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Autograft Fibers in the Cornea
AUTOGRAFT FIBERS IN T H E CORNEA H. ZAUBERMAN, M.D., AND H. NATHAN,
M.D.
Jerusalem, Israel
The reaction induced in corneal tissue by commonly used suture material has received careful attention. Silk is known to produce an infiltration of polymorphonuclear cells, followed by necrotic changes in the area that surrounds the suture and a prolifera tion of highly vascularized fibroblastic tissue.1 With plain and chromic catgut the reaction is similar but subsides when the su ture is fragmented and absorbed.2"4 Collagenous sutures obtained from the rat tail and sterilized with ethylene dioxide are also fol lowed by infiltration and vascularization of the rabbit cornea in the vicinity of the wound,3 although the reaction is milder than with silk or catgut. From experimental, clinical and histologie findings of other workers in this field we can deduce that all existing suture materials give rise to some local inflammatory reac tion, a feature which is particularly undesir able in the cornea. One of us (H. N.) suggested the use of thin collagenous fibers from tendons or aponeuroses as autograft sutures to use in the cornea. The method of preparation of the fibers was such as to prevent changes in their chemical or immunologie properties in order to minimize inflammatory reaction. This study was undertaken to test whether these autograft fibers would produce less local in flammatory reaction than conventional fibers. To the best of our knowledge, up to the present no work on this subject has been re ported in the literature. MATERIALS AND METHODS
Corneas of four albino rabbits weighing From the Department of Ophthalmology, Hadassah University Hospital and the Hebrew University-Hadassah Medical School, and the De partment of Anatomy and Anthropology, The University of Tel Aviv Medical School, and Tel Hashomer Hospital
four kg were used. The animals were an esthetized by injecting 30 mg/kg body weight of pentobarbital sodium into the au ricular vein. Sterile conditions were main tained during the operations and prepara tion of the fibers, to insure their sterility without any special treatment that might modify their natural properties. The fibers were obtained from the sacrospinalis aponeurosis according to a technique devised by one of us (H. N.) as follows : A rectangular patch, approximately 10 by 15 cm posterior to the scapula and lateral to the dorsal spine, was shaved clean of hair and the surface painted with 2% mercurochrome. An incision was made in the skin 2.0 cm lateral and parallel to the spine, be ginning 1.0 cm behind the scapula and ex tending posteriorly for 5.0 cm. The skin was separated from the underlying fascia and the deep fascia and the latissimus dorsi muscle were cut until the aponeurotic ten don covering the sacrospinalis muscle was exposed. In order to remove long segments of tendon, the skin around the incision was displaced as far anteriorly as possible. A piece of tendon close to the midline and ap proximately 3.0-5.0 mm in width was clamped and cut out at the upper end of the clamp. The clamped tendon was pulled and eased away from the underlying muscle. While the tendon was pulled in an anteroposterior direction, the skin around the inci sion was displaced in the same direction to expose a greater segment of tendon, facili tating the removal of the longest possible strip. This strip of tendon was removed and placed in sterilized Petri dishes. Fine for ceps were used to dissect the tendons into thin fibers, their eventual thickness being that of 4-0 catgut. While still moist, these fibers were easily separated from the main bundle and then threaded into 82-type Grieshaber needles for immediate use.
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AUTOGRAFT SUTURES
The entire procedure of removing and preparing the fibers took about 10 minutes. To compare tissue reactions to those pro duced by the autograft fibers, 6-0 silk su tures and 5-0 catgut sutures were used. Some of the fibers were retained for fur ther study of their physical characteristics. Detailed data on these findings will be given in another report. Testing the fibers in the cornea. The fibers under test were inserted immediately after preparation into the corneal stroma over a distance of 4.0-5.0 mm. Both ends of the fibers were then cut flush with the cor neal epithelium. Some of the fibers were in serted radially, the limbal end being at a dis tance of 2.0 to 4.0 mm from the limbus, while others were placed tangentially 4.0 mm away from the limbus. Two or three fibers were inserted in a single cornea in order to obtain comparative observations on the tissue reactions. The corneas were examined daily with the Zeiss biomicroscope. Particular attention was paid to the presence of (1) corneal edema and infiltration and (2) vascularization of the cornea at the site of the implant ed material. Photographs were taken at var ious periods of time during the experiment. Two animals were killed 19 days and the remaining two 33 days after the implanta tion of the fibers. The eyes were fixed in 10% formalin. The areas containing the su tures were removed, embedded in paraffin, sectioned and stained with hematoxylin and eosin prior to histologie study. Sections were taken of the middle one third of the fibers being tested. RESULTS
The results of the experiments are de scribed individually in each of the four rab bits utilized for this study. RABBIT 1
The location of the fibers and subsequent appearance of the cornea at seven days is shown in Figure 1. (a) Autograft fiber,
429
4-o'clock meridian; (b) Silk, 6-o'clock me ridian) (c)catgut; 8-o'clock meridian. The limbal ends of the radially inserted fibers are about two mm from the limbus. The ex periment continued for 19 days. Twenty-four hours after insertion. Slitlamp examination showed : Autograft fiber. Mild corneal edema was present, without infiltration, at the lim bal end of the fiber. Silk. The corneal tissue surrounding the fiber was markedly edematous and infiltrated. Catgut. Reactions were similar to those of silk. Seventy-two hours postoperatively and subsequent progress. Autograft fiber. Corneal invasion by a sparce leash of vessels had progressed by the fourth day up to the limbal end of the fiber; it then began to regress and the edema simultaneously disappeared. No re newed reaction was subsequently noted to the conclusion of the experiment. Silk. A dense invasion of new vessels took place, particularly marked near the lim bal end of the fiber. By the sixth day these vessels showed four mm of progression into the corneal stroma surrounding the fiber. Numerous vascular loops were in evidence, the apices of each presenting a number of sprouts around which scattered hemor rhages were noted. Although marked edema and infiltration around the fiber continued until the end of the experiment, the vascular invasion tended to remain static. Catgut. The corneal reaction with respect to edema, infiltration and neovascularization was similar to that described for the silk fiber. Histology Autograft fiber (fig. 2 ) . The inserted fiber appears homogeneous, surrounded by normal corneal lamellae. No cellular reaction is seen in the surrounding tissue. Silk (fig. 3 ) . The remnants of the suture are seen in the form of polyhedric figures, which are surrounded by densely arranged corneal fibers infiltrated by mononuclear
430
AMERICAN JOURNAL OF OPHTHALMOLOGY
SEPTEMBER, 1967
Fig. 1 (Zauberman and Nathan). Appearance of fibers seven days after insertion, (a) The autograft fiber shows minimal vascularization and no infiltration whereas (b) the 6-0 silk and (c) the 5-0 catgut demonstrate dense vascularization and infiltration. cells that are in close relationship with the remnants of the silk fibers. Occasional for eign-body giant cells are seen in close rela tionship with the suture material.
Fig. 2 (Zauberman and Nathan). No cellular reaction is seen in the corneal tissue around the autograft fiber 19 days after insertion. (Hematoxy lin-eosin, χ160.)
Fig. 3 (Zauberman and Nathan). Nineteen days after insertion, the remnants of the 6-0 silk appear polyhedric in form. Dense infiltrations of mononuclear cells and occasional foreign-body giant cells surround the silk suture. (Hematoxylin-eosin, X160.)
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AUTOGRAFT SUTURES
431
Catgut (fig. 4 ) . The suture fiber is seen as an homogeneous eosinophilic structure surrounded by dense bundles of corneal fibers. In close relationship with the fiber is a dense infiltration of mononuclear cells. RABBIT 2
The location of the fibers and corneal ap pearance at seven days are shown in Figure 5. The limbal ends of the radially inserted fibers are about four or five mm from the limbus. The experiment lasted 33 days. Slitlamp examination Autograft fiber. No edema or infiltration around the fiber was observed throughout the experiment. We had the impression that these fibers became somewhat more trans parent after about the 15th postoperative day. Silk. Twenty-four hours after insertion, edema and infiltration were observed around the silk; this increased in intensity during the following three days and then regressed somewhat to become static. This reaction persisted until the end of the experiment. Histology. The sections of the autograft fiber a and ai and silk presented the same characteristics as those described for Rabbit 1. RABBIT 3
The location of the fibers and duration of the experiment was similar to that of Rabbit 1. Slitlamp examination differed in that no corneal reaction whatsoever was observed for the autograft fiber, which appeared to have become more transparent in the pe ripheral half by the end of the study. His tologie appearances were identical to those in Rabbit 1. RABBIT 4
Two fibers only, autograft and silk, were utilized, and placed tangentially 5.0-6.0 mm from the limbus. The duration of the exper iment was 33 days (as for Rabbit 2). Biomicroscopic and histologie appearances were similar to those seen in Rabbit 2.
Fig. 4 (Zauberman and Nathan). Nineteen days after insertion, dense infiltration by mononuclear cells is seen close to the catgut fibers. (Hematoxylin-eosin, χ160.) DISCUSSION AND CONCLUSIONS
It would appear from the present study that corneal tolerance to autograft fiber is far greater than to the other suture materials studied. The present observations regarding the corneal reaction to silk and catgut are similar to those of former workers, with the constant presence of surrounding. edema and infiltration; this reaction was virtually absent with the autograft fibers. Further more, when the peripheral ends of the silk or catgut fibers were located within a critical distance from the limbus, that is, 3.0-4.0 mm, corneal vascularization occurred. The maximal vascular density and degree of penetration were opposite the location of the sutures. This finding is in agreement with the previous work of Campbell and Michaelson.5 The vascular reaction to the autograft fiber when its peripheral end was within the critical distance from the limbus was mini mal. One case showed no reaction and the
432
AMERICAN JOURNAL OF OPHTHALMOLOGY
SEPTEMBER, 1967
Fig. 5 (Zauberman and Nathan). Seven days after insertion of the autograft fiber (a and ai) and the silk (b). There is no reaction to the autograft fiber but infiltration surrounds the silk fiber.
other a sparse leash of vessels, which re gressed after having entered the cornea for one mm. This mild reaction might be at tributed either to surgical trauma or to the suture itself. These findings are corroborat ed by histologie studies, which also confirm the known fact that silk and catgut dis integrate in the corneal tissue. It is believed that this disintegration is related to the inci dence of polymorphonuclear cell invasion. The autograft fiber shows no such signs of disintegration. Furthermore, the impression was gained that the autograft fiber became more transparent in its new surroundings. This impression should be checked in fur ther studies over longer periods of time. Among the requisites of suture material used in the cornea it is obviously important that inflammatory reaction be at a minimum.
In this respect autograft fiber is superior to the other suture material tested. It remains to be seen whether it can fulfill other requi sites of suture material. We have recently used fibers taken from the fascia lata for human lamellar keratoplasty. Further work remains to be done with this material, but our results to date suggest that this fiber may have important uses because it does not produce local reactions. SUMMARY
1. Fresh collagenous fibers from tendons or aponeuroses of rabbits were prepared, taking care to leave unaltered their natural and immunologie characteristics. These fi bers were inserted in the corneas of the donor animals. The tissue reaction was com pared biomicroscopically and histologically
VOL. 64, NO. 3
AUTOGRAFT SUTURES
to that produced by silk and catgut fibers similarly inserted in the same cornea. 2. The silk and catgut fibers produced surrounding edema and infiltration ac cording to known patterns. These reactions were not observed around the autograft fibers. 3. Intense corneal vascular invasion was noted around the silk and catgut fibers when inserted close to the limbus; a very mild vascular reaction, progressing only up to the limbal end of the fiber, was observed under similar conditions with the autograft fiber in one case, the others showing no apparent reaction. 4. The possibility of using autograft fiber as corneal suture material is discussed. P.O. Box 499
433 ACKNOWLEDGMENTS
We are indebted to Dr. Mario Ulmansky, Depart ment of Pathology, Hebrew University Medical School, for his help in examining the sections and to Dr. Ignaz Rabinowicz, Moorfields Eye Hospital, London, England, for his valuable as sistance with the manuscript. REFERENCES
1. Dunnington, J. H. and Regan, E. F. : The effect of sutures and of thrombin upon ocular wound healing. Am. J. Ophth. 35:167, 1952. 2. : Absorbable sutures in cataract sur gery. Arch. Ophth. 50:54S, 1953. 3. Larmi, T. : Collagenous suture material in surgery of the cornea and sciera. Acta Ophth. Suppl. 63:105, 1961. 4. McPherson, S.D. : The use of absorbable su tures in surgery of the cornea. Tr. Am. Ophth. Soc. 57:700, 1959. 5. Campbell, F. W. and Michaelson, I. C. : Blood vessel formation in the cornea. Brit. J. Opthth. 33:248, 1949.
CORNEAL TRANSPLANTATION IN ADVANCED FUCHS' THE
FATE O F H O M O T R A N S P L A N T E D H U M A N E N D O T H E L I A L A.
HAGEDOORN,
DYSTROPHY CELLS
M.D.
Amsterdam, Holland Brown, Dohlman and Boruchoff,1 in 1965, described three cases of dislocation of Descemet's membrane during keratoplasty. The clinical diagnosis was substantiated by histologie sections in one case. In the third case, discission of Descemet's membrane was performed with a resulting visual acui ty of 20/200. The case reported here is the second on record. CASE
REPORT
A 72-year-old man was admitted to the hos pital because of bilateral corneal edema secondary to advanced Fuchs' dystrophy. Vision was re duced to counting fingers at one meter. The pa tient was from abroad and had consulted several ophthalmologists and insisted upon an operation. Although these advanced cases (Group 3-4 of Castroviejo3) are unfavorable, there is still a modest possibility for providing an improvement in visual acuity. From the Department of Ophthalmology, Wilhel mina Gasthuis, University of Amsterdam.
On October 10, 1965, a 6.5-mm full-thickness graft was inserted. The operation was uneventful. The disc in the recipient cornea was incised near ly completely with the trephine and a minimum cut with scissors was necessary. The graft was in good position with a simple overlying Castroviejo suture. Corneal appositional sutures were not used. The patient was nervous and tense and it was not possible because of squeezing of his eyelids to perform a slitlamp examination until four weeks later. At that time I was astonished to find a small, supernumerary "anterior chamber" poste rior to the graft, and was concerned that I had pushed back Descemet's membrane with the tre phine. At that time it was feared that this might cause a deterioration in the condition of the pa tient's cornea. The possibility of a retrocorneal membrane ( Hales,' Rycroff1) was considered, but thought unlikely because of its early occurrence after uneventful transplantation. On December 6, 1965, a discission was done of the recipient's detached Descemet's membrane, which had progressively lost its translucency. At present the graft is clear in the area that was not adherent to the Descemet's membrane. In the su perior nasal quadrant where Descemet's mem-
M.D.
Jerusalem, Israel
The reaction induced in corneal tissue by commonly used suture material has received careful attention. Silk is known to produce an infiltration of polymorphonuclear cells, followed by necrotic changes in the area that surrounds the suture and a prolifera tion of highly vascularized fibroblastic tissue.1 With plain and chromic catgut the reaction is similar but subsides when the su ture is fragmented and absorbed.2"4 Collagenous sutures obtained from the rat tail and sterilized with ethylene dioxide are also fol lowed by infiltration and vascularization of the rabbit cornea in the vicinity of the wound,3 although the reaction is milder than with silk or catgut. From experimental, clinical and histologie findings of other workers in this field we can deduce that all existing suture materials give rise to some local inflammatory reac tion, a feature which is particularly undesir able in the cornea. One of us (H. N.) suggested the use of thin collagenous fibers from tendons or aponeuroses as autograft sutures to use in the cornea. The method of preparation of the fibers was such as to prevent changes in their chemical or immunologie properties in order to minimize inflammatory reaction. This study was undertaken to test whether these autograft fibers would produce less local in flammatory reaction than conventional fibers. To the best of our knowledge, up to the present no work on this subject has been re ported in the literature. MATERIALS AND METHODS
Corneas of four albino rabbits weighing From the Department of Ophthalmology, Hadassah University Hospital and the Hebrew University-Hadassah Medical School, and the De partment of Anatomy and Anthropology, The University of Tel Aviv Medical School, and Tel Hashomer Hospital
four kg were used. The animals were an esthetized by injecting 30 mg/kg body weight of pentobarbital sodium into the au ricular vein. Sterile conditions were main tained during the operations and prepara tion of the fibers, to insure their sterility without any special treatment that might modify their natural properties. The fibers were obtained from the sacrospinalis aponeurosis according to a technique devised by one of us (H. N.) as follows : A rectangular patch, approximately 10 by 15 cm posterior to the scapula and lateral to the dorsal spine, was shaved clean of hair and the surface painted with 2% mercurochrome. An incision was made in the skin 2.0 cm lateral and parallel to the spine, be ginning 1.0 cm behind the scapula and ex tending posteriorly for 5.0 cm. The skin was separated from the underlying fascia and the deep fascia and the latissimus dorsi muscle were cut until the aponeurotic ten don covering the sacrospinalis muscle was exposed. In order to remove long segments of tendon, the skin around the incision was displaced as far anteriorly as possible. A piece of tendon close to the midline and ap proximately 3.0-5.0 mm in width was clamped and cut out at the upper end of the clamp. The clamped tendon was pulled and eased away from the underlying muscle. While the tendon was pulled in an anteroposterior direction, the skin around the inci sion was displaced in the same direction to expose a greater segment of tendon, facili tating the removal of the longest possible strip. This strip of tendon was removed and placed in sterilized Petri dishes. Fine for ceps were used to dissect the tendons into thin fibers, their eventual thickness being that of 4-0 catgut. While still moist, these fibers were easily separated from the main bundle and then threaded into 82-type Grieshaber needles for immediate use.
428
VOL. 64, NO. 3
AUTOGRAFT SUTURES
The entire procedure of removing and preparing the fibers took about 10 minutes. To compare tissue reactions to those pro duced by the autograft fibers, 6-0 silk su tures and 5-0 catgut sutures were used. Some of the fibers were retained for fur ther study of their physical characteristics. Detailed data on these findings will be given in another report. Testing the fibers in the cornea. The fibers under test were inserted immediately after preparation into the corneal stroma over a distance of 4.0-5.0 mm. Both ends of the fibers were then cut flush with the cor neal epithelium. Some of the fibers were in serted radially, the limbal end being at a dis tance of 2.0 to 4.0 mm from the limbus, while others were placed tangentially 4.0 mm away from the limbus. Two or three fibers were inserted in a single cornea in order to obtain comparative observations on the tissue reactions. The corneas were examined daily with the Zeiss biomicroscope. Particular attention was paid to the presence of (1) corneal edema and infiltration and (2) vascularization of the cornea at the site of the implant ed material. Photographs were taken at var ious periods of time during the experiment. Two animals were killed 19 days and the remaining two 33 days after the implanta tion of the fibers. The eyes were fixed in 10% formalin. The areas containing the su tures were removed, embedded in paraffin, sectioned and stained with hematoxylin and eosin prior to histologie study. Sections were taken of the middle one third of the fibers being tested. RESULTS
The results of the experiments are de scribed individually in each of the four rab bits utilized for this study. RABBIT 1
The location of the fibers and subsequent appearance of the cornea at seven days is shown in Figure 1. (a) Autograft fiber,
429
4-o'clock meridian; (b) Silk, 6-o'clock me ridian) (c)catgut; 8-o'clock meridian. The limbal ends of the radially inserted fibers are about two mm from the limbus. The ex periment continued for 19 days. Twenty-four hours after insertion. Slitlamp examination showed : Autograft fiber. Mild corneal edema was present, without infiltration, at the lim bal end of the fiber. Silk. The corneal tissue surrounding the fiber was markedly edematous and infiltrated. Catgut. Reactions were similar to those of silk. Seventy-two hours postoperatively and subsequent progress. Autograft fiber. Corneal invasion by a sparce leash of vessels had progressed by the fourth day up to the limbal end of the fiber; it then began to regress and the edema simultaneously disappeared. No re newed reaction was subsequently noted to the conclusion of the experiment. Silk. A dense invasion of new vessels took place, particularly marked near the lim bal end of the fiber. By the sixth day these vessels showed four mm of progression into the corneal stroma surrounding the fiber. Numerous vascular loops were in evidence, the apices of each presenting a number of sprouts around which scattered hemor rhages were noted. Although marked edema and infiltration around the fiber continued until the end of the experiment, the vascular invasion tended to remain static. Catgut. The corneal reaction with respect to edema, infiltration and neovascularization was similar to that described for the silk fiber. Histology Autograft fiber (fig. 2 ) . The inserted fiber appears homogeneous, surrounded by normal corneal lamellae. No cellular reaction is seen in the surrounding tissue. Silk (fig. 3 ) . The remnants of the suture are seen in the form of polyhedric figures, which are surrounded by densely arranged corneal fibers infiltrated by mononuclear
430
AMERICAN JOURNAL OF OPHTHALMOLOGY
SEPTEMBER, 1967
Fig. 1 (Zauberman and Nathan). Appearance of fibers seven days after insertion, (a) The autograft fiber shows minimal vascularization and no infiltration whereas (b) the 6-0 silk and (c) the 5-0 catgut demonstrate dense vascularization and infiltration. cells that are in close relationship with the remnants of the silk fibers. Occasional for eign-body giant cells are seen in close rela tionship with the suture material.
Fig. 2 (Zauberman and Nathan). No cellular reaction is seen in the corneal tissue around the autograft fiber 19 days after insertion. (Hematoxy lin-eosin, χ160.)
Fig. 3 (Zauberman and Nathan). Nineteen days after insertion, the remnants of the 6-0 silk appear polyhedric in form. Dense infiltrations of mononuclear cells and occasional foreign-body giant cells surround the silk suture. (Hematoxylin-eosin, X160.)
VOL. 64, NO. 3
AUTOGRAFT SUTURES
431
Catgut (fig. 4 ) . The suture fiber is seen as an homogeneous eosinophilic structure surrounded by dense bundles of corneal fibers. In close relationship with the fiber is a dense infiltration of mononuclear cells. RABBIT 2
The location of the fibers and corneal ap pearance at seven days are shown in Figure 5. The limbal ends of the radially inserted fibers are about four or five mm from the limbus. The experiment lasted 33 days. Slitlamp examination Autograft fiber. No edema or infiltration around the fiber was observed throughout the experiment. We had the impression that these fibers became somewhat more trans parent after about the 15th postoperative day. Silk. Twenty-four hours after insertion, edema and infiltration were observed around the silk; this increased in intensity during the following three days and then regressed somewhat to become static. This reaction persisted until the end of the experiment. Histology. The sections of the autograft fiber a and ai and silk presented the same characteristics as those described for Rabbit 1. RABBIT 3
The location of the fibers and duration of the experiment was similar to that of Rabbit 1. Slitlamp examination differed in that no corneal reaction whatsoever was observed for the autograft fiber, which appeared to have become more transparent in the pe ripheral half by the end of the study. His tologie appearances were identical to those in Rabbit 1. RABBIT 4
Two fibers only, autograft and silk, were utilized, and placed tangentially 5.0-6.0 mm from the limbus. The duration of the exper iment was 33 days (as for Rabbit 2). Biomicroscopic and histologie appearances were similar to those seen in Rabbit 2.
Fig. 4 (Zauberman and Nathan). Nineteen days after insertion, dense infiltration by mononuclear cells is seen close to the catgut fibers. (Hematoxylin-eosin, χ160.) DISCUSSION AND CONCLUSIONS
It would appear from the present study that corneal tolerance to autograft fiber is far greater than to the other suture materials studied. The present observations regarding the corneal reaction to silk and catgut are similar to those of former workers, with the constant presence of surrounding. edema and infiltration; this reaction was virtually absent with the autograft fibers. Further more, when the peripheral ends of the silk or catgut fibers were located within a critical distance from the limbus, that is, 3.0-4.0 mm, corneal vascularization occurred. The maximal vascular density and degree of penetration were opposite the location of the sutures. This finding is in agreement with the previous work of Campbell and Michaelson.5 The vascular reaction to the autograft fiber when its peripheral end was within the critical distance from the limbus was mini mal. One case showed no reaction and the
432
AMERICAN JOURNAL OF OPHTHALMOLOGY
SEPTEMBER, 1967
Fig. 5 (Zauberman and Nathan). Seven days after insertion of the autograft fiber (a and ai) and the silk (b). There is no reaction to the autograft fiber but infiltration surrounds the silk fiber.
other a sparse leash of vessels, which re gressed after having entered the cornea for one mm. This mild reaction might be at tributed either to surgical trauma or to the suture itself. These findings are corroborat ed by histologie studies, which also confirm the known fact that silk and catgut dis integrate in the corneal tissue. It is believed that this disintegration is related to the inci dence of polymorphonuclear cell invasion. The autograft fiber shows no such signs of disintegration. Furthermore, the impression was gained that the autograft fiber became more transparent in its new surroundings. This impression should be checked in fur ther studies over longer periods of time. Among the requisites of suture material used in the cornea it is obviously important that inflammatory reaction be at a minimum.
In this respect autograft fiber is superior to the other suture material tested. It remains to be seen whether it can fulfill other requi sites of suture material. We have recently used fibers taken from the fascia lata for human lamellar keratoplasty. Further work remains to be done with this material, but our results to date suggest that this fiber may have important uses because it does not produce local reactions. SUMMARY
1. Fresh collagenous fibers from tendons or aponeuroses of rabbits were prepared, taking care to leave unaltered their natural and immunologie characteristics. These fi bers were inserted in the corneas of the donor animals. The tissue reaction was com pared biomicroscopically and histologically
VOL. 64, NO. 3
AUTOGRAFT SUTURES
to that produced by silk and catgut fibers similarly inserted in the same cornea. 2. The silk and catgut fibers produced surrounding edema and infiltration ac cording to known patterns. These reactions were not observed around the autograft fibers. 3. Intense corneal vascular invasion was noted around the silk and catgut fibers when inserted close to the limbus; a very mild vascular reaction, progressing only up to the limbal end of the fiber, was observed under similar conditions with the autograft fiber in one case, the others showing no apparent reaction. 4. The possibility of using autograft fiber as corneal suture material is discussed. P.O. Box 499
433 ACKNOWLEDGMENTS
We are indebted to Dr. Mario Ulmansky, Depart ment of Pathology, Hebrew University Medical School, for his help in examining the sections and to Dr. Ignaz Rabinowicz, Moorfields Eye Hospital, London, England, for his valuable as sistance with the manuscript. REFERENCES
1. Dunnington, J. H. and Regan, E. F. : The effect of sutures and of thrombin upon ocular wound healing. Am. J. Ophth. 35:167, 1952. 2. : Absorbable sutures in cataract sur gery. Arch. Ophth. 50:54S, 1953. 3. Larmi, T. : Collagenous suture material in surgery of the cornea and sciera. Acta Ophth. Suppl. 63:105, 1961. 4. McPherson, S.D. : The use of absorbable su tures in surgery of the cornea. Tr. Am. Ophth. Soc. 57:700, 1959. 5. Campbell, F. W. and Michaelson, I. C. : Blood vessel formation in the cornea. Brit. J. Opthth. 33:248, 1949.
CORNEAL TRANSPLANTATION IN ADVANCED FUCHS' THE
FATE O F H O M O T R A N S P L A N T E D H U M A N E N D O T H E L I A L A.
HAGEDOORN,
DYSTROPHY CELLS
M.D.
Amsterdam, Holland Brown, Dohlman and Boruchoff,1 in 1965, described three cases of dislocation of Descemet's membrane during keratoplasty. The clinical diagnosis was substantiated by histologie sections in one case. In the third case, discission of Descemet's membrane was performed with a resulting visual acui ty of 20/200. The case reported here is the second on record. CASE
REPORT
A 72-year-old man was admitted to the hos pital because of bilateral corneal edema secondary to advanced Fuchs' dystrophy. Vision was re duced to counting fingers at one meter. The pa tient was from abroad and had consulted several ophthalmologists and insisted upon an operation. Although these advanced cases (Group 3-4 of Castroviejo3) are unfavorable, there is still a modest possibility for providing an improvement in visual acuity. From the Department of Ophthalmology, Wilhel mina Gasthuis, University of Amsterdam.
On October 10, 1965, a 6.5-mm full-thickness graft was inserted. The operation was uneventful. The disc in the recipient cornea was incised near ly completely with the trephine and a minimum cut with scissors was necessary. The graft was in good position with a simple overlying Castroviejo suture. Corneal appositional sutures were not used. The patient was nervous and tense and it was not possible because of squeezing of his eyelids to perform a slitlamp examination until four weeks later. At that time I was astonished to find a small, supernumerary "anterior chamber" poste rior to the graft, and was concerned that I had pushed back Descemet's membrane with the tre phine. At that time it was feared that this might cause a deterioration in the condition of the pa tient's cornea. The possibility of a retrocorneal membrane ( Hales,' Rycroff1) was considered, but thought unlikely because of its early occurrence after uneventful transplantation. On December 6, 1965, a discission was done of the recipient's detached Descemet's membrane, which had progressively lost its translucency. At present the graft is clear in the area that was not adherent to the Descemet's membrane. In the su perior nasal quadrant where Descemet's mem-