Purpose
To analyze the outcomes of traumatic wound dehiscence after deep anterior lamellar keratoplasty (DALK).
Design
Retrospective and interventional case series.
Methods
setting : Single hospital. patients : A total of 338 consecutive cases were reviewed. Eleven eyes that had wound dehiscence related to ocular trauma were included. main outcome measures : Incidence and causes, best-corrected visual acuity (BCVA), and endothelial cell density were evaluated. Complications and secondary surgeries were recorded.
Results
Seven patients were male (63.6%) and 4 patients were female (36.4%), with a mean age of 30.6 years (range, 24-40 years). The incidence of wound dehiscence was 3.2% (11/338). The mean interval between the initial DALK procedure and wound dehiscence was 9.45 months (range, 2-16 months). The mean follow-up time was 6 years. The most common trauma was a fist blow injury (36.3%). Descemet membrane perforation was observed in 8 eyes (72.7%); lens damage and vitreous prolapse occurred in 2 eyes (18.1%). The final BCVA was 0.51 and was maintained in 4 eyes (36.3%). At the final visit, 10 grafts (90.9%) were clear. The mean endothelial cell loss was 55.8% between before DALK and last visit.
Conclusion
Although the intact Descemet membrane protects against dehiscing traumas after DALK, a relative weakness at the graft-host junction tends to persist and a severe deforming force may result in graft dehiscence. This case series indicates that despite the fact that the visual results following the repair are acceptable, corneal endothelium seems to be subjected to severe damage, which puts graft survival chances at risk in the long term.
Traumatic wound dehiscence after penetrating keratoplasty (PK) is not a rare occurrence, suggesting that the graft-host interface does not achieve the tensile strength of a primary corneal tissue. Even years after PK, wound dehiscence may happen with a relatively minor trauma. Deep anterior lamellar keratoplasty (DALK) has been recommended as a viable surgical option to PK for the management of corneal disease with a healthy endothelium. As the Descemet membrane is kept intact in DALK surgery, it is arguable that the healing is faster and the wound more durable compared to PK. Additional support provided by an uninterrupted endothelium, a healthier restoration process, and reduced need for topical steroids may contribute to the formation of a stronger graft-host interface.
To date, there are only a few case reports about traumatic graft dehiscence following lamellar keratoplasty. Also, long-term results of the wound repair are yet to be demonstrated. In this study, we investigated causes and characteristics of traumatic wound dehiscence in eyes with DALK. We also summarized data related to graft survival and visual prognosis, changes in endothelial cell density, and secondary complications. On the other hand, our PubMed research yielded no data related to the effect of traumatic wound dehiscence on endothelial cell density in eyes with DALK.
Subjects and Methods
This study is a retrospective, noncomparative, interventional case series. Medical records of all patients having undergone DALK surgery between January 1, 2003 and August 30, 2012 at Kartal Training and Research Hospital, Istanbul, Turkey for the treatment of different corneal pathologies were reviewed. Eyes that had a wound dehiscence related to ocular trauma were included in the study. Eyes with nontraumatic loosening or breakage of corneal sutures were not included. Patients who were lost to follow-up were also excluded. Informed consent was obtained from all patients in accordance with the Declaration of Helsinki and the study was approved by the Institutional Review Board of Kartal Training and Research Hospital.
Initial DALK procedures were performed using the big-bubble technique previously described by Anwar and Teichmann. When a big bubble could not be generated after repeated attempts, a layer-by-layer manual dissection was performed. All patients received immediate surgical intervention within several hours after the admission. The wound was repaired under local anesthesia with interrupted or continuous 10/0 nylon sutures. Anterior vitrectomy, crystalline lens extraction, or iris repositioning was performed at the same session when necessary. Subsequent secondary surgeries, if any, were noted.
All patients underwent ophthalmic examination including decimal Snellen best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, and assessment of endothelial cell density (ECD) and graft clarity. The endothelium was evaluated with a Topcon SP 2000p noncontact specular microscope (Topcon Corp, Tokyo, Japan). Twenty endothelial cells were marked for each count and 3 measurements of ECD were averaged. Causes of the ocular trauma, demographic characteristics of patients, extents of the wound dehiscence, and surgical complications were also recorded. Quantitative data were described as mean ± standard deviation (range). The mean changes in endothelial cell density and BCVA were compared using SPSS statistics software package v. 15.0 (SPSS, Inc, Chicago, Illinois, USA). A P value less than .05 was considered statistically significant.
Results
In our clinic, the DALK procedure was performed in 351 eyes during the years 2003-2012. Thirteen eyes were lost to follow-up and excluded from the data analyses. Among the remaining 338 eyes, 11 eyes (3.2%) presented with wound dehiscence attributable to ocular trauma. The Kaplan-Meier survival curve is demonstrated in the Figure . Demographic data of the patients are summarized in Table 1 . Seven patients were male (63.6%) and 4 patients were female (36.4%). Their mean age was 30.6 ± 5.4 years (range, 24-40 years). The indication for DALK surgery was keratoconus in 6 eyes (54.5%), stromal dystrophies in 3 eyes (27.3%), and herpetic keratitis in 2 eyes (18.1%). DALK was performed with big-bubble technique in 7 eyes (63.7%) and with layer-by-layer stromal dissection in 4 eyes (36.4%). Following the trauma, the sutures had to be completely removed in 2 eyes (18.1%) and partially removed in 9 eyes (81.9%) by the treating ophthalmologist at the time of the injury. The mean interval between initial DALK procedure and traumatic wound dehiscence was 9.45 ± 5.0 months (range, 2-16 months). The mean follow-up time after the repair surgery was 6.09 ± 2.77 years (range, 1-9 years).
| Patient | Age at Trauma (y) | Sex | Indication for DALK | Dissection Plane of the DALK Surgery | Interval DALK to Wound Dehiscence (mo) | Nature of Trauma | Number of Wound Dehiscence Quarants | Descemet Membrane Status Just After Trauma | Lens | Posterior Segment | Follow-up Time (y) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 25 | M | Stromal dystrophy | dDALK | 16 | Fist blow | 2 | Perforated | – | – | 9 |
| 2 | 26 | F | Keratoconus | dDALK | 12 | Fist blow | 1 | Intact | – | 9 | |
| 3 | 33 | F | Keratoconus | pdDALK | 6 | Fell during a fight | 3 | Perforated | Crystalline lens expulsion | Vitreous loss | 9 |
| 4 | 34 | M | Stromal dystrophy | dDALK | 6 | Fist blow | 1 | Intact | – | – | 8 |
| 5 | 38 | F | Keratoconus | dDALK | 14 | Struck by door | 2 | Perforated | – | – | 6 |
| 6 | 31 | M | Herpes keratitis | dDALK | 2 | Fist blow | 2 | Perforated | – | – | 6 |
| 7 | 28 | M | Keratoconus | pdDALK | 4 | Struck by metal object | 3 | Perforated | Crystalline lens expulsion | Vitreous loss | 4 |
| 8 | 24 | F | Keratoconus | pdDALK | 11 | Fell during a fight | 1 | Intact | – | – | 4 |
| 9 | 34 | M | Herpes keratitis | pdDALK | 12 | Struck by door | 2 | Peforated | – | – | 8 |
| 10 | 40 | M | Stromal dystrophy | dDALK | 16 | Fell on the face and struck eye | 2 | Perforated | – | – | 3 |
| 11 | 24 | M | Keratoconus | dDALK | 5 | Struck by door | 2 | Perforated | – | – | 1 |
The most common type of trauma was a fist blow injury (4 cases; 36.4%). In all eyes, the wound dehiscence occurred at the graft-host interface. The dehiscence involved 3 quadrants in 2 eyes (18.1%), 2 quadrants in 6 eyes (54.5%), and 1 quadrant in 3 eyes (27.3%). Descemet membrane perforation attributable to the trauma was observed in 8 eyes (72.7%). During the repair surgery, microperforation occurred at the graft-host junction in 1 eye (9.1%). The repair surgery was continued with the help of air injection into the anterior chamber. All eyes were phakic before the trauma. Crystalline lens damage and vitreous prolapse occurred in 2 eyes (18.1%), which required lens extraction combined with anterior vitrectomy.
The course of mean visual acuities is summarized in Table 2 . The mean BCVA was 0.04 ± 0.03 (range, 0.01-0.1) before DALK and 0.60 ± 0.20 (range, 0.1-0.8) at the last visit before the trauma. BCVA on admission immediately after the traumatic wound dehiscence was light perception in 2 eyes (18.1%), hand movements in 3 eyes (27.3%), and counting fingers in 6 eyes (54.5%). At the final visit after the repair surgery the mean BCVA was 0.51 ± 0.19 (range, 0.05-0.8). The difference between the mean BCVA at the last visit before trauma and the mean BCVA at the final visit was not found to be statistically significant ( P > .05). BCVA was maintained in 4 eyes (36.4%) and decreased in 7 eyes (63.6%) after the trauma.
| Patient | BCVA Before DALK | BCVA Before Trauma | BCVA Immediately After Trauma | Final BCVA | ECD Before DALK (Cells/mm 2 ) | ECD Before Trauma (Cells/mm 2 ) | Final ECD (Cells/mm 2 ) | Graft Clarity | Additional Complications and Surgeries |
|---|---|---|---|---|---|---|---|---|---|
| 1 | 0.1 | 0.8 | Hand movements | 0.7 | 3322 | 3053 | 1198 | Clear | Phacoemulsification and IOL implantation |
| 2 | 0.05 | 0.4 | Counting fingers | 0.4 | 3216 | 3018 | 1956 | Clear | – |
| 3 | 0.05 | 0.7 | Light perception | 0.5 | NDA | 2954 | 958 | Clear | Secondary IOL implantation with scleral fixation |
| 4 | 0.05 | 0.6 | Counting fingers | 0.6 | NDA | 2658 | 1745 | Clear | Phacoemulsification and IOL implantation |
| 5 | 0.05 | 0.8 | Hand movements | 0.6 | NDA | 2957 | 1013 | Clear | |
| 6 | 0.01 | 0.1 | Hand movements | 0.05 | NDA | 2156 | NDA | Hazy | Corneal melting, regrafting with penetrating keratoplasty |
| 7 | 0.1 | 0.5 | Light perception | 0.5 | 3162 | 2867 | 963 | Clear | Secondary IOL implantation with scleral fixation |
| 8 | 0.01 | 0.8 | Counting fingers | 0.8 | 2658 | 2448 | 1652 | Clear | |
| 9 | 0.05 | 0.6 | Counting fingers | 0.4 | NDA | 2348 | NDA | Clear | |
| 10 | 0.05 | 0.7 | Counting fingers | 0.6 | 3215 | 2956 | 1133 | Clear | |
| 11 | 0.01 | 0.6 | Counting fingers | 0.5 | 3148 | 3014 | 1249 | Clear |
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