Healon5 tamponade of corneal perforation during transplantation surgery

Healon5 tamponade of corneal perforation during transplantation surgery Ga´bor Rado´, MD, Andra´s Berta, DSc In “a chaud” keratoplasty in cases of corneal perforation, the main difficulty is the trephination of the recipient cornea in a soft eye. A temporary tamponade of the perforation can be provided by filling the anterior chamber with sodium hyaluronate 2.3% (Healon姞5). The cornea can then be grasped with vacuum and trephinated. J Cataract Refract Surg 2002; 28:1520 –1521 © 2002 ASCRS and ESCRS

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pontaneous corneal perforation requires the immediate closure of the globe to prevent intraocular infection. Various surgical solutions are reported in the literature.1–3 One is an “a chaud” perforating keratoplasty. Low intraocular pressure (IOP) makes the trephination of the recipient cornea technically difficult. We describe a method in which the leaking corneal wound is temporarily closed with a viscoadaptive substance, allowing successful trephination of the perforated cornea.

Surgical Technique A peribulbar block of 1.5 mL lidocaine and 1.5 mL bupivacaine hydrochloride (Marcaine威) is administered without oculopression. The anterior chamber is filled with sodium hyaluronate 2.3% (Healon威5) through a limbal paracentesis. The trephination of the host cornea is performed with an Asmotom motor trephine, perforating the wound over 180 degrees of the circumference. The trephine is removed and counterpressure observed. The Healon5 is removed with the rock ’n roll technique

Accepted for publication January 28, 2002. From the 2nd Department of Ophthalmology, Semmelweis University, Budapest (Rado´), and the Department of Ophthalmology, University of Debrecen, Debrecen (Berta), Hungary. Reprint requests to Ga´bor Rado´, MD, 2nd Department of Ophthalmology, Semmelweis University, 1085 Ma´ria Utca 39, Budapest, Hungary. E-mail: [email protected]. © 2002 ASCRS and ESCRS Published by Elsevier Science Inc.

before the graft is positioned. The graft is sutured in place with a 10-0 running nylon suture.

Results This technique was performed in 3 eyes. All patients presented with a visual acuity of counting fingers at 1 to 3 m, a central corneal perforation, no anterior chamber, and an IOP of 0 mm Hg. Table 1 shows the preoperative patient characteristics. In Case 1, the nucleus was spontaneously expressed through the perforated anterior capsule. The posterior capsule remained intact but was bulging. After a posterior capsulorhexis was made, an anterior vitrectomy was performed through the capsulorhexis with a vitreous cutter. As the vitreous decompression had to be repeated several times, no intraocular lens (IOL) was implanted. In Case 2, the nucleus was also expressed spontaneously; however, decompression was done via the pars plana while the posterior capsule remained intact. A poly(methyl methacrylate) IOL was implanted. In Cases 1 and 2, the wound healing was successful. The best corrected visual acuity was 0.6 after 11 months in Case 1 and 0.4 after 4 four months in Case 2. The first patient refused IOL implantation. In Case 3, in which a posterior synechia was present, a corneal melt with loosening of the suture was observed 6 weeks postoperatively. The graft, however, remained in situ. The graft was resutured with 10-0 single sutures, and amnioplasty was done. Six weeks after the amnion 0886-3350/02/$–see front matter PII S0886-3350(02)01384-6

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Table 1. Preoperative patient characteristics.

Case

Eye

Age (Y)

Sex

1

R

62

Male

2

L

74

3

L

72

Diagnosis

Comments

Metaherpetic keratitis

Long-lasting steroid therapy

Female

Conjunctival pemphigoid

Constricted fornices

Female

Chronic rheumatoid polyarthritis

membrane grafting, the eye showed no signs of inflammation.

Discussion Healon5 has strong cohesive characteristics and is highly resistant to suction.4,5 It creates adequate temporary closure of the perforated cornea, allowing it to be grasped and lifted using 10 mm Hg vacuum and subsequent motor trephination. During vacuum fixation, the cornea is lifted, facilitating trephination. This is in contrast to traditional trephination, in which the cornea is under pressure and deformation of the hypotonic eye with an irregular trephination wound often results. Comparing the trephination procedure we used in our 3 cases to that of conventional penetrating keratoplasty techniques, we found no difference. In our 3 cases, the eyes were open and the IOP was 0 mm Hg. The extreme counterpressure might have been caused by the lack of

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oculopression after peribulbar anesthesia. To counteract this, we suggest using general anesthesia for intraoperative management and vitreous decompression via the pars plana.

References 1. Bernauer W, Ficker LA, Watson PG, Dart JKG. The management of corneal perforations associated with rheumatoid arthritis; an analysis of 32 eyes. Ophthalmology 1995; 102:1325–1337 2. Duchesne B, Tahi H, Galand A. Use of human fibrin glue and amniotic membrane transplant in corneal perforation. Cornea 2001; 20:230 –232 3. Saini JS, Sharma A, Grewal SPS. Chronic corneal perforations. Ophthalmic Surg 1992; 23:399–402 4. Dick HB, Krummenauer F, Augustin AJ, et al. Healon5 viscoadaptive formulation: comparison to Healon and Healon GV. J Cataract Refract Surg 2001; 27:320 –326 5. Tetz MR, Holzer MP, Lundberg K, et al. Clinical results of phacoemulsification with the use of Healon5 or Viscoat. J Cataract Refract Surg 2001; 27:416 –420

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