998955

research-article2021
EJO0010.1177/1120672121998955European Journal of OphthalmologyBafna et al.

EJO European
Journal of
Ophthalmology
Surgical technique

European Journal of Ophthalmology

Novel technique of tetra trephination

1­–7
© The Author(s) 2021
Article reuse guidelines:
for elliptical-shaped tectonic patch grafts sagepub.com/journals-permissions
https://doi.org/10.1177/1120672121998955
DOI: 10.1177/1120672121998955

in peripheral sterile keratolysis journals.sagepub.com/home/ejo

Rahul Kumar Bafna , Nidhi Kalra* ,

Mohamed Ibrahime Asif* , Rinky Agarwal ,
Suman Lata, Jeewan Singh Titiyal, Namrata Sharma
and Shiv Jee Vikas

Abstract
Purpose: To describe a novel technique of tectonic patch grafts for elliptical-shaped peripheral sterile keratolysis with
iris prolapse.
Methods: We performed a full thickness corneo-scleral patch graft in five eyes of five patients with elliptical-shaped
peripheral sterile keratolysis with perforation and iris tissue prolapse. In this technique, four disposable trephines with
predetermined diameter were employed to fashion both the host and the donor without any free-hand dissection. An
intact anatomical integrity of the globe without the need for any repeat tectonic measures was considered as a successful
outcome.
Results: The mean age was 34.2 ± 10.2 years (18–45). The mean total surgical time and donor preparation time was
94.4 ± 7.12 min and 7.6 ± 1.14 min, respectively. The intraoperative course was uneventful in all cases and all eyes had a
well-maintained corneal integrity till 6 months follow up.
Conclusion: We describe a simple, reproducible, and time-saving technique of performing elliptical shaped corneoscleral
patch grafts for peripheral corneal perforations with iris prolapse.

Keywords
Peripheral ulcerative keratitis, sterile keratolysis, patch graft, match and patch, tetra trephine

Date received: 14 January 2021; accepted: 9 February 2021

Introduction Elliptical shaped peripheral sterile keratolysis with

Corneal perforation is a sight-threatening ocular complica-
tion resulting from various infectious and non-infectious
corneal conditions such as microbial keratitis, trauma, and
immune-mediated disorders. It presents as an ophthalmic
emergency and if left untreated can result in blindness.
A perforated cornea, especially with iris tissue prolapse,
mandates urgent attention to preserve ocular integrity and
prevent endophthalmitis.1 Various approaches described
for its management include tissue glue with bandage con-
tact lens, amniotic membrane transplantation, tectonic cor-
neal or scleral patch grafts, pericardial patch graft, lamellar
or penetrating keratoplasty, and conjunctival flaps.2–5 The
choice of treatment depends on their size, location, under-
lying cause, and visual prognosis.
coexisting perforation and iris tissue prolapse are complex
to manage with above-mentioned modalities of treatment.
Corneal gluing carries risk of dislodgement and intraocular
toxicity, amniotic membrane grafting, conjunctival flaps
and tenon’s grafts have unpredictable tensile strength,
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute
of Medical Sciences, New Delhi, India
*These authors contributed equally to this work.
Corresponding author:
Namrata Sharma, Cornea, Lens & Refractive Surgery Services, 481, R P
Centre, All India Institute of Medical Sciences, Ansari Nagar East, New
Delhi 110029, India.
Email: namrata.sharma@gmail.com
2 European Journal of Ophthalmology 00(0)

Figure 1.  Case of Mooren’s Ulcer with corneal perforation and iris proplase: (a) pseudomembrane peeled off, (b) Iris prolapse
released from the edges of the perforation, (c) corneal edge marked with gentian violet, (d) limbal edge (outer rim) of the defect
marked with gentian violet, (e) edges of defect trimmed to create smooth edges, (f) trephine 3 used to punch the cornea, (g) length
marked along the limbal edge (outer rim) of the donor button, (h) breadth marked perpendicular from the center, (i) trephine 4
aligned along the three marks and punched to get a customized elliptical graft, (j) the elliptical graft separated, (k) graft placed over
the host bed, and (l) graft placed over host and sutured.

large grafts are fraught with risk of angle crowding, sec-
ondary glaucoma, and donor rejection6 while eccentric
circular grafts can involve the visual axis and cause high
astigmatism.7
Various techniques have been described to fashion an
appropriately shaped and sized donor graft in such cases.
These include match and patch technique, mushroom
shaped grafting, and free hand dissection for non-circular
grafts.8–10 However, all these techniques are complex and
time-consuming. We describe a novel tetra-trephine tech-
nique of customized full thickness tectonic patch grafts
for elliptical-shaped peripheral sterile keratolysis with
perforations. The technique is safe, reproducible, fast, and
yields satisfactory results in these cases.
Materials and methods
Five eyes of five patients with perforated peripheral ulcer-
ative keratitis having elliptical shape defect were enrolled
in our study. A baseline ophthalmic and systemic work-up
was done, and medical management was started. Written
informed consent was obtained. The surgery was per-
formed under general anesthesia.
The surgery was performed under aseptic precautions.
The pseudo-membrane over the prolapsed iris was peeled
off gently and viable iris tissue was repositioned back
inside anterior chamber with the help of a viscoelastic sub-
stance. (Figure 1(a) and (b)). A localized limbal peritomy
adjacent to the site of perforation was performed with con-
junctival scissors and bleeders were cauterized.
The elliptical shaped tissue defect had two edges, an
outer (Limbal) and an inner (corneal) edge. The horizontal
white to white (WTW) diameter of the cornea was meas-
ured with Castroviejo calipers. This reading was used as a
guide to select a handheld disposable trephine (Nano edge
corneal trephines, Madhu Instruments, New Delhi), the
diameter of which was similar to the patient’s WTW. This
trephine was called as Trephine 1 or T1 and would further
be used to mark the outer edge of the defect.
For marking the inner edge of the defect, a simplified
technique was followed (Figure 2). An imaginary line was
used to divide the elliptical shape defect along its longest
dimension. The area on either side of this line was com-
pared with each other. If the two sides appeared equal or
symmetrical, a trephine as same size of T1 was selected
to be Trephine 2 or T2. (Figure 2(a)) If both sides were
unequal and the inner half appeared larger than the outer
side, a smaller size of trephine would be required. Hence,
a trephine smaller than T1 was selected and checked for
curve match with the inner edge. (Figure 2(b)) In case of
Bafna et al. 3

Figure 2.  Selecting the appropriate trephine for corneal (inner rim): (a) an imaginary vertical line joining the two apices of the
ellipse showing equal size of both sides and requiring same size trephine as T1, (b) inner side appears smaller than outer side,
requires a larger trephine than T1, and (c) inner side appears larger than outer side, requiring a smaller size trephine than T1.

Figure 3.  Graft preparation: (a) host cornea showing the final dimensions of the defect, (b) donor cornea Point A and B 0.5 mm
more than the host representing chord length of the graft, (c) point C marked on the donor from the center of AB representing
the width of the graft, and (d) trephine 4 passing through three points-A, B, and C on the donor.

a mismatch, the size was progressively reduced until a
best curvature match was obtained and the final trephine
was selected as T2. Similarly, if the outer side appeared
larger than the inner side, a larger size of trephine would
be required. Hence, a trephine larger than T1 was selected
and checked for curve match with the inner edge. (Figure
2(c)) In case of a mismatch, the size was progressively
increased until a best curvature match was obtained, and
the final trephine was selected as T2.
Both limbal and corneal edges of the defect were then
marked with gentian violet using T1 and T2 trephines,
respectively. (Figure 1(c) and (d)) Edges of the defect were
trimmed along both the marks to create smooth edges on
each side of the defect. (Figure 1(e)) The final dimensions of
this defect (length and width) were then measured with the
Castroviejo caliper (Length (L) × Width (W)). (Figure 3(a))
For donor preparation, two trephines each oversized by
0.5 mm from previously determined sizes were selected
(Trephine 3 or T3 = Trephine 1 +0.5 mm, Trephine 4 or
T4 = Trephine 2 +0.5 mm). The donor tissue was placed
over a Teflon block and T3 was used to punch the cornea
(Figure 1(g)). The corneal button was left in place along
with the scleral rim. Length (L) +0.5 mm was marked with
Castroviejo calipers along the outer edge of the donor but-
ton (point A and point B) (Figures 1(g) and 3(b)) and Width
(W) +0.5 mm was marked perpendicular from the center
of AB (point C) (Figures 1(h) and 3(c)). T4 was aligned
along these three marks (point A, B, and C) and punched
to get a customized elliptical shaped graft (Figures 1(i) and
3(d)). To summarize and simplify the above technique, the
trephine sizes and their uses are enumerated below:
1. T1 = same as horizontal white to white corneal
diameter, used to mark the limbal host edge
2. T2 = evaluated by a technique as described in
Figure 2, used to mark the corneal host edge
4 European Journal of Ophthalmology 00(0)

3. T3 = T1 + 0.5 mm, used to trephine the donor lim-

preparation
time (min)
bal edge

Donor
4. T4 = T2 + 0.5 mm, used to trephine the donor cor-
neal edge

6
8
7
8
9
Best corrected duration
Table 1.  Indications, etiology, patient demographics, graft size, trephine 1, trephine 2, anatomical and visual outcomes, surgical duration, and donor preparation time.

Postoperative Surgical
This elliptical shaped graft obtained with this technique was

(min)

84
94
92
100
102
then separated (Figure 1(j)). and placed over the host defect
(Figure 1(k)). It was sutured with 10-0 interrupted mono-
filament sutures (Figure 1(l)) (see online supplement video).

visual acuity
(Log Mar)
Postoperatively all patients were prescribed topical
prednisolone acetate (1%), moxifloxacin hydrochloride
(0.3%) and carboxymethylcellulose (0.5%) each 4 times/

1.3
0.6
0.3
0.5
0.3
day. Oral immunosuppression was prescribed in cases

Best corrected

The average surgical duration was 94.4 min ± 7.12 (range 84–102 min). The average donor tissue customization time was 7.6 min ± 1.14 min (range 6–9 min).
where there was no contraindication.

Sex Size of the graft Trephine 1 Trephine 2 Anatomical Preoperative

visual acuity
Total surgical time was defined as the time taken from

(Log Mar)
the draping till the last corneal suture was buried. Donor
preparation time started from measurement of the corneal

1.5
0.8
1.5
1.5
1.0
horizontal diameter and ended with the separation of the

Successful
Successful
Successful
Successful
Successful
elliptical shaped graft from the donor cornea. The surgery

(length × width) Diameter Diameter outcome

was considered successful if the globe was formed on
every follow-up without the need for any repeat tectonic
measures.

12 mm
8 mm

8 mm
9 mm
8 mm
Results
Five eyes of five patients with perforated peripheral kera-
tolysis having elliptical shaped defect were included in

12 mm
11 mm
11 mm
11 mm
11 mm
our study. Sizes of the graft finally used, details of patient
demographics, etiology, anatomical outcomes, visual out-
comes, surgical time, and donor preparation time are enu-
merated in Table 1.
7 × 4 mm
5 × 2 mm
6 × 3 mm
7 × 3 mm
6 × 3 mm
The surgery was uneventful in all patients in the imme-
diate postoperative period, anterior chamber was well-
formed in all patients. At 6 months, no patient had infection,
graft dehiscence, rejection, or glaucoma. (Figure 4)
M
M

M
F
F
(years)

Discussion
Age

40
36
32
18
45

For best visual and anatomical outcomes there should be

Mooren’s Ulcer

Mooren’s ulcer

proper apposition between the host and the graft. Various

Tuberculosis

techniques of patch grafts for crescentic shaped peripheral

Etiology

Herpes
Herpes

sterile keratolysis with perforations, have been described

in literature. A summary of these techniques is described
in Table 2. Most of these techniques are based on free hand
Peripheral ulcerative keratitis
Peripheral ulcerative keratitis
Peripheral ulcerative keratitis
Peripheral ulcerative keratitis
Peripheral ulcerative keratitis

dissection of the donor. In the copy and fix technique of

preparing donor tissues, the donor rim is placed directly
over the host defect to trace the desired pattern which is
then excised free hand with corneal scissors in the desired
pattern8 while the prick and print technique involves use
of a transparent sheet to create a stencil.9 In our technique,
S No Indication

there is no free hand dissection in the preparation of donor

tissue which makes this procedure quicker and reproduc-
ible even for novice surgeons and results in a smooth,
regular edge. This helped in better apposition in the post-
operative period in our cases. This method also avoids the
1.
2.
3.
4.
5.
Bafna et al. 5
Figure 4.  Preoperative and postoperative clinical photograph at 6 months: (a) case 1 preoperative picture, (b) case 1 post-
operative 6 months, (c) case 2 preoperative picture, and (d) case 2 postoperative 6 months.
need for mounting the corneoscleral button on an artificial
anterior chamber and suturing it on a draped glass orbital
implant as described by Wong et al.11
Kerenyi and Süveges evaluated the corneal topographic
results after an eccentric biconvex penetrating keratoplasty
using trephines. However, their technique used diameter of
trephines between 10 and 12 mm.12 Subsequently, the use
of trephines was not described in literature probably due
to no definite sizing guidelines. Various combinations of
trephines were technically challenging and not reproduc-
ible, thereby causing mismatch of the graft–host junction.
In our study, we customized the size of trephines to match
each individual perforation size, simplifying this seem-
ingly complex procedure. This led to four of our patients
requiring a T2 size of 8–9 mm, causing minimal loss of
normal corneal tissue. Only one patient required trephine
size of 11–12 mm. We oversized the donor trephines by
0.5 mm each. Few studies have suggested taking an under-
sized, same size or a 0.25 mm oversized graft to provide a
compressive effect in order to reduce the corneal astigma-
tism caused by thinning and steepening in the periphery.13
However, in eyes with corneal perforations, hypotony, col-
lapsed globe and reduced scleral rigidity may underesti-
mate the actual defect, an error which may be overcome
by using an appropriately oversized graft. Eventually, the
choice of graft-host disparity is best guided by surgeon’s
experience and may be altered according to their prior
postoperative anatomical and visual results. In our tech-
nique, after using T3 to punch the donor, the scleral rim is
not removed but left in place. This provides support to the
tissue and avoids tissue slippage or movement during fur-
ther trephination and ensures an exact perpendicular and
sharp cut.
One of the limitations of our technique was that corneal
topography was not performed and the effect of this sur-
gery on the central cornea and host astigmatism could not
be evaluated. However, the outcomes of this study were
based primarily on achieving anatomical success in clo-
sure of these challenging peripheral perforations and in
simplifying a seemingly complex procedure for novice
corneal surgeons. Future improvement in this technique
can be planned with prospective studies and the inclusion
of corneal topography.
Trephination of host and donor with trephines pro-
duces congruous, sharp, and vertical edges with minimal
manipulation of tissues that provides excellent host-donor
approximation. Our technique helps to dissect an appro-
priately shaped and sized graft corresponding to the defect
whose curvature precisely matches with the host defect. It
provides graft-host apposition akin to penetrating kerato-
plasty grafts, albeit without the need of a large graft. As
edges of tissue are punched it is relatively less time con-
suming than free hand dissection and requires less surgi-
cal expertise. However, considering overall benefits, the
technique is expected to shorten the learning curve and
encourage novice surgeons in undertaking these surgeries.
To conclude, this novel tetra-trephine technique is a
simple, reproducible, and time-saving method of perform-
ing elliptical-shaped patch grafts for peripheral sterile ker-
atolysis with perforation and iris tissue prolapse.
 6
Table 2.  Summary of techniques used for crescentic and biconvex peripheral grafts.
References Technique Indication Host dissection Donor dissection Remarks

Wong et al.11 Lamellar Ball Lamellar grafts Not described 1. T wo layers of sterile fabric wrapped tightly around a 1. Requires mounting the donor on orbital implant.
glass orbital implant
2. C orneoscleral rim sutured to the fabric. 2. Only for lamellar grafts
3. L amellar dissection done with crescent blade.
4. L amellar graft punched with corneal trephine.
Vanathi et al.6 Full thickness, Central, paracentral 1. Corneal trephine 0.5–1 mm larger than the Not described. 1. Donor dissection not described for full thickness
Lamellar and and peripheral perforation used to mark the involved area. and lamellar grafts.
Mushroom perforations 2. Free hand dissection of host with scissors or 2. Mushroom graft involves free hand lamellar
lamellar dissector. dissection of peripheral rim.
Kerenyi and Biconvex Full thickness 1. Host defect marked with 10–12 mm trephines. 1. Fixed diameter of trephines between 10-12 mm used 1. Fixed trephine sizes of 10–12 mm used leading to
Süveges12 penetrating crescentic to dissect the donor outer and inner edges. likelihood of either leaving behind diseased tissue or
keartoplasty and biconvex 2. Free hand dissection 2. S teps of donor dissection not described in detail loss of normal tissue.
perforations
Samarawickrama Copy and fix Full thickness, 1. Diseased cornea marked with a marking pen. 1. D onor corneoscleral rim placed on host tissue. 1. Requires mounting the donor on artificial anterior
et al.9 lamellar and Tuck in 2. Diseased host tissue removed with blade and 2. F ine surgical marking pen used to trace the pattern chamber.
grafts for peripheral scissors for full thickness, lamellar dissector for on the donor under direct visualization. oversizing
diseases lamellar and crescent blade to create a pocket by 0.5 mm in full thickness grafts.
in tuck in grafts. 3. Rim mounted on anterior chamber 2. Pattern created on donor rim with marking pen, may
smudge and oversize.
4. G
 raft dissected with blade and scissors following the 3. Free hand dissection of donor.
copied mark.
Chai et al.8 Match and patch Lamellar “C” or 1. Corneal trephines used to mark the inner and 1. L amellar ball or artificial anterior chamber used. 1. Involves free hand dissection of donor tissue after
banana shaped outer rim of the area of thinning. marking the pattern on the donor with trephines.
peripheral thinning 2. Distance between both rims is measured at the 2. T he same corneal and dermatological trephines are 2. May be used for full thickness grafts also but again
edges and the mid-point. used to mark the corneoscleral rim and create an free hand dissection required.
appropriate pattern on the donor.
3. Appropriated dermatological trephines are used 3. F ree hand dissection of donor by following the
to mark the edges. marked pattern.
4. Farthest distance between the edges of
dissection bed is measured.
5. Freehand partial thickness dissection of the
marked area using a lamellar dissector.
Parmar et al.10 Prick and Print: Full thickness 1. Host defect marked with a pen 1. D
 onor cornea mounted on anterior chamber 1. Donor rim not directly placed on host, less risk of
Stenciling peripheral endothelial damage or infection.
perforations 2. Sterile transparent plastic placed over host bed. 2. P lastic sheet placed on donor and printing done on 2. More accurate sizing because of the needle as pen
the donor through the stencil. may cause oversizing and smudging.
3. 26G needle used to create stencil by pricking 3. F ree hand dissection of shaped donor cornea. 3. More suitable for larger crescentic grafts than
along the marks. biconvex grafts.
4. Linear cuts placed outside the stencil
Current Study Tetra-Trephine Full thickness 1. Corneal Trephines used to mark the outer and 1. Appropriate corneal trephines used to punch the 1. No free hand dissection of donor tissue.
peripheral elliptical inner edge of the defect. outer and inner edge of the donor.
or biconvex 2. Edges trimmed along the marks by free hand 2. Customized trephines for each individual
perforations dissection. perforation, less arc of tissue dissected at limbus,
less loss of normal tissue.
3. An oversize of 0.5 mm used for better apposition.
4. Maybe used in lamellar grafts either by scoring the
Descemet membrane or by trephining after lamellar
dissection. However, lamellar grafts would require
same size or 0.25 mm oversize trephines for donor
unlike 0.5 mm in full thickness.
European Journal of Ophthalmology 00(0)
Bafna et al. 7
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Rahul Kumar Bafna https://orcid.org/0000-0002-6795-0508
Nidhi Kalra https://orcid.org/0000-0002-8017-0637
Mohamed Ibrahime Asif https://orcid.org/0000-0002-9949
-3962
Rinky Agarwal https://orcid.org/0000-0002-4576-4915
Namrata Sharma https://orcid.org/0000-0002-2124-7542
Supplemental material
Supplemental material for this article is available online.
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