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PHOTO ESSAY
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 261-262

Post-traumatic isolated host bed dehiscence with an intact limbal sparing lamellar keratoplasty graft-host junction: A rare case report


1 Department of Cornea, Refractive, Ocular Surface Services, Aditya Birla Sankara Nethralaya, Kolkata, India
2 Cornea, Refractive, Ocular Surface Services, Batra Hospital and Medical Research Centre, New Delhi, India
3 MGM Hospital, Mumbai, India

Date of Submission15-Apr-2021
Date of Acceptance24-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Mona Bhargava
Aditya Birla Sankara Nethralaya, 147, EM Bypass, Mukundapur, Kolkata, West Bengal - 700 099
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_879_21

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  Abstract 


Keywords: Compression sutures, host bed dehiscence, keratoglobus, limbal sparing lamellar keratoplasty


How to cite this article:
Bhargava M, Dastidar AG, Benurwar S, Paul RS, Bhambhani VG. Post-traumatic isolated host bed dehiscence with an intact limbal sparing lamellar keratoplasty graft-host junction: A rare case report. Indian J Ophthalmol Case Rep 2022;2:261-2

How to cite this URL:
Bhargava M, Dastidar AG, Benurwar S, Paul RS, Bhambhani VG. Post-traumatic isolated host bed dehiscence with an intact limbal sparing lamellar keratoplasty graft-host junction: A rare case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 23];2:261-2. Available from: https://www.ijoreports.in/text.asp?2022/2/1/261/334987



A 12-year-old boy, right-eye phthisical, underwent Limbal Sparing Lamellar keratoplasty (LSLK) in the left eye (OS) with a 13.5-mm donor corneoscleral graft secured in recipient corneoscleral pocket [Figure 1]. He had a maintained best-corrected-visual-acuity (BCVA) of 20/60 for four years. He then presented with a drop in BCVA to 20/160 after sustaining blunt trauma to OS with metallic wire one day back. Slit-lamp examination revealed graft edema with interface separation with no dehiscence at the graft-host junction (GHJ) [Figure 2]a. Anterior-segment optical-coherence-tomography (ASOCT) showed host-bed dehiscence with clefts at 4 and 7 o'clock positions with interface fluid but intact GHJ [Figure 3]. Air was injected into the anterior chamber and its egress into interface was noted at 4 and 7 o'clock for determining the potential sites of host-bed rupture. Venting incisions were given to drain interface fluid and appose graft-lamellae and host-bed. The suspected leaking sites were repaired with three corneal compression sutures and internal tamponade with air was achieved. Postoperatively, the graft was clear, well-attached with no interface-fluid [Figure 2]b and [Figure 4]. BCVA improved to 20/60, which was maintained over a 2-year follow-up period.
Figure 1: (a) ASOCT image showing ectatic cornea of 220-micron thickness in a keratoglobus patient (b) Corneal thickness map of keratoglobic cornea showing globally thin cornea, thinnest being 208 microns. (c) ASOCT image at 6 months post-LSLK showing good apposition between residual host-bed of 180 microns and donor-lamellar graft of 482 microns. (d) Corneal thickness map at 6-month post-LSLK showing increased global thickness, the thinnest being 547 microns

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Figure 2: Slit-lamp photograph showing (a) post-traumatic diffuse microcystic edema and sectoral stromal edema with interface separation (orange arrow), (b) post-traumatic repair with clear and attached graft, obliterated interface space (green arrow), and three compression sutures (green stars)

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Figure 3: Post-traumatic ASOCT image collage at different scan levels showing interface fluid leading to separation of lamellar graft from host bed almost 360° (b–h) except supero-nasal area (a). Bed dehiscence leading to fluid seep-in is depicted in figure 3g

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Figure 4: Post-surgical repair ASOCT image collage at different scan levels showing complete apposition of host corneal bed with overlying lamellar corneal graft (a–h). Compression suture sites are marked with yellow arrows in figures 4d, 4g

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  Discussion Top


Traumatic wound dehiscence following keratoplasty is associated with inherent weakness of GHJ that persists almost lifelong.[1],[2] The incidence of traumatic wound dehiscence following deep anterior lamellar keratoplasty (DALK) was found to be 3.2% versus 5.8% after penetrating keratoplasty.[2],[3] Till date, there are isolated case reports about traumatic graft dehiscence following lamellar keratoplasty (LK),[2] especially LSLK. Various studies have put together young and elderly age groups, trauma in young, falls in the elderly, male gender, and noncompliance to protective glasses postoperatively as significant risk factors.[1],[2],[3] In almost all cases, GHJ is the most vulnerable site to dehisce following trauma[1],[2],[3], and an intact Descemet layer provided tectonic support, preventing globe rupture.[3] Surprisingly, in our case, it was the lamellar-graft that provided the required structural integrity and the host corneal bed took the brunt of the injury. There have been reports of associated Descemet rupture along with GHJ dehiscence leading to open globe,[2] but to the best of our knowledge, this is the first report of isolated Descemet-bed rupture. LSLK may not eliminate the risk of traumatic wound dehiscence but can definitely reduce it.[4] Nonetheless, post-LK dehiscence has been reported with good visual outcomes,[1] as was in our case.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meyer JJ, McGhee CN. Incidence, severity and outcomes of traumatic wound dehiscence following penetrating and deep anterior lamellar keratoplasty. Br J Ophthalmol 2016;100:1412-5.  Back to cited text no. 1
    
2.
Sari ES, Koytak A, Kubaloglu A, Culfa S, Erol MK, Ermis SS, et al. Traumatic wound dehiscence after deep anterior lamellar keratoplasty. Am J Ophthalmol 2013;156:767-72.  Back to cited text no. 2
    
3.
Kawashima M, Kawakita T, Shimmura S, Tsubota K, Shimazaki J. Characteristics of Traumatic globe rupture after keratoplasty. Ophthalmology 2009;116:2072-6.  Back to cited text no. 3
    
4.
Karimian F, Baradaran-Rafii A, Faramarzi A, Akbari M. Limbal stem cell-sparing lamellar keratoplasty for the management of advanced keratoglobus. Cornea 2014;33:105-8.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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