumed to act as a barrier to traumatic globe rupture in DALK, graft–host junction weakness persists after surgery and a severe deforming force can rupture
Journal of AAPOS
Volume 15 Number 5 / October 2011 the graft–host junction. In a normal eye, the corneo-scleral limbus and sclera behind the rectus muscles are vulnerable sites for rupture after blunt trauma. The full-thickness rupture at the graft–host junction in our patient suggests that vulnerability following DALK may shift to this site. The regular use of eye protection should be considered in cases of anterior lamellar corneal transplantation, particularly in children, who are more at risk of injuries.7
Literature search PubMed and Google were searched using the following keywords in combination: traumatic wound dehiscence after keratoplasty, deep anterior lamellar keratoplasty, globe rupture after lamellar keratoplasty. All relevant publications were reviewed.
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References 1. Lam FC, Rahman MQ, Ramaesh K. Traumatic wound dehiscence after penetrating keratoplasty—a cause for concern. Eye 2007;21: 1146-50. 2. Lee WB, Mathys KC. Traumatic wound dehiscence after deep anterior lamellar keratoplasty. J Cataract Refract Surg 2009;35:1129-31. 3. Prasher P, Muftuoglu O, Mootha V. Traumatic graft dehiscence after anterior lamellar keratoplasty. Cornea 2009;28:240-42. 4. Kalantan H, Shahwan SA, Torbak AA. Traumatic globe rupture after deep anterior lamellar keratoplasty. Indian J Ophthalmol 2007;55: 69-70. 5. Gloor P. Pediatric penetrating keratoplasty. In: Krachmer JH, Mannis MJ, Holland EJ, eds. Cornea: Surgery of the Cornea and Conjunctiva. St Louis, MO: Elsevier Mosby Publishers; 2005. 6. Gasset AR, Lorenzetti DW, Ellison EM, Kaufman HE. Quantitative corticosteroid effect on corneal wound healing. Arch Ophthalmol 1969;81:589-91. 7. MacEwan C, Baines P, Desai P. Eye injuries in children: The current picture. Br J Ophthalmol 1998;83:933-6.
