Seminars in Ophthalmology

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/isio20

Lamellar corneal patch grafts in the management

of corneal thinning and perforations without using
extra corneas

Umit Calli, Selim Genc, Osman Şalkacı & Asena Ömeroğlu

To cite this article: Umit Calli, Selim Genc, Osman Şalkacı & Asena Ömeroğlu (2021): Lamellar
corneal patch grafts in the management of corneal thinning and perforations without using extra
corneas, Seminars in Ophthalmology, DOI: 10.1080/08820538.2021.1896754

To link to this article: https://doi.org/10.1080/08820538.2021.1896754

Published online: 06 Apr 2021.

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SEMINARS IN OPHTHALMOLOGY
https://doi.org/10.1080/08820538.2021.1896754

Lamellar corneal patch grafts in the management of corneal thinning and

perforations without using extra corneas
a b
Umit Calli , Selim Genc , Osman Şalkacıc, and Asena Ömeroğlub
a
Fatih Sultan Mehmet Research and Training Hospital, Ophthalmology Department, Istanbul, Turkey; bBeyoglu Research and Training Hospital,
Ophtalmology Department, Istanbul, Turkey; cKartal Dr. Lütfi Kırdar Research and Training Hospital, Ophtalmology Department, Istanbul, Turkey

ABSTRACT ARTICLE HISTORY

Objectives: To report the tectonic role of circular and square-shaped lamellar grafts without using extra Received 27 January 2021
corneas. Revised 16 February 2021
Materials and Methods: We retrospectively reviewed 23 lamellar patch grafts performed over a six-year Accepted 18 February 2021
period for various tectonic indications in corneal thinning and perforations. The anterior stroma of corneal Keywords
endothelium peeled for Descemet Membrane Endothelial Keratoplasty were used to prepare circular Corneal donor; corneal
lamellar corneal grafts. After punch trepanation of donor corneas for penetrating keratoplasty, the melting; patch graft; tectonic
remaining rim of the cornea was used to prepare square-shaped grafts. lamellar keratoplasty
Results: Circular lamellar grafts were used in 13 eyes that had paracentral or central corneal thinning or
perforations. Square-shaped grafts were used in 10 eyes, nine of which had peripheral corneal thinning or
perforations, and one, limbal. Anatomical success after tectonic grafts was achieved in 22 of 23 eyes
(95.6%) at a mean follow-up of 9.83 ± 6.27 months. The mean of the best-corrected visual acuity improved
from logMAR 2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 postoperatively, at the final follow-up.
Conclusions: The main disadvantage of patch grafts is the shortage in corneal supply due to insufficient
cornea donation in developing countries like Turkey. By evaluating unused corneal rims, extra corneas will
not be required.

Introduction
Tectonic lamellar keratoplasties (LKP), also known as “patch
grafts”, are mainly used to repair corneal thinning, perfora­
tions, or descemetoceles. Reconstructive LKP allows for the
subsidence of inflamed and unstable eyes, such as those with
corneal perforation or descemetoceles, before vision-
rehabilitating penetrating keratoplasty (PKP), which is per­
formed later.1,2 In this period, systemic immunosuppressive
medical treatment has a chance to halt collagenolytic corneal
breakdown in rheumatologic patients.3
We retrospectively reviewed 23 lamellar patch grafts per­
formed over a six-year period for various tectonic indications in
severe corneal melting with or without perforation. The main
disadvantage of patch grafts is the provision of the cornea due to
insufficient cornea donations in developing countries like Turkey.
We evaluated the reconstructive role of two types of tectonic
lamellar grafts without using extra corneas: circular grafts
obtained from the anterior stroma of donor corneas used for
Descemet Membrane Endothelial Keratoplasty (DMEK)s surgery
(Figure 1) and square-shaped grafts obtained from the rim of
donor corneas used for PKP (Figure 2).
Materials And Methods
We performed tectonic grafts in 23 eyes of 23 patients with
corneal thinning and perforations from January 2014 to
December 2020. The inclusion criteria were central, paracentral,
or peripheral perforations or thinning. Cases of perforation with
a bandage contact lens and primary suturation failures were also
included. The following parameters were analyzed: age, sex, initial
diagnosis, preoperative visual acuity, location of the lesion (cen­
tral, paracentral, peripheral, or limbal), type of lamellar graft
(circular or square-shaped), postoperative visual, clinical out­
come, and complications. The patients also underwent anterior
segment optical coherence tomography preoperatively and
postoperatively.
Circular Lamellar Corneal Graft
Trypan blue solution was used to stain the edges of the Descemet
membrane (DM). With a balanced salt solution, a liftable edge
was created using a Sinskey hook anterior to Schwalbe’s line, and
a 360° circumference DM edge was separated. A free area of the
DM edge was grasped with tying forceps and peeled away from
the stroma. When the DM was stripped partially, the graft was
re-stained and replaced over the stroma. Superficial partial-
thickness trephination was performed from the endothelial
side with the previously determined diameter, and the entire
endothelium was peeled from the donor stroma. The circular
lamellar corneal graft was prepared from this stroma, and the
remaining endothelial graft was transferred to an Optisol corneal
storage medium.

CONTACT Umit Calli umitcalli52@hotmail.com Fatih Sultan Mehmet Research and Training Hospital, Ophthalmology Department, Yaprak Street No: 4/21
Umraniye, Istanbul, Turkey.
The manuscript has been read and approved by all the authors.
© 2021 Taylor & Francis
2 U. CALLI ET AL.
Figure 1. Square-shaped lamellar patch graft in a peripheral corneal perforation
due to trauma.
Figure 2. Circular lamellar patch graft in a paracentral/central corneal melting
case secondary to rheumatoid arthritis.
Donor stroma was cut by a trephine to punch out a circular
button.
The recipient cornea was trephined to a partial stromal depth
using a disposable trephine with the obturator set for the requi­
site depth, or alternatively, cut in a freehand fashion. Lamellar
dissection was performed with either a spatulate, lamellar inci­
sional blade, or a sharp-point blade. Viscoelastic material was
injected into the anterior chamber through either the perforation
or through a separate paracentesis to improve global turgor and
to reduce anterior chamber collapse during dissection.
Square-shaped Corneal Lamellar Graft
After punch trepanation of the donor cornea used for kerato­
plasty, the remaining rim of the cornea was cut to 50% thick­
ness and suitably sized for the lesion. The recipient bed was
formed by cutting the cornea approximately 1–2 mm outside
the lesion borders in a rectangular or square shape in partial
thickness by a crescent knife.
In circular or square-shaped grafts, the donor corneal
button was sized 0.25–0.50 mm or larger than the recipient
bed. The externalized or incarcerated iris was either reposi­
tioned or excised. Grafts were sutured with interrupted
10–0 nylon sutures. All eyes received topical antibiotic
drops, and some eyes received an additional subconjuncti­
val antibiotic injection. The eyes were covered with a patch
and metal shield.
Topical moxifloxacin and preservan-free artificial tears were
used four times daily for the first four weeks postoperatively.
Topical preservan-free steroid drops (Dexasine SE, LİBA) were
used four times daily and gradually tapered. Systemic immu­
nosuppression, either with corticosteroids or cytotoxic agents,
was continued in cases of rheumatoid arthritis and systemic
lupus erythematosus, as advised by the rheumatologist, for
systemic control of the disease.
Statistical analyses were performed using SPSS version 19.0
(IBM Corp., Armonk, NY, USA). Snellen visual acuity mea­
surements were converted to logMAR equivalents to allow for
quantification of the numerous visual acuity values that were in
the counting fingers (logMAR 2), hand motions (logMAR 2.3),
and light perception (logMAR 2.8) range. The Wilcoxon
signed-rank test and Mann-Whitney U test were performed
to assess statistical differences. Statistical significance was
defined as p < .05.
Results
Twenty-three eyes of 23 patients underwent tectonic lamellar
grafts. The mean age of the patients was 53.04 ± 19.96 years.
There were 13 female and 10 male patients. The indications for
tectonic lamellar grafts were immunologic disease in 10 eyes,
bacterial infectious keratitis in 7 eyes, trauma in 2 eyes, expo­
sure keratopathy in 2 eyes, and neurotrophic keratitis in two
eyes. Circular lamellar grafts were used for 13 eyes with para­
central or central corneal thinning or perforation. Square-
shaped lamellar grafts were used for nine eyes with peripheral
and one eye with limbal corneal thinning or perforation.
Anatomical success after tectonic grafts was achieved in 22 of
23 eyes (95.6%) at a mean follow-up of 9.83 ± 6.27 months. The
characteristics and outcomes of patients are summarized in
Table 1.
The mean of the best-corrected visual acuity improved from
logMAR 2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 post­
operatively, at the final follow-up. While preoperative visual
acuity was not significantly different, postoperative visual
acuity was significantly better in eyes with peripheral corneal
ulcerations than in eyes with central ulcerations (logMAR
1.16 ± 0.24 and logMAR 1.51 ± 0.21, respectively).
Remelting of the graft was seen in three eyes, which then
underwent a second lamellar patch graft. One patient under­
went PKP after failure of the second LKP. Corneal abscess was
seen in two eyes, which were then treated with topical fortified
antibiotic drops. Pseudochamber formation at the interface
was detected in six patients (Figure 3).

Table 1. Characteristics and outcomes of patients.
Female/male
Age, years 53.04 ± 19.96
İndications;
İmmunologic diseas
İnfectious keratitis
Trauma
Other
Sites of perforation/thining
Paracentral/central
Peripheral
Limbal
Anatomic success 22/23 (95.6%)
Visual improvement 19/23 (82.6%)
Functional success (with visual acuity of 20/100 or better) 6/23 (%26,1)
Discussion
Corneal thinning or perforations (impending or recent) can
occur secondary to inflammatory diseases, trauma, or micro­
bial keratitis. Small perforations may be treated effectively with
cyanoacrylate tissue adhesives, but in more extensive lesions or
in cases of cyanoacrylate tissue-adhesive failure, lamellar cor­
neal patch grafts are effective in providing tectonic support and
in stabilizing the eye while systemic immunosuppression takes
effect.4 Lamellar patch grafting is also useful in the removal of
necrotic stroma, which is a source of collagenase.5,6 The ana­
tomical success in cases of PKP in corneal melting is generally
inferior7,8 to that described in cases of LKP.3,4 In a study by
Bernauer et al., the application of tissue adhesive as a definitive
repair failed in all five eyes, lamellar grafting was anatomically
successful in three of four eyes, and PKP was successful in 10
(45%) of 22 eyes. The most common cause of early failure of
penetrating grafts was recurrent melting.2 In a study by Nobe
et al., all six PKPs performed for corneal melting secondary to
immunologic diseases failed.7 Palay et al. reported an 87%
success rate in preserving global integrity with PKP in patients
with rheumatoid arthritis; however, after five years, PKP sur­
vival decreased to 48%.8
Tectonic LKPs are effective in providing tectonic support
and in stabilizing the eye while systemic immunosuppression
treatment takes effect. In a study by Raizman et al., the PKP
success rate was 88% and the LKP success rate was 92% in
corneal melting.3 Soong et al. reported that tectonic LKP for
active corneal melting was effective in saving the integrity of
Figure 3. Pseudochamber formation after patch graft.
SEMINARS IN OPHTHALMOLOGY 3
the globes in all 80 eyes of 64 patients.4 In the present study, we
13/10 evaluated the effects of tectonic LKP on the integrity of the
globe and visual rehabilitation in patients with corneal melting
10
7
and perforations. Tectonic or anatomical success was achieved
2 in 22 of 23 eyes (95.6%). This high success rate was similar to
4 that reported in previous studies.3,4
13
Although tectonic LKP applied in cases of active corneal
9 melting or perforation is a successful method for maintaining
1 globe integrity, its effect on visual acuity is limited due to the
underlying disease’s destructive process .4,9 The fact that some
patients we evaluated in our study reached ambulatory vision
levels support this. Soong et al. reported that the visual acuity
improved in 34 cases (42% of the eyes) after tectonic LKP, even
though only 14 (17.5%) cases resulted in visual acuities of 20/100
or better. The mean logMAR acuity preoperatively was 1.831
and postoperatively was 1.653 in their study.4 In another study,
the mean of the best corrected visual acuity (expressed in deci­
mals) improved from 0.2 ± 0.26 preoperatively to 0.34 ± 0.26
postoperatively at the final follow-up.9 In our study, the mean of
the best-corrected visual acuity improved from logMAR
2.29 ± 0.23 preoperatively to logMAR 1.35 ± 0.2 postoperatively
at the final follow-up. The visual acuity improved in 19 (95.6%)
of 23 eyes after tectonic LKP, even though only 6 (26.1%) cases
resulted in visual acuities of 20/100 or better.
In the present study, the postoperative visual acuities were
significantly better in the peripheral square-shaped LKP
patients than in the central circular LKP patients. Soong et al.
similarly reported that postoperative visual acuity was signifi­
cantly better in eyes with peripheral corneal ulcerations than in
eyes with central ulcerations.4 However, the effect of the shape
of the corneal lamellar graft on final visual acuity is still vague.
Peripheral square shaped-LKP cases should be compared with
peripheral circular LKP cases to clarify the effects of square-
shaped lamellar grafts on visual acuity.
Postoperative bacterial keratitis occurred in two eyes in our
study. Soong et al. reported three bacterial keratitis cases in 80
eyes; all three keratitis cases occurred in previously uninfected
eyes. Vanathi et al. reported microbial keratitis in 41 eyes after
LKP in a patient with traumatic limbal perforation with iris
incarceration. In our study, bacterial keratitis on the graft
cornea after LKP was seen in patients with corneal perforation
secondary to bacterial keratitis.
4 U. CALLI ET AL.
Tectonic grafts of varying size, shapes, and positions are
used in the treatment of refractory corneal diseases that
endanger the integrity of the globe.10 Twenty-four full-
thickness tectonic grafts, nine mushroom grafts, and nine
lamellar patch grafts were performed in the study of
Vanathi et al.9 In our study, if the patient had
a peripheral thinning or perforation, we used a square-
shaped lamellar patch graft obtained from the remaining
rim of a corneal graft used for PKP. We also performed two
transplants from a single cornea by obtaining a circular
lamellar patch graft from the anterior stroma of the cornea
used for DMEK in central/paracentral cases. The main
disadvantages of patch grafts are their cost and surgical
complexity.4 In this way, particularly by evaluating unused
corneal rims, extra corneas are not required.
In our study, graft melting was observed in three out of 23 eyes
(13%). Graft melting was reported in five out of 41 eyes (12.2%) by
Vanathi et al.9 and in 15 out of 80 eyes (19%) by Soong et al.4
The primary goal of tectonic LKP surgery is structural
restoration, with visual improvement being a secondary con­
sideration. Subsequent vision-restoring PKP can be performed
once the active disease becomes quiescent and the eye is
deemed stable at a later stage.
Preoperative and postoperative inflammation suppression is
an important factor for surgical success, though in our study,
remelting developed in only three grafts as a complication.
Likewise, suppression of inflammation is important for graft
success after PKP. Abscess developing on the graft in two cases
also indicated the importance of frequent and careful post­
operative follow-up in these patients. Tectonic LKP can also
be performed without using extra corneas by using the corneal
rims and remaining stroma from DMEK surgery. The main
disadvantage of patch grafts is the shortage of corneas due to
insufficient cornea donation in developing countries like
Turkey. In this way, particularly by evaluating unused corneal
rims and remaining anterior stroma from DMEK surgery,
extra corneas are not required.
DISCLOSURE STATEMENT
The authors report no conflicts of interest.
Funding
None.
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