|Year : 2021 | Volume
| Issue : 1 | Page : 98-99
Contralateral autologous corneal transplantation in an human immunodeficiency virus-positive patient with multiple failed grafts: A challenging experience
Sudhakar Potti, Aparna N Nayak
Department of Cornea, Sankara Eye Hospital, Guntur, Andhra Pradesh, India
|Date of Submission||30-Apr-2020|
|Date of Acceptance||20-Jul-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Sudhakar Potti
Sankara Eye Hospital, Guntur-Vijayawada Expressway, Pedakakani, Guntur - 522 509, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
A 61-year-old human immunodeficiency virus (HIV)-positive female patient, planned for a repeat penetrating keratoplasty in the left eye after two failed grafts, also had an absolute right eye and a clear cornea with healthy endothelium (CD4-2445 cells/mm2) with no perception of light. Due to an unexpected damage to the only optical grade tissue that occurred during surgery, consent was taken from the patient to perform an autokeratoplasty from the contralateral blind eye and was successfully performed on the left eye with visual potential. The blind eye received a therapeutic grade donor tissue.
Keywords: Autokeratoplasty, Autologous corneal transplantation, bilateral keratoplasty, contralateral bind eye
|How to cite this article:|
Potti S, Nayak AN. Contralateral autologous corneal transplantation in an human immunodeficiency virus-positive patient with multiple failed grafts: A challenging experience. Indian J Ophthalmol Case Rep 2021;1:98-9
|How to cite this URL:|
Potti S, Nayak AN. Contralateral autologous corneal transplantation in an human immunodeficiency virus-positive patient with multiple failed grafts: A challenging experience. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 27];1:98-9. Available from: https://www.ijoreports.in/text.asp?2021/1/1/98/305479
Plange (1908) was the first to report autokeratoplasty, where he used a lamellar graft from the contralateral eye to replace a opaque cornea from lime injury. Since then, there have been sporadic reports on the same entity with good results. Obtaining cornea from the same person poses a lower risk than an allograft. Thus, these procedures enable restoration of functional visual potential in patients who would otherwise remain blind.
| Case Report|| |
A 61-year-old HIV-positive female (CD4 count-740 cells/mm3; on Anti-retroviral therapy: Efavirenz 600 mg Once a day, Lamivudine 150 mg twice a day, Tenofovir 300 mg once a day) presented to us with an absolute right eye (Negative Light Perception) and failed optical Penetrating keratoplasty (PKP) (twice) (PL positive with accurate projection of rays) in the left eye, insisting on a repeat keratoplasty in the left eye. High risk of graft failure on repeating third keratoplasty was explained and an option of contralateral autokeratoplasty with its benefit was explained in view of two failed grafts. Patient was partially willing and was concerned about the cosmesis of the blind eye if the graft fails. She was assured regarding mangament of the failed graft with cosmetic contact lens, corneal tattooing as well as evisceration with custom made orbital implant as a last resort. She was skeptical about evisceration.
Anterior segment evaluation in the right eye showed clear healthy cornea, near mature cataract and fixed dilated pupil. Left eye showed failed vascularized opaque graft with wet ocular surface. Intraocular pressure recorded by applanation tonometry was 28 mmHg in the right eye and 12 mmHg in the left eye respectively. There was no view of fundus in both eyes, although old medical records showed Glaucomatous optic atrophy and pale disc in the right and left eye respectively. B-scan ultrasonography showed significant cupping in the right eye and left eye was normal. Specular microscopy in the blind eye showed healthy endothelium with Cell density of 2445 cells/mm2
A third PKP was planned under guarded visual prognosis as per patient's preference. Mannitol 200 ml (0.5-1/kg) intravenously was given half an hour before surgery and planned under peribulbar anesthesia. Proper aseptic precautions were taken. Disposable handheld trephines were used. Optical donor tissue trephination (7.5 mm) was done with endothelial side up. In the patient's left eye, partial trephination (7 mm) done and cut with corneal scissors. The trephined optical donor button could not be located on the Teflon block. A thorough search revealed that it was misplaced while still being sterile. Examination under the microscope showed total DM stripping. As it wasn't viable for further use, decision was made to perform Autokeratoplasty. After the situation was explained, patient consented for the same. As a temporary measure, the DM stripped tissue was used to seal the recipient left eye with four 10-0 nylon sutures to prevent any intra-operative complication.
Peribulbar anesthesia was given to the absolute right eye. A new set of instruments and gloves were used. An 8 mm therapeutic standby donor corneal tissue was trephined. Flieringa ring was used to stabilize the globe. The cornea was partially trephined (7.5 mm) and cut with corneal scissors. The donor therapeutic grade tissue was placed with 4 sutures as a temporary measure.
Focus was now shifted on to the sighted left eye. Gloves were changed again and with first set of instruments, the DM stripped tissue was removed from the left eye and the freshly harvested auto-graft from the contralateral blind eye was carefully placed with 16 interrupted 10-0 nylon sutures [Figure 1]. Suturing was completed in the right eye in a similar manner [Figure 2]. Bandage contact lens was placed in both eyes.
|Figure 1: Slit lamp photograph showing autologous corneal graft on the left eye with pseudophakia (a) Diffuse and (b) Slit beam illumination|
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|Figure 2: Slit lamp photograph showing a therapeutic grade tissue on the absolute eye (Right) with cataract (a) Diffuse and (b) Slit beam illumination|
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Postoperatively systemic antibiotics, analgesics, topical steroids and preservative-free lubricants were given. Patient was followed up for 1 week, 2 weeks and 1 month. 1 week follow up showed clear graft with best-corrected visual acuity (BCVA) of 6/60. Steroids were gradually tapered. 1 month follow up showed clear graft. Fundus examination showed pale disc with a dull foveal reflex with BCVA of 6/36. At 6 months postoperative period, all sutures were loose and removed, graft was healthy, and had a BCVA of 6/24 [Figure 3]. Patient is satisfied, ambulatory, and compliant with her medications.
|Figure 3: Slit lamp photograph (post operative. 6 months) showing clear graft in the left eye (a) and absolute blind eye (b)|
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| Discussion|| |
Contralateral autokeratoplasty is a beneficial option in patients who have lost function of a potentially seeing eye due to corneal pathology and have a clear healthy cornea with no visual potential in the opposite eye. There is no risk of immunological graft rejection since it is autologous in nature. The surgery is especially beneficial in patients with high risk for graft rejection like multiple failed grafts and dense stromal vascularization. Autologous grafts have been reported to stay clear and free of vascularization, even when operated on densely vascularized host. Another benefit of this surgery is in view of the nonavailability of adequate optical grade corneal tissues and waiting period in a developing country like ours.,
Surgical procedure is similar to conventional full-thickness PKP. Because of damage to the harvested donor graft, a decision was made to perform contralateral autokeratoplasty and peribulbar anesthesia was the only option. Many studies reported this procedure under general anesthesia, as they were planned surgeries., In our case, the patient was co-operative and was comfortable throughout the procedure. No intra-operative complications occurred.
In the case of a planned Autokeratoplasty, A therapeutic grade corneal tissue can be used to temporarily seal the blind eye whereas other surgeons used Landers temporary keratoprosthesis, glycerine preserved corneas and eye shield. Considering the priority for the eye on which autokeratoplasty is to be performed, the blind eye can be temporarily sealed with a therapeutic grade tissue with 4 sutures, the surgery on the eye with visual potential is completed and then surgery is completed in the blind eye. Another option would be to complete the surgery in the blind eye while keeping the freshly harvested autologous graft in a storage medium. A Landers temporary keratoprosthesis can be considered as an alternative if available. The surgeon must use a different set of instruments while operating on each eye respectively.
Sharma et al. recommend the donor cell count above 2,000 cells/square millimeters in cases considered for autokeratopalsty. Specular microscopy in the blind eye showed cell density of 2445 cells/square millimeters which is a good predictor of graft survival.
Unfortunately, in extreme situations where the trephined donor button is misplaced or unable to be traced, there are few options: A standby therapeutic grade tissue. If unavailable, glycerol preserved corneal button can be used as a temporary method. Another option would be suturing the host button itself provided it's not perforated. If perforated, preserved scleral button can be trehpined and sutured onto the recipient bed. If available, a temporary keratoprosthesis can also be placed.
Although autokeratoplasty is not performed routinely, their appropriate use would clearly help the surgeons to avoid rejection in high-risk allograft corneal transplantation. It should be reserved only for selected cases, mainly for patients with a clear cornea with visual dysfunction due to pathology affecting the retina, the optic nerve and the contralateral eye having a visual potential, limited only by corneal disease (Bullous keratopathy secondary to a GDD tube with anterior synechiae,, Alkali burn scar, failed keratoplasty, high-risk cases with vascularized bed). Autokeratoplasty eliminates the need of long-term postoperative steroids. This may be important in steroid responders and patients with preexisting glaucoma.
| Conclusion|| |
This is a challenging case because of the unusual complication of misplacing the only optical grade tissue available during surgery. The iatrogenic complication was successfully managed by performing an autokeratoplasty from the contralateral blind eye (a fortunate coincidence of serendipity) under peribulbar anesthesia without any major complications. The need for a standby therapeutic/glycerin stored tissue for emergency purpose cannot be over emphasized.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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 their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]