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 Table of Contents  
CASE SERIES
Year : 2021  |  Volume : 59  |  Issue : 1  |  Page : 61-64

Tuck-in tenon's patch graft for corneal perforation


Department of Cornea, RIO GOH, Chennai, Tamil Nadu, India

Date of Submission21-Sep-2020
Date of Acceptance20-Oct-2020
Date of Web Publication27-Mar-2021

Correspondence Address:
Dr. Amogh Laxman Jambagi
Flat A012 DLF Commanders Court, Ethiraj Salai Egmore, Chennai-08, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_139_20

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  Abstract 


Corneal perforation remains to be one of the most dreaded complications of ocular trauma and its prompt diagnosis and management is key to quick recovery. Tuck-in Tenon's patch graft is an extremely viable and handy technique to tackle corneal perforation. The tenon's tissue, being autologous, reduces the chance of rejection while providing good tectonic support. This is a case series of tuck-in Tenon's patch graft done for cases of corneal perforation. Through the case series, we try to put forth our experience with this novel technique.

Keywords: Cornea, corneal perforation, patch graft, tenon's patch graft, tuck-in graft


How to cite this article:
Vadivelu SD, Jambagi AL, Senthilkumar G T, Gandhi N, Sivakami M. Tuck-in tenon's patch graft for corneal perforation. TNOA J Ophthalmic Sci Res 2021;59:61-4

How to cite this URL:
Vadivelu SD, Jambagi AL, Senthilkumar G T, Gandhi N, Sivakami M. Tuck-in tenon's patch graft for corneal perforation. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Apr 22];59:61-4. Available from: https://www.tnoajosr.com/text.asp?2021/59/1/61/312292




  Introduction Top


Corneal perforation is an ocular emergency, with dreaded complications requiring urgent surgical correction. The surgical options available are tissue adhesives, amniotic membrane graft (AMG), and therapeutic keratoplasty.[1],[2] Most of them have their own disadvantages, the most common being the risk of rejection.

The use of autologous tissue to reinforce the perforation has been reported in the literature before.[3] However, the use of autologous tenon's tissue to do a patch graft using overlay suturing is fairly rare.[4],[5] The use of autologous tenon's tissue as a patch graft was first described by Rasik Vajpayee et al. in 2012 in a short video clip demonstrating the technique.[6] This technique was further improved upon by Sayan Basu who tucked in the tenon's tissue in the perforation and used overlay sutures to hold the tissue in place.[7] The tissue can be used to seal sterile corneal perforations of size 3–5 mm. Since the tissue is autologous, the risk of rejection is reduced and it also reduces the dependence on donor tissue.

We have attempted to present our experience with this technique in our case series of four cases of corneal perforation.


  Materials and Methods Top


In this prospective case series, four patients who underwent tuck-in tenon's patch graft with overlay sutures during the study period of 30 days were included.

Preoperatively, the patients were explained regarding the procedure, and then an informed consent was taken. In order to maintain uniformity, the surgery was performed by the same surgeon using the same surgical sutures 10-0 Ethilon monofilament (Ethicon, Johnson and Johnson, US) and similar postoperative management protocol was followed, with provision for additions.The surgery was performed under peribulbar block. The eye was scrubbed and draped. The wound edges were freshened and a stromal pocket created around the wound margin. Then, superior conjunctiva was exposed and a linear peritomy was done. The conjunctiva was separated from the tenon's tissue by blunt dissection using Conjunctival scissors. The tenon's tissue, of appropriate size, was obtained by blunt dissection of underlying episcleral tissue.

The harvested tenon's tissue was placed over the wound and gently tucked into the stromal pocket. It was sutured into place using 10-0 Ethilon monofilament (Ethicon, Johnson and Johnson, US) using overlay sutures [Figure 1]. A watertight compartment was ensured and a bandage contact lens was placed over the cornea. The patient was started on antibiotic eye drops (moxifloxacin hydrochloride 0.5%, one drop six times a day), steroid eye drops (prednisolone acetate 1% one drop six times a day) and tear substitutes.
Figure 1: Diagrammatic representation of the overlay suturing technique[8]

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The postoperative assessment was done on postoperative day (POD) 1, 7, 14, and 30 under the slit lamp. The surgical site was checked for any aqueous leak, signs of healing, inflammation, or rejection. Antibiotic and steroid eye drops were titrated accordingly.


  Results Top


Our case series includes four patients having sterile corneal perforation of mean size 1.375 ± 0.75 mm. Two of the patients had comorbidities. The baseline characteristics are represented in [Table 1]. Of the four patients, one of them had undergone therapeutic keratoplasty for a corneal melt.
Table 1: Baseline characteristics of the patients

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In all the four cases, intraoperative anterior chamber water tightness was obtained which was maintained throughout the follow-up period. The graft was accepted well and the patients did not need any supplementary medication.

Case 1 was a patient with paracentral corneal perforation due to firecracker injury. He had a well-formed anterior chamber with clearing of Descemet's membrane folds in the immediate postoperative period. The wound healed with a leukomatous scar. He developed a traumatic cataract and underwent phacoemulsification with foldable intraocular lens implantation. Anterior segment-optical coherence tomography (AS-OCT) and slit-lamp photo were taken on POD 60, to check for any graft host interface reaction. The AS-OCT showed that the TPG did not cause any interface reaction [Figure 2].
Figure 2: Photos of case 1 (a) Preoperative profile photograph showing corneal thermal burns (b) Collage showing affected eye on the intraoperative day, day 1, day 2, and day 60 (c) anterior segment OCT of the right eye on postoperative day 60

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Case 2 was a patient with Rheumatoid arthritis (RA) who had a central corneal perforation postkeratoplasty. She showed good integration of the TPG with the perforated corneal graft. She had a vision of Counting fingers close to face (CFCF) after a period of 2 months postprocedure. This patient required a follow-up keratoplasty.

Case 3 was a patient with paracentral corneal perforation due to trauma by an insect; he showed good wound healing with a drastic vision improvement from 2/60 to 6/60 on the Snellen's chart at the final follow-up of 1 month.

Case 4 had a marginal corneal perforation due to PUK. He showed healing of the perforation and arrest of the progression of the PUK. The vision improved to 6/36 at the end of 1 month, which was satisfactory, However the final visual acuity depended mostly on the site of perforation.

None of the patients were lost to follow-up and showed no signs of wound leak at the end of POD 30 [Figure 3].
Figure 3: Diffuse slit-lamp photograph preoperatively and on Day 30 of (a) case 2, (b) case 3, and (c) case 4

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  Discussion Top


There have been various materials, allogenous, and autologous, which are being' used to aid and provide tectonic support in corneal fistulas, sclerocorneal wounds, and pterygium surgeries.[9],[10],[11] The alternatives to TPG include tissue adhesives like cyanoacrylate glue, AMG, penetrating keratoplasty, lamellar grafts, temporalis fascia lata, and periosteum, each one having their own set of advantages and disadvantages.[12] While some of these alternatives need a second surgery to harvest the tissue, the others need donor tissue. The main issue with using an allogenic material is that they carry an increased risk of tissue rejection and infection

Tenon's tissue is a fascial covering of the eyeball lying between the conjunctiva and the episclera. Although the use of autologous and lab-cultured tenon's tissue for case of post trabeculectomy bleb site leak and pterygium surgeries has been reported before, the mention of the use of TPG to treat corneal perforations is very rare.[13],[14],[15]

The study by Sharma et al. reported tenon's patch graft done on 31 cases of sterile corneal perforation of range 3–5 mm and they achieved good results with a mean healing time of 25.7 ± 6.7 days in 27 of the 31 patients.[4] One of these cases required resuturing due to the displacement of graft. Most of the cases in their study showed healing with a leukomatous scar by 16.9 ± 2.7 weeks. Korah et al. did a 6-year retrospective study on 28 patients who had corneal perforations of size 3–6 mm and underwent TPG and reported healing in 20 patients with the maintenance of the anterior chamber.[5]

The advantages of TPG are that the tissue is autologous and hence the chance of autoimmune reaction and rejection is less.[12] And because it is autologous, the procedure is economically viable, and there is a reduced chance of infection. Since in our technique we have created a stromal pocket around the wound, tucked in the tenon's tissue, and sutured with overlay sutures, the risk of iris tissue incarceration and wound leak is drastically reduced. The use of such autologous tissue also reduces the dependence on eye banks for donor tissue, which can be utilized for keratoplasty and research purposes.

The drawbacks of the technique are that the TPG can be used for sterile corneal perforations of size 3-5mm only. Perforations of size larger than 5 mm need a patch graft as the support provided by TPG is inadequate. In our technique, we have harvested tenon's tissue from the superior quadrant, as the tissue from the inferior quadrant carries a risk of getting infected due to inadequate closure by the lids. Harvesting the tissue from the medial or lateral side is avoided as it can cause mild restriction of extraocular movement, due to the tug on medial and lateral check ligaments respectively. Most of the allogenic tectonic supports used for the eye, TPG included, produce a leukomatous scar. And hence, if the scar is in the visual axis, TPG has to be followed up with a keratoplasty to achieve optimum vision.

We conclude that TPG is an effective, inexpensive, and safe technique to manage corneal perforations, which has reduced the risk of tissue rejection and infection. This technique has proven to be very useful especially during the COVID pandemic where the tissue availability is very limited. We have successfully reproduced results in our case series, though a larger study with a longer follow-up period with serial AS-OCTs would determine how well the TPG is integrated into the cornea.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: https://www.aao.org/eyenet/article/corneal-perforations. [Last accessed on 2020 Jul 01].  Back to cited text no. 1
    
2.
Krysik K, Dobrowolski D, Wylegala E, Lyssek-Boron A. Amniotic Membrane as a Main Component in Treatments Supporting Healing and Patch Grafts in Corneal Melting and Perforations. J Ophthalmol 2020;2020:1-7:4238919.  Back to cited text no. 2
    
3.
Sharma A, Mohan K, Sharma R, Nirankari VS. Scleral patch graft augmented cyanoacrylate tissue adhesive for treatment of moderate-sized noninfectious corneal perforations (3.5-4.5 mm). Cornea 2013;32:1326-30.  Back to cited text no. 3
    
4.
Sharma N, Singhal D, Maharana PK, Vajpayee RB. Tuck-in tenon patch graft in corneal perforation. Cornea 2019;38:951-4.  Back to cited text no. 4
    
5.
Korah S, Selvin SS, Pradhan ZS, Jacob P, Kuriakose T. Tenons patch graft in the management of large corneal perforations. Cornea 2016;35:696-9.  Back to cited text no. 5
    
6.
Tenon Patch Graft for Corneal Perforation: American Academy of Ophthalmology. Available from: https://www.aao.org/annual-meetingvideo/tenon-patch-graft-corneal-perforation. [Last acessed on 2020 Jul 03].  Back to cited text no. 6
    
7.
Basu S. TenonsPatchGraft eXPLAINED. Available from: https://youtu.be/YTAlxO4dIWw. Last accessed on 2020 Sep 10].  Back to cited text no. 7
    
8.
Parrish CM, Faris DA, O'Day DM. Mattress bridge sutures for graft fixation in pediatric keratoplasty: New use of an old technique. Ophthalmic Surg 1988;19:795-8.  Back to cited text no. 8
    
9.
Maharana PK, Singhal D, Sahay P, Titiyal JS. Tenon patch graft for corneal fistula: a rare entity treated by a simple technique.Web exclusive article, BMJ Case Rep 2017;2017:bcr2017222790. Available on https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5720249/. [Last accessed on 2020 Jul 12].  Back to cited text no. 9
    
10.
Bae JH, Seong HK, Kim HK, Nam WH. Use of Autologous Tenon's Capsule Graft for Repair of Traumatic Scleral Perforation. J Korean Ophthalmol Soc 2008;49:1706-10.  Back to cited text no. 10
    
11.
Agarwal T, Gupta S, Sharma N. Textbook of Pterygium Management, 2017 Jaypee Brothers Medical Publications. p. 137-9.  Back to cited text no. 11
    
12.
Deshmukh R, Stevenson LJ, Vajpayee R. Management of corneal perforations: An update. Indian J Ophthalmol 2020;68:7-14.  Back to cited text no. 12
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13.
Kawai M, Nakabayashi S, Shimizu K, Hanada K, Yoshida A. Autologous transplantation of a free tenon's graft for repairing excessive bleb leakage after trabeculectomy: A case report. Case Rep Ophthalmol 2014;5:297-301.  Back to cited text no. 13
    
14.
Hong S, Yun JH, Kim ES, Kim JS, Tchah H, Hwang C. Human conjunctival epithelial sheets grown on poly (lactic-co-glycolic) acid membranes and cocultured with human tenon's fibroblasts for corneal repair. Invest Ophthalmol Vis Sci 2018;59:1475-85.  Back to cited text no. 14
    
15.
De Falco E, Scafetta G, Napoletano C, Puca R, Vingolo EM, Ragona G, et al. A standardized laboratory and surgical method for in vitro culture isolation and expansion of primary human Tenon's fibroblasts. Cell Tissue Bank 2013;14:277-87.  Back to cited text no. 15
    


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