Coneal perforation etiology clinical presentation and managment

The ppt summarizes corneal perforation etiology clinical evaluation and possible management for ophthalmology residents

1. Presenter: Dr Alazar M. (R1II) Moderator : Dr. Fikerte A (Assistant prof. of Ophthalmology, Cornea subspecialist) University of Gondar, College of Medicine and Health Science Department of Ophthalmology Gondar CORNEAL PERFORATION

2. Outline Introduction Causes Aproach to corneal perforation Management Options References 06/05/2023

3. Introduction Corneal perforation is a cause of ocular morbidity and profound visual loss. It is the end result of various infectious and noninfectious disorders that include microbial keratitis, trauma, and immune disorders. Descemetoceles and perforations are ophthalmic emergencies that require immediate recognition and intervention. The primary causes include infection, inflammation, and trauma. Management should be directed toward prevention of corneal perforation 06/05/2023

4. TERMINOLOGY A corneal ulcer refers to a defect in the epithelial layer with some degree of stromal loss, often with infiltration or necrosis A descemetocele refers to a lesion in which there is destruction of the epithelium and stroma, with only the Descemet membrane and endothelium remaining impending perforation is refers to any ulceration with severe stromal thinning that clinically appears capable of perforating in the near future. Perforation refers to a definite full-thickness defect in the cornea and there is communication between the anterior chamber and surface of the eye. 06/05/2023

5. ... Corneal melting and subsequent perforation can result from a breach in the corneal epithelium Exceptionals Corynebacterium diphtheriae, Haemophilus aegyptius, Neisseria gonorrhoeae, and N. meningitidis, and Shigella and Listeria species alterations in the basement membrane of the epithelial cells PED Stromal melting by proteolytic enzymes from altered epithelial cells and PMN cells When most of the stroma melts away, the Descemet’s membrane bulges forward, forming a descemetocele 06/05/2023

6. ETIOLOGY The major causes of corneal ulceration leading to corneal perforation can be broadly grouped as infectious, noninfectious (ocular surface-related and autoimmune), and traumatic. 06/05/2023

7. ... I. INFECTIOUS CORNEAL PERFORATION common cause of corneal perforation. bacterial and fungal corneal infections are frequent in the developing world recurrent herpetic keratitis causing stromal necrosis is the major cause of corneal perforation in developed countries. 06/05/2023

8. ... Bacterial Keratitis produces corneal ulceration leading to corneal perforation. Most bacteria require a break in the corneal epithelium to gain access to the corneal tissue. interleukin 1 and tumor necrosis factor (TNF) are released attracting polymorphonuclear cells. virulent organisms such as Pseudomonas, release of enzymes like collagenase accelerates the process of corneal perforation. Predisposing Factors outdoor occupation, trauma with vegetative matter, central location of corneal ulcer, lack of corneal neovascularization and failure to start timely management 06/05/2023

9. ... Herpes Keratitis by necrosis of corneal stroma. the host immune response is believed to be the principal cause. Destruction of the corneal stroma is largely mediated by matrix metalloproteinases and collagenases from the polymorphonuclear cells and macrophages. necrotizing stromal keratitis the epithelium breaks down over a dense stromal infiltrate, forming a super-ficial ulcer that may slowly or rapidly deepen, 06/05/2023

10. ... Fungal Keratitis Fungal keratitis is more prevalent in the developing world. available antifungal therapy is not optimal, mainly due to low ocular penetration. Overall, one-third of all fungal infections require surgical intervention because of treatment failures or corneal perforations. The rate of corneal perforation in fungal keratitis ranges from 4% to 33%. 06/05/2023

11. ... II. NONINFECTIOUS CORNEAL PERFORATION 1. Ocular Surface--Related Dry eye syndrome vitamin A deficiency, erythema multiforme, and benign mucous membrane pemphigoid . Chronic epithelial defects combined with poor healing may lead to sight threatening infectious corneal ulceration, sterile thinning, and/or perforation 06/05/2023

12. ... 2 . Autoimmune Causes Collagen vascular diseases such as rheumatoid arthritis, systemic lupus erythematosus, temporal arteritis, Wegener granulomatosis, sarcoidosis, and inflammatory bowel disease PUK and Mooren Ulcer 06/05/2023

13. ... III. Traumatic Corneal Perforation Corneal trauma can result from a penetrating or perforating eye injury 06/05/2023

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15. Approach to Managementof Corneal Perforation A. History and Corneal Work-up Symptoms Pain Decreased visual acuity Increased “tearing” Signs Shallow or flat anterior chamber (perforation) Positive Seidel test (perforation) Uveal tissue to the posterior cornea or frank prolapse (perforation) Hypotony (perforation) Central clear zone (often bulging) within area of infiltrate or thinning (descemetocele) Radiating folds in Descemet membrane emanating from the base of the ulceration (descemetocele) 06/05/2023

16. ... patient should be discouraged from squeezing during the examination, minimal manipulation of the globe and minimal application of topical medications should be performed. pressure Seidel tes small or self-sealing Corneal perforation Infectious ulcers will have a significant amount of purulent material and mucus. Suspected perforation central clear zone within a large, dense infiltrate shallowing of the anterior chamber in the absence of high IOP and pupillary block The presence of a hypopyon that suddenly clears on subsequent reexamination occurred.

17. ... B LABORATORY DIAGNOSIS In cases with concurrent keratitis, a gentle corneal scraping is required for microbiological diagnosis. C. SYSTEMIC WORK-UP For collagen vascular diseases 06/05/2023

18. Management of Corneal Perforations A. Non - Surgical Management 1. Treating the Infectious Cause Monotherapy with fluoroquinolones The fourth-generation fluoroquinolones,moxifloxacin and gatifloxacin, have a greatly lowered resistance rate providing better Gram-positive activity than previous-generation fluoroquinolones. enhanced transcorneal penetration Even when the corneal perforation is suspected to be noninfectious, prophylactic topical antibiotic therapy should be given 06/05/2023

19. ... 2. Antivirals acyclovir is the mainstay for treatment and pre_x0002_vention of recurrent herpetic eye disease. Necrotizing stromal disease Rxed with acyclovir and steroid 3. Anti-glaucoma Drugs Pharmacologic suppression of aqueous production encourages wound healing reduces pressure that may cause extrusion of intraocular contents. 4. Anti-collagenases Systemic tetracyclines hasten corneal re-epithelialization doxycycline inhibits corneal matrix metalloproteinase activity, chelating the metal ions. 06/05/2023

20. ... 5. Anti-inflammatory Therapy judicious use of topical steroids may be beneficial in the management of bacterial keratitis. after 2--5 days of appropriate antibiotic treatment. chosen antibiotic is effective against the organism Steroids should not be used in the initial treatment of posttraumatic and contact lens--related ulcers Use of Steroid-sparing Agents Systemic immunosuppressive medication may be beneficial in unresponsive severe noninfectious corneal inflammatory disease 06/05/2023

21. ... 6. Optimizing Epithelial Healing preservative-free artificial tears and ointment delaying evaporation. Punctal or intracanalicular plugs autologous serum drops small corneal perforations and progressive melting, soft contact lenses may be helpful 06/05/2023

22. ... B. Surgical Management Tissue Adhesives - Corneal Gluing used to manage small corneal perforations. Currently, two types nonbiologic (cyanoacrylate) and biologic (fibrin glue) adhesives 06/05/2023

23. ... Cyanoacrylate glue are ester derivatives of cyanoacrylic acid best suited to perforations that measure less than 3 mm in diameter, are concave in profile, and located away from the limbus. Cyanoacrylates undergo polymerization upon contacting water or weak bases, causing them to harden. Short chain derivatives are strongest, reaching peak bonding strength occurring at 2 min 06/05/2023

24. ... Cyanoacrylates are also bacteriostatic, particularly against gram positive organisms including Staphylococcus aureus, Streptococcus pneumoniae, and group A Streptococci disrupts stromal melting, in both infective and noninfective cases. Large numbers of PMN cells are present in active corneal ulcers and promote corneal melting. stimulated by the interaction between re epithelializing epithelium and the subjacent keratocytes. Potent collagenolytic and proteolytic activity Cyanoacrylates inhibit re epithelialization and consequently inhibit the polymorphonuclear leucocytic infiltration in the diseased area 06/05/2023

25. ... Techniques of application can be applied at the slit lamp But it is preferable to perform the procedure in the operating theatre, using the operating microscope under aseptic conditions. Using topical or local anesthesia an eye speculum is used to gain adequate exposure of the ocular surface noncompressing lid speculum being preferred. the site of gluing is debrided of necrotic epithelium beforehand and kept dry throughout the procedure 06/05/2023

26. ... In case iris tissue plugs the perforation or where the anterior chamber collapses Reform the anterior chamber using viscoelastic material or an air bubble to prevent contact between the glue and intraocular structures 06/05/2023

27. ... T echnique 1 – direct application of glue using a Rycroft cannula A 1 ml syringe is used to withdraw glue using a 20-guage needle. A cannula (27 gauge) is placed over the tip of syringe. The plunger is pushed in till a small drop of glue is visible at the tip of the cannula. glue spreads to seal the wound and within seconds polymerizes to form an even seal. if there is any residual leak, f urther drops can be applied around the seal as top-up This technique can be helpful in small perforations. 06/05/2023

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29. ... T echnique 2 – use of a plastic disc with the glue small disc is cut from the thin non-adhesive part of the surgical drape The plastic end of the cellulose sponge is dipped in the chloramphenicol ointment acts as a lubricant to support the plastic disc. A drop of the glue is placed over the disc. then the disc is placed gently over the perforated area. The glue sets in quickly the plastic disc providing a smooth surface to reduce irritation and also preventing the glue from dislodging easily 06/05/2023

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31. ... Technique 3 – modified technique – use of 30G-cannula instead of cellulose sponge 06/05/2023

32. ... Bandage Soft Contact Lens after gluing 06/05/2023

33. ... Complications and adverse effects primary concern is its stromal, endothelial, and lenticular toxicity raised intraocular pressure microbial keratitis sterile hypopyon, glaucoma giant papillary conjunctivitis retinal toxicity and symblepharon formation 06/05/2023

34. ... B Fibrin glue a biologic product containing fibrinogen and thrombin. It is completely biodegradable induces minimal stromal inflammation or tissue necrosis. less toxic than cyanoacrylate, providing a more suitable environment for healing. thrombin catalyzes the conversion of fibrinogen to fibrin in the coagulation pathway resulting in the formation of a hemostatic plug. 06/05/2023

35. ... When applied to a corneal perforation, this hemostatic plug forms an effective sealant. used for defects up to 2 mm is as effective softer and smoother than cyanoacrylate glue used over and under a superficial covering layer (amniotic membrane or conjunctiva), and tend to cause less discomfort and fewer symptom fibrin glue degrades more quickly than cyanoacrylate glue does not have antibacterial properties lower tensile strength than cyanoacrylate bovine‑derived products may transmit prion or viral disease 06/05/2023

36. ... Postoperative Management topical and/or systemic aqueous sup_x0002_pressants noninfectious, prophylactic broad-spectrum topical antibiotics should be used 3-6 times a day. A protective shield or glasses should be placed on the eye at all times. Preservative-free artificial tears should be used at least 4-8 times a day a bacterial infection is suspected topical fortified antibiotics and/or fluoroquinolones, every hour Antiviral or antifungal therapy should be instituted if a herpetic or fungal etiology is suspected 06/05/2023

37. ... Tenon’s patch graft has the abilityto produce autologous fibroblasts and connective tissue allowing it to be incorporated into the host’s corneal tissue for large corneal perforations up to 6 mm, where tissue adhesive is not suitable Harvesting the Tenon’s graft Tenon’s capsule arises 2 mm posterior to the limbus Incisions are made posterior to the scleral insertion of Tenon’s capsule, in the inferotemporal and inferonasal quadrant, and a portion of the capsule excised. 06/05/2023

38. ... It is advised that the size of the graft is slightly larger than the size of the corneal defect. Applying the Tenon’s patch graft Cornea is debrided, removing debris, and the epithelium adjacent to the perforation. The graft is then ironed into a thin layer and placed over the defect secured in place using either tissue adhesive or sutures. the anterior chamberis reformed using an air bubble As healing occurs, the Tenon’s graft is incorporated into the corneal scar and the success of this procedure is up by 75% 06/05/2023

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40. ... Advantages It is an autologous transplant, hence no immune response is evoked and thus tissue rejection does not occur. does not rely on donor tissue or eye banks supply can be more readily guaranteed. there are no heterologous antigenic sensitization corneal grafting is more likely to succeed if performed at a later stage. 06/05/2023

41. ... Conjunctival flaps biological patch provides trophic factors, mechanically protects the cornea, and offers analgesic effects. Superior forniceal conjunctival advancement pedicels, such Gundersen or Cies’s racquet conjunctival flap, are typically used for indolent, nonhealing, peripheral corneal ulcers, and impending perforations require extensive conjunctival dissection and obscure the cornea postoperatively. They promote extensive corneal vascularization which facilitates corneal healing 06/05/2023

42. ... complications increased risk of graft rejection if one is performed at a later stage. corneal vascularization flap perforation or fenestration, and partial or complete flap displacement, particularly when managing central lesions in large perforations carry an increased risk of nonadherence to the cornea. resulting in hypotony and predisposing the eye to endophthalmitis 06/05/2023

43. ... Amniotic membrane transplant Amniotic membrane epithelium contains growth factors hepatocyte growth factor, keratocyte growth factor,and epidermal growth factor. aid epithelial healing by promoting differentiation and migration of epithelial cells that are in contact with the amniotic membrane. Inhibitory proteases released by the amniotic membrane induce apoptosis of local inflammatory cells reducing the risk of corneal melt. 06/05/2023

44. ... stromal tissue may synthesized from the amniotic membrane in cases involving deep ulcers or descemtocoeles Indicated for the treatment of corneal epithelial defects. Rx of severe neurotrophic keratopathy management of corneal perforations particularly useful in cases of central perforation large perforations 06/05/2023

45. ... Surgical technique and outcomes Multilayered AMT is preferred for deep corneal ulcers or perforations. filling the defect with multiple pieces of amniotic membrane before covering the entire cornea with a final layer of transplanted tissue. The transplanted membrane can then be secured using sutures or fibrin glue a 100%healingrate formicro‑perforations andanalmost 75% rate of closure for perforations up to 1.5 mm in diameter multilayered AMT in combination with fibrin glue to treat defects greaterthan 3 mm 06/05/2023

46. ... Keratoplasty procedures Large corneal perforations Tectonic corneal transplants restore globe integrity by filling corneal stromal defects. Surgical techniques full‑thickness keratoplasty, lamellar keratoplasty, and corneal patch grafts chosen depending on the size, depth, location, and cause of perforation 06/05/2023

47. ... Corneal perforations secondary to infective keratitis Therapeutic keratoplasty restores the integrity of the globe reduces the microbial and necrotic tissue load, reduces the associated toxins and enzymes which contribute to the progression of infective keratitis and corneal stromal melt If anterior chamber is flat, grafting needs to be performed within 24-48 hours Otherwise improved graft survival in cases where keratoplasty was delayed All necrotic tissue should be excised with a 1 mm margin of healthy tissue, to ensure a healthy donor bed free of infection 06/05/2023

48. ... Corneal perforations in sterile melts Tectonic epikeratoplasty (TEK) corneal patch graft 06/05/2023

49. ... Peripheral corneal perforations Corneal wedge resection management of pellucid marginal degeneration (PMD) excising the cornea in the region of peripheral thinning filling the resultant defect with a segment of healthy donor corneal tissue. effective in patients with small areas of corneal thinning Crescentic lamellar keratoplasty Terrien’s marginal degeneration (TMD) or Mooren’s ulcer 06/05/2023

50. References Cornea, Fundamentals, Diagnosis and management; From p 1414-1428. Management of Corneal Perforation;Vishal Jhanji, MD, Alvin L. Young, MMedSc (Hons), FRCSI, Jod S. Mehta, MD, Namrata Sharma, MD, Tushar Agarwal, MD, and Rasik B. Vajpayee, MS, FRCS (Edin),FRANZCO A brief review of techniques used to seal corneal perforation using cyanoacrylate tissue adhesive;M. Ranaa, V. Savant Management of corneal perforations: An update; Rashmi Deshmukh, Louis J Stevenson, Rasik Vajpayee 06/05/2023