The corneal perforations1 are complications cases of various ocular pathologies2. They are classified into traumatic3,4 and non-traumatic causes, which include sharp and blunt objects resulting in lacerated and punctured wounds with perforation. Trauma may be associated with infections, including most commonly bacterial and fungal infections, which may also occur without prior trauma and if not treated within time, leading to perforation5,6,7,8. Infection is most common cause of corneal perforation9. Sequence of events in corneal infections include direct infiltration of micro-organisms, proteolytic enzymes secreted by organisms, inflammatory cells, repeated damage of epithelial cells and decreased corneal sensitivity, all facilitate progression of corneal perforation.
Scleral autograft is cost effective, easily
available method in the management of corneal
perforation. Moreover, this method is superior to
other available methods, as corneal perforation
is an emergency and this method is easily
approachable, free from screening and rejection
Bacterial micro-organisms which infect cornea includes Pseudomonas aeruginosa, streptococcus species, staphylococcus species and salmonella species. Fungal infections commonly infecting organisms include Fusarium solani, aspergilus fumigates, Pencillium citrinium, Candida albicans, cephalosporium cuvularia10. Protozoa like acantha amoeba can cause ulceration and perforation in contact lens wearers with history of swimming in dirty water11.Inadequate tear film and ocular surface disorders may also cause ulceration and perforation12. Other causes include neurotrophic ulcer, exposure keratitis13 and rarely hydrops with keratoconus14. Inflammatory pathologies cause corneal thinning and subsequent ulceration and perforation15. Collagen vascular disorders include Rheumatoid arthritis16, Systemic lupus erythematosis, wegners granulomatosis and other inflammatory causes include Poly arteritis nodosa, sarcoidosis, inflammatory bowel disease which may cause thinning and perforation. Degeneration and ectasia: like Terriens marginal degeneration, Pellucid marginal degeneration may end-up in corneal ulceration and perforation17. Dry eye and xerosis caused by Kerato-conjunctivitis sicca, Vitamin A Deficiency, ocular Cicatricial pemphigoid, steven Johnson syndrome, Sjogren syndrome may lead to corneal ulceration and perforation. Management of corneal perforation relies upon etiology, site, size and previously taken treatment. Corneal perforation usually present with shallow anterior chamber with visible perforation site. In some cases, site of corneal perforation is obscured by necrotic, infiltrated or oedematous tissue with minimally shallow anterior chamber. In these cases of siedel test is diagnostic. Cause of corneal perforation is mostly evident but in certain cases it must be investigated thoroughly. The Aim of treatment is not only to save integrity of globe but also to treat underlying cause. Treatment options presently available are tarsorraphy, tissue adhesives ie fibrin glue or cyano acrylate glue,18,19 conjunctival flapping, bandage contact lens, tectonic scleral autograft, amniotic membrane transplantation20 and lamellor penetrating keratoplaty.21
MATERIAL AND METHODS:
The prospective study for assessment of efficacy of scleral autograft in corneal perforation is performed at the department of Ophthalmology Chandka medical college hospital Larkana on after approval from Ethical Review Committee SMBBMU Larkana. Patients with corneal perforation, were selected from Out Patients Department (OPD) are admitted in Ophthalmology department With the complication of corneal perforation secondary to non-traumatic (corneal ulcer) or traumatic corneal perforation. Total number of cases were 52, ages range from 15 to 50 years and both gender were included in this study and some patients were excluded with history of collagen vascular disorders, ocular surgery and scleral disease. All patients underwent visual status with assessment on visual acuity chart both distance and near with best corrected visual acuity (BCVA) and slit lamp examination, fundus examination and tonometry for intraocular pressure, laboratory investigations and ultra-sonography was done. The procedure of scleral graft (autograft) was explained to the patient and written consent taken from all patients. Patients were also informed regarding course of recovery, importance of follow up visits and necessity of other additional surgery including keratoplasty. Technique. First of all, the area of corneal perforation was measured with keratometer, to obtain a little bigger sized scleral lamellar button. Limbal based conjunctival flap was formed at the area adjacent to corneal perforation in a way similar as in trabeculectomy. In peripheral corneal perforation a partial thickness scleral flap (rotational) was made with its intact base, is rotated back to cover the corneal perforation and a separate flap of partial thickness of sclera was obtained to cover perforated area in central or para-central corneal perforations. Care was taken to make larger scleral flap in order to cover the whole area of corneal perforation, to avoid leakage. 10/0 nylon sutures were applied with burying knots toward corneal area. Conjunctiva was closed with 8/0 silk suture and therapeutic bandage contact lens was applied to avoid foreign body sensation. After doing scleral grafts in corneal perforations, all patients were examined on its 1st postoperative day. Visual acuity checked for improvement. All patients were examined on slit lamp for stability of graft including any leakage and status of anterior chamber. Patients were checked for any inflammation and infection. Intra ocular pressure was checked on noncontact tonometer (Pneumo- tonometer). All patients were prescribed oral as well as topical antimicrobial (Moxifloxacin eye drops) therapy along with topical steroid eye drops (Dexamethasone eye drops) to prevent infection and inflammation. Patients were discharged from hospital on 1st postoperative day and checked after 01 week on follow up visit. Whole exercise was repeated again including visual acuity testing, slit lamp examination and intra ocular pressure checking. All patients were assessed on 3rd, 4th weeks and after 2 months with visual acuity testing, slit lamp examination and intra ocular pressure was checked by noncontact tonometer. All the collected information was entered into the predesigned performa. Statistical analysis was done through SPSS 22.0 Version mean + standard deviation were calculated for age, duration for corneal perforation, frequency and percentage were calculated for gender, efficacy of scleral auto-graft - yes/no, post stratification applies chi-square taken p-value less than 0.05 as significant.
This study was conducted on 52 patients out of which 27 (51.92%) were male and 25 (48.07%) were female. (Figure 1) Age ranged from 15 to 50 years. (Table 1)Mean age is 35 years. 52 patients were operated for corneal perforation (Figure 2-A), 27 (51.92%) out of 52 patients had central corneal perforation (Figure 2-B), 12 (23.07%) had para central corneal perforation while 13 (25%) (Table 2) had peripheral corneal perforations. According to etiology of 29 ( 55.76%) patients had previous fungal corneal ulcers, 15 (28.84%) were suffering from bacterial corneal ulcers while remaining 08(15.38%) had corneal perforations due to trauma. On 1st postoperative day 4 (7.69%) patients developed anterior chamber leakage with shallow anterior chamber, confirmed on siedel test, and were managed successfully. (Table 3) After one week of surgery, all patients had adequate anterior chamber. 16 (30.76%) patients were complaining of foreign body sensation and watering was improved in 28 patients (53.84%) to 6/60, in 14 (26.92%) patients to 6/24 and in 10 (19.23%) (Table.4) patient’s vision improved 6/18, specially in peripheral corneal perforations. After two weeks of surgery 01 (1.92%) patient developed suture abscess with hypopyon formation. (Figure 3-A and 3-B) All other patients had stable visual acuity, adequate anterior chamber depth and intra ocular pressure within normal range, with well placement of scleral autograft. After 3 weeks of surgery 31 (59.61%) patients developed corneal vascularization and after 4 weeks of surgery 08 (15.38%) more patients developed corneal vascularization. 05 (9.61%) patients had central or para-central corneal perforation. (Figure 4) While 03 (5.76%) had peripheral corneal perforation. (Figure 5-A and 5-B) All other patients had stable visual acuity, adequate anterior chamber and intraocular pressure below 16mm Hg . After 6 weeks of surgery, 32 (61.53%) patients were managed for corneal vascularization, improved regarding symptoms of foreign body sensation and photophobia. After 8 weeks of surgery, 15 (28%) patients developed spontaneous extension of graft due to loosening of sutures. Healing under the graft were observed with scar formation. (Figure 6) After 12 weeks of surgery, 24 (46.15%) patients were referred to the center where keratoplasty facility was available.
Corneal perforation is an emergency which should be dealt promptly. Methods of management includes bandage contact lens, adhesive glues. Amniotic membrane transplantation, keratoplasty and conjunctival flapping. Bandage contact lens and adhesive glues are more effective in small corneal perforation, which are 1-2 mm in size. Conjunctival flapping is mostly considered when visual prognosis is poor. Amniotic membrane transplantation is an effective method but also carries storage problems because corneal perforation is an emergency and there is no prior warning to obtain donor tissue. Moreover, it also has screening, rejection problems and conjunctival flapping mostly used if no hope of vision. In this context, a method was needed which fulfill all requirements, so tectonic sclera autograft is cost effective, easily available method which can save the integrity of globe in emergencies. In our study, 52 eyes of 52 patients with corneal perforations were operated with sclera autograft. 39 (75%) cases developed corneal vascularization, 04 (7.69%) cases developed anterior chamber leakage and 01 (1.92%) case developed infection (suture abscess). According to our knowledge this is the new study in Pakistan of sceral autograft in the management of corneal perforation, however this study already have been done in other countries. Pawan Prasher et al22 described the case report of a patient with paracentral corneal perforation which after 3 months of scleral autograft improved vision less than 6/60 with stable anterior chamber and focal posterior synachiae. In our study after 3 months , in 28 patients (53.84%) vision improved to less than 6/60 , in 14 patients (26.92%) patients vision improved to less than 6/24 and in 10 (19.23%) patients vision improved to 6/18. J. I. Praydal et al23 reported 3 cases of peripheral corneal perforation in which vision was less than 6/60 at the time of perforation and after scleral autograft surgery, vision recovered to 6/9. In our study 13 (25%) patients were operated who had peripheral corneal perforation. Their vision was improved to less than 6/18. In another study of Zhong Quo,Xio Chang et al24 they described the report of 18 cases of corneal perforation. 05 (27.77%) cases had avulsive laceration, severe corneal fistula in 08 (44.44%) cases and localized Staphyloma of cornea in 02 cases. In our study 39 (75%) patients developed corneal vascularization, 04 (7.69%) cases developed anterior chamber leakage while one(1.92%) case developed infection (suture abscess). No case of corneal fistula or Staphyloma was seen. Maurice D.Met al25 described the report of 14 cases of scleral autograft with 02 (14.28%) cases of anterior chamber leakage on second postoperative day, with no sign of infection or inflammation seen. In our study of 52 cases, we observed 04(7.69%) cases with anterior chamber leakage on second postoperative day. Cheng C.l., Tan DT et al26 described the report of 06 cases of scleral autograft, in which 04(66.66%) cases developed corneal vascularization after 3 weeks. In our study 39 (75%) cases developed corneal vascularization after one month of surgery. Maria T, Iradier MD et al27 described the report of 12 cases of scleral autograft with 01 (8.33%) case of infection (endophthalmitis) on second postoperative day. In our study of 52 cases, 01 (1.92%) case of infection (suture abscess) was seen after 3 weeks of surgery.
This study concludes that scleral graft is an effective and easily available method for management of corneal perforation. This method has advantage of being easily available in emergency situations, is cost effective, safe as there is no need of screening and there is no expected graft rejection problems.