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A new Technique for Corneal Mushroom Grafts*
DELAY OF CORNEAL EPITHELIZATION
27
22. : Morphologic changes in cells of corneal epithelium in wound healing. Arch. Ophth., 41:306, 1949. 23. Loewenstein, A. : Experimentelle Untersuchungen über die Regeneration des Hornhautepithels. Arch. f. Ophth., 85:221, 1913. A N E W T E C H N I Q U E FOR CORNEAL MUSHROOM GRAFTS* A N D ITS INDICATION FREDERICK W.
STOCKER,
M.D.
Durham, North Carolina Paufique, Sourdille, and Offret1 among others have drawn attention to the fact that, in cases of heavily vascularized corneal scars, perforating grafts stand a better chance of remaining clear if preceded by a large lamel lar graft. According to Filatov2 the improve ment in environment brought about by the lamellar graft may be caused by a trophic in fluence of the graft on the diseased recipient cornea. The combination of lamellar and perforat ing grafts may be accomplished in two stages (fig. 1,1 and II) or in one stage (fig. 1, I I I ) . With either of these methods two separate grafts are used. Franceschetti and Doret 3 pointed out that it might be preferable to use a single graft with a large lamellar and a small perforating portion. Because of the suggestive shape, they called this type a "mushroom" graft (fig. 1, I V ) . Trying to overcome the technical difficulty of cutting this mushroom-shaped graft out of the donor cornea, they devised an apparatus by which this could be done mechanically. While theirs is an ingenious instrument, its manipulation very likely would cause considerable trauma to the tissues of the graft. With the tech nique to be presented, it is possible to cut a mushroom graft from the donor cornea with a minimum of damage to the tissues. The delicate endothelial layer, in particular, is not disturbed. This is, of course, most desir able. * From the McPherson Hospital and the Divi sion of Ophthalmology, Department of Surgery, Duke University School of Medicine. Read at the XVIII International Congress of Ophthalmology, September 8-12, 1958, Brussels, Belgium.
The technique is illustrated by Figures 2, 3, and 4. The size of both the lamellar and the perforating portion of the graft may be chosen to fit each specific case. I have found that in most cases a diameter of six mm. is most desirable for the perforating portion and a diameter of 11 mm. for the lamellar portion. Recently I have made the perforat ing portion as large as 7.5 mm. with satis factory results. An assistant holds the donor eye in a piece of gauze, exerting a moderate squeezing pressure in order to increase the firmness of the globe. A guarded 11 mm. trephine is then applied and the cornea incised to about half its thickness. A few pricks are made with calipers to outline the area to which the per forating graft should be confined. These marks are 2.5 mm. inside of the incision of the 11 mm. trephine if a six-mm. perforating portion is planned. Starting with Paufique's angulated knife, later using a large cutting blade, the cornea is then split in the plane of its half-thickness until the area outlined by the calipers is reached. Using a Graefe knife, the anterior chamber is opened, and the whole cornea, together with a small scierai ring, is excised. The cornea is placed, endothelial side up, on a paraffin block on which a concavity cor responding to the corneal curvature had been made. Again, the limits of the perforating part of the graft are outlined with calipers. A six-mm. trephine is gently applied in that central area, cutting through Descemet's membrane and part of the stroma. The ring, consisting of the deeper layers of the stroma,
28
FREDERICK W. STOCKER
Fig. 1 (Stocker). (I) Lamellar graft. (II) Lamellar graft followed by small perforating graft. ( I l l ) Small perforating graft covered by large lamellar graft. (IV) Graft containing a central perforating and a large lamellar portion ("mushroom" graft).
which is to be discarded is completely excised with scissors. Care must be taken that one blade of the scissors always remains between the corneal layers and that the cutting is done exactly along the incision line marked by the six-mm. trephine. In such a manner, a mush room graft with a six-mm. perforating and an 11-mm. lamellar part is obtained. Two silk sutures are inserted through the lamellar part at opposite sides, and the graft is im mersed in serum obtained from the patient to be grafted.
The preparation of the recipient's eye is rather simple. A superficial corneal lamella 11 mm. in diameter is sliced off in the usual manner. A central plug, six mm. in diameter, is next removed by the usual trephination, and the graft is immediately put into place. It is sutured to the recipient's cornea using from 10 to 16 silk sutures. Since only the lamellar part has to be sutured, this is much less difficult than the edge-to-edge suturing of an ordinary perforating graft. Air is usu ally not injected into the anterior chamber, or
Fig. 2 (Stocker). (Left) The lamellar portion of the graft is out lined with an 11-mm. trephine. (Right) The area of the graft which will be perforating is out lined with calipers.
CORNEAL MUSHROOM GRAFTS
29
Fig. 3 (Stocker). (Left) The lamellar portion of the graft is dissected up to the area which will be occupied by the perforating por tion. (Right) The total cornea to gether with a small ring of sciera is excised.
only with great caution, because, if under pressure, it tends to spread between the pa tient's cornea and the lamellar part of the graft. This should be avoided. Both eyes are closed for three to five days, but the patient is out of bed the day after the operation. No spreading of the wound or iris prolapse is to be feared because of the protecting action of the lamellar ring of the graft. The sutures may be removed on the 10th to 12th post operative day.
Postoperative complications are few be cause of the previously mentioned protection of the lamellar part of the graft, the most severe one being secondary glaucoma. This condition may develop, particularly in se verely diseased eyes, as it does with any other type of graft and is hardly related to the spe cific technique described. In the cases of heavily vascularized corneal scars, vascularization may persist or develop postoperatively between the lamellar part of the graft
Fig. 4 (Stocker). (Upper) The excised cornea is placed, endothelium up, on a paraffin block and the central perforating part of the graft is outlined. (Middle) The deeper layers of the graft to be discarded are excised. (Lower) Final shape of graft ("mushroom").
30
FREDERICK W. STOCKER
Fig. 5 (Stocker). Some of the results. (Left) Be fore operation. (Right) After mushroom graft.
and the recipient cornea. Usually, however, it stops at the edge of the perforating part. In addition to dense and severely vascularized corneal scars, I have extended my in
dication for this procedure to the heavily scarred corneas resulting from previous un successful grafts, to perforating ulcers, and w e r e bullous keratopathy after cataract extraction. As previously reported4 I have, in the past, treated the latter condition with large lamellar grafts. I now feel that I get better results from mushroom grafts, with fewer recurrences of the symptoms and in some cases even visual improvement. If one should use perforating grafts in these cases, quite large grafts would be necessary, as in Fuchs' dystrophy. Since this is a very hazard ous procedure in aphakic eyes because of the possibility of large vitreous loss, the tech nique presented here appears to be safer. When discussing the results obtained with the present technique of corneal mushroom grafts, one should remember that so far this method has been used only in almost desper ate cases. Some of the patients with severe bullous keratopathy had become so desperate because of intractable pain as to demand re moval of the offending eye. If in such a case the eye can be made comfortable and some vision, however little, restored, much is ac complished. Of the 13 cases operated on by the method presented, 12 remained free or almost free of symptoms. In nine cases visual acuity has been somewhat improved. In one case, a se vere bullous keratopathy after cataract extrac tion, visual acuity had improved from recog nizing finger movements to 20/40 and had remained so when last seen six months after the operation. Figure 5 illustrates some of the results. 1110 West Main Street.
REFERENCES
1. Paufique, L., Sourdille, G. P., and Off ret, G. : Les greffes de la corneé. Rapport Soc. Franc. d'ophtal. Paris, Masson, 1948, p. 337. 2. Filatov, V. P.: Vest. Oftal, 10:635, 1937. (Ref. Zentralbl. f. Ophth., 41:185, 1938.) 3. Franceschetti, A., and Doret, M.: Kératoplaste combinée lamellaire et perforante. XVI Concilium Ophthalmologicum Acta, 2:1050-1060, 1950. 4. Stocker, F. W. : Management of endothelial and epithelial corneal dystrophy. Tr. Am. Acad. Ophth , 1956, pp. 567-573.
27
22. : Morphologic changes in cells of corneal epithelium in wound healing. Arch. Ophth., 41:306, 1949. 23. Loewenstein, A. : Experimentelle Untersuchungen über die Regeneration des Hornhautepithels. Arch. f. Ophth., 85:221, 1913. A N E W T E C H N I Q U E FOR CORNEAL MUSHROOM GRAFTS* A N D ITS INDICATION FREDERICK W.
STOCKER,
M.D.
Durham, North Carolina Paufique, Sourdille, and Offret1 among others have drawn attention to the fact that, in cases of heavily vascularized corneal scars, perforating grafts stand a better chance of remaining clear if preceded by a large lamel lar graft. According to Filatov2 the improve ment in environment brought about by the lamellar graft may be caused by a trophic in fluence of the graft on the diseased recipient cornea. The combination of lamellar and perforat ing grafts may be accomplished in two stages (fig. 1,1 and II) or in one stage (fig. 1, I I I ) . With either of these methods two separate grafts are used. Franceschetti and Doret 3 pointed out that it might be preferable to use a single graft with a large lamellar and a small perforating portion. Because of the suggestive shape, they called this type a "mushroom" graft (fig. 1, I V ) . Trying to overcome the technical difficulty of cutting this mushroom-shaped graft out of the donor cornea, they devised an apparatus by which this could be done mechanically. While theirs is an ingenious instrument, its manipulation very likely would cause considerable trauma to the tissues of the graft. With the tech nique to be presented, it is possible to cut a mushroom graft from the donor cornea with a minimum of damage to the tissues. The delicate endothelial layer, in particular, is not disturbed. This is, of course, most desir able. * From the McPherson Hospital and the Divi sion of Ophthalmology, Department of Surgery, Duke University School of Medicine. Read at the XVIII International Congress of Ophthalmology, September 8-12, 1958, Brussels, Belgium.
The technique is illustrated by Figures 2, 3, and 4. The size of both the lamellar and the perforating portion of the graft may be chosen to fit each specific case. I have found that in most cases a diameter of six mm. is most desirable for the perforating portion and a diameter of 11 mm. for the lamellar portion. Recently I have made the perforat ing portion as large as 7.5 mm. with satis factory results. An assistant holds the donor eye in a piece of gauze, exerting a moderate squeezing pressure in order to increase the firmness of the globe. A guarded 11 mm. trephine is then applied and the cornea incised to about half its thickness. A few pricks are made with calipers to outline the area to which the per forating graft should be confined. These marks are 2.5 mm. inside of the incision of the 11 mm. trephine if a six-mm. perforating portion is planned. Starting with Paufique's angulated knife, later using a large cutting blade, the cornea is then split in the plane of its half-thickness until the area outlined by the calipers is reached. Using a Graefe knife, the anterior chamber is opened, and the whole cornea, together with a small scierai ring, is excised. The cornea is placed, endothelial side up, on a paraffin block on which a concavity cor responding to the corneal curvature had been made. Again, the limits of the perforating part of the graft are outlined with calipers. A six-mm. trephine is gently applied in that central area, cutting through Descemet's membrane and part of the stroma. The ring, consisting of the deeper layers of the stroma,
28
FREDERICK W. STOCKER
Fig. 1 (Stocker). (I) Lamellar graft. (II) Lamellar graft followed by small perforating graft. ( I l l ) Small perforating graft covered by large lamellar graft. (IV) Graft containing a central perforating and a large lamellar portion ("mushroom" graft).
which is to be discarded is completely excised with scissors. Care must be taken that one blade of the scissors always remains between the corneal layers and that the cutting is done exactly along the incision line marked by the six-mm. trephine. In such a manner, a mush room graft with a six-mm. perforating and an 11-mm. lamellar part is obtained. Two silk sutures are inserted through the lamellar part at opposite sides, and the graft is im mersed in serum obtained from the patient to be grafted.
The preparation of the recipient's eye is rather simple. A superficial corneal lamella 11 mm. in diameter is sliced off in the usual manner. A central plug, six mm. in diameter, is next removed by the usual trephination, and the graft is immediately put into place. It is sutured to the recipient's cornea using from 10 to 16 silk sutures. Since only the lamellar part has to be sutured, this is much less difficult than the edge-to-edge suturing of an ordinary perforating graft. Air is usu ally not injected into the anterior chamber, or
Fig. 2 (Stocker). (Left) The lamellar portion of the graft is out lined with an 11-mm. trephine. (Right) The area of the graft which will be perforating is out lined with calipers.
CORNEAL MUSHROOM GRAFTS
29
Fig. 3 (Stocker). (Left) The lamellar portion of the graft is dissected up to the area which will be occupied by the perforating por tion. (Right) The total cornea to gether with a small ring of sciera is excised.
only with great caution, because, if under pressure, it tends to spread between the pa tient's cornea and the lamellar part of the graft. This should be avoided. Both eyes are closed for three to five days, but the patient is out of bed the day after the operation. No spreading of the wound or iris prolapse is to be feared because of the protecting action of the lamellar ring of the graft. The sutures may be removed on the 10th to 12th post operative day.
Postoperative complications are few be cause of the previously mentioned protection of the lamellar part of the graft, the most severe one being secondary glaucoma. This condition may develop, particularly in se verely diseased eyes, as it does with any other type of graft and is hardly related to the spe cific technique described. In the cases of heavily vascularized corneal scars, vascularization may persist or develop postoperatively between the lamellar part of the graft
Fig. 4 (Stocker). (Upper) The excised cornea is placed, endothelium up, on a paraffin block and the central perforating part of the graft is outlined. (Middle) The deeper layers of the graft to be discarded are excised. (Lower) Final shape of graft ("mushroom").
30
FREDERICK W. STOCKER
Fig. 5 (Stocker). Some of the results. (Left) Be fore operation. (Right) After mushroom graft.
and the recipient cornea. Usually, however, it stops at the edge of the perforating part. In addition to dense and severely vascularized corneal scars, I have extended my in
dication for this procedure to the heavily scarred corneas resulting from previous un successful grafts, to perforating ulcers, and w e r e bullous keratopathy after cataract extraction. As previously reported4 I have, in the past, treated the latter condition with large lamellar grafts. I now feel that I get better results from mushroom grafts, with fewer recurrences of the symptoms and in some cases even visual improvement. If one should use perforating grafts in these cases, quite large grafts would be necessary, as in Fuchs' dystrophy. Since this is a very hazard ous procedure in aphakic eyes because of the possibility of large vitreous loss, the tech nique presented here appears to be safer. When discussing the results obtained with the present technique of corneal mushroom grafts, one should remember that so far this method has been used only in almost desper ate cases. Some of the patients with severe bullous keratopathy had become so desperate because of intractable pain as to demand re moval of the offending eye. If in such a case the eye can be made comfortable and some vision, however little, restored, much is ac complished. Of the 13 cases operated on by the method presented, 12 remained free or almost free of symptoms. In nine cases visual acuity has been somewhat improved. In one case, a se vere bullous keratopathy after cataract extrac tion, visual acuity had improved from recog nizing finger movements to 20/40 and had remained so when last seen six months after the operation. Figure 5 illustrates some of the results. 1110 West Main Street.
REFERENCES
1. Paufique, L., Sourdille, G. P., and Off ret, G. : Les greffes de la corneé. Rapport Soc. Franc. d'ophtal. Paris, Masson, 1948, p. 337. 2. Filatov, V. P.: Vest. Oftal, 10:635, 1937. (Ref. Zentralbl. f. Ophth., 41:185, 1938.) 3. Franceschetti, A., and Doret, M.: Kératoplaste combinée lamellaire et perforante. XVI Concilium Ophthalmologicum Acta, 2:1050-1060, 1950. 4. Stocker, F. W. : Management of endothelial and epithelial corneal dystrophy. Tr. Am. Acad. Ophth , 1956, pp. 567-573.