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CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 59-60

Tectonic Tenon transplants for four different corneal melts


Department of Cornea and Refractive Surgery, Sankara Nethralaya, Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission30-Jun-2021
Date of Acceptance17-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Radhika Natarajan
Sankara Nethralaya, Medical Research Foundation, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1700_21

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  Abstract 


Tenon's tissue with good tensile strength, pliability, and availability is a valuable patch graft resource for small corneal perforations. We have extended its tectonic use to other corneal melts and leaks with anatomic success. Tenon's patch graft (TPG) was employed for tissue building in four different corneal melts: Mooren's ulcer, leaking cicatrix, persistent epithelial defect, and perforation. The minimum follow-up was six months. TPG is less resource-intensive and longer lasting than cyanoacrylate glue and multilayered-amniotic grafts. It is safe, providing good tectonic outcomes not only in corneal perforations but also in melts secondary to infective, immune, and toxic causes.

Keywords: Corneal melt, fibrin glue, leaking cicatrix, Mooren's ulcer, tectonic support, Tenon's patch graft


How to cite this article:
Natarajan R, Nagpal N. Tectonic Tenon transplants for four different corneal melts. Indian J Ophthalmol Case Rep 2022;2:59-60

How to cite this URL:
Natarajan R, Nagpal N. Tectonic Tenon transplants for four different corneal melts. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 23];2:59-60. Available from: https://www.ijoreports.in/text.asp?2022/2/1/59/334902



Tenon's capsule or fascia bulbi stretches from behind the limbus to envelop the eyeball. Histologically made of connective tissue, it provides a cushioning cover to the ocular coats.[1] Tenon's tissue has been used as a pedicle flap in ocular surface ischemia[2] and as a graft to seal small corneal perforations. Its tensile strength, pliability, and easy availability have made it a valuable resource as a patch graft.[3]

We have extended this tectonic use of Tenon's tissue to other causes of corneal melts and leaks with successful anatomical results. This article reports the use of Tenon's tissue as a tissue-building agent for four indications, namely Mooren's ulcer, leaking cicatrix, melt due to persistent epithelial defect, and small corneal perforation, only after failure of conservative treatments. It also discusses the potential of such usage in comparison with other methods such as the use of cyanoacrylate glue, multilayered amniotic grafts, and corneal patch grafts.[4]


  Case Reports Top


A 55-year-old man presented with Mooren's ulcer in his right cornea of 3 months duration. There was 3 mm wide perilimbal guttering along 3 clock hours with 50% thinning in the inferior temporal quadrant [Figure 1]a. After conjunctival resection and debridement, a Tenon's patch graft (TPG) was done with fibrin glue to build tissue and covered with a bandage contact lens (BCL) to promote epithelization. Post-operative treatment included a tapering dose of topical steroids, antibiotics, and lubricating eye drops for all the cases in this article. He was also put on systemic immunosuppression by a rheumatologist and the Mooren's ulcer resolved over two months [Figure 1]b.

A teenager presented with radiation keratopathy in his left cornea following treatment of ipsilateral acoustic neuroma. There was a 4-mm central cicatricial scar with aqueous leak [Figure 1]c. The cicatrix was de-epithelized and the spongy tissue debrided. An appropriately sized TPG was secured with fibrin glue and anchored with 10-0 nylon interrupted sutures. Epithelial healing occurred under a BCL with sealed leak and macular scar formation at 3 months [Figure 1]d.
Figure 1: (a) Mooren's ulcer preoperative with 30% peripheral melt. (b) Mooren's ulcer with TPG integrated post-operatively at 3-month follow-up. (c) Leaking cicatrix pre-operative with spongy stromal tissue. (d) Sealed leak with TPG with macular scar formation postoperatively at 4-month follow-up

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A 20-year-old boy was on prolonged treatment for fungal keratitis for over a month in his left eye. He presented with a 4-mm persistent epithelial defect with blunt edges and 70% stromal thinning and scarred infiltrate [Figure 2]a. The edges were debrided, and a TPG was performed with BCL, similar to the previous case. The crater in the cornea healed completely with integration of the graft and re-establishment of the overlying epithelium at one month [Figure 2]b.
Figure 2: (a) Persistent epithelial defect with central stromal crater pre-operative. (b) Healed defect with scarred TPG and smooth surface post-operatively at 4-month follow-up. (c) Small corneal perforation pre-operative. (d) Sealed perforation with TPG, postoperatively at 3-month follow-up

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A 31-year-old man presented with a central 3-mm corneal perforation following resolution of infectious keratitis in his left eye [Figure 2]c. In this case, a tuck-in Tenon's patch graft was done after debridement. The TPG was tucked into a ledge created around the perforation in the healthy cornea and secured with 10-0 nylon sutures with a small amniotic membrane patch and BCL placed over it. At the 3-month follow-up, the perforation had healed completely, and suture removal was done [Figure 2]d. All TPGs remained stable at the 6-month follow-up.


  Discussion Top


The use of TPG secured with sutures and cyanoacrylate glue has been described in small corneal perforations less than 5 mm in diameter.[3] A tuck-in approach where the frill is inserted into a ledge around the perforation provides better anchorage.[5] The surrounding cornea should be healthy for good healing. For larger perforations, a corneal patch graft is needed. TPG is less resource-intensive than multilayered amniotic membrane used for the same purpose and with no danger of disease transmission.[6] The tissue building and surface contouring are permanent, unlike the removable cyanoacrylate glue. Its use has also been described as cover for scleral grafts and Tenoplasty flap rather than graft in ocular surface ischemia.[2]

Abundant availability, easy access, and negligible risks prompted us to use TPG successfully for tissue building in other indications of corneal melt such as Mooren's ulcer, leaking cicatrix, and persistent epithelial defect. In all these, the primary problem was controlled and TPG was done for tectonic support. All the patients showed well-integrated graft with a quiet eye at follow-up.

TPG was used though cyanoacrylate glue was available because its integration to the corneal stroma provides a smoother base for re-epithelization, better contour, and refractive neutrality, replaces stromal loss, and adds tissue should the melts recur. Though the functional outcome is not discussed here, two patients improved in vision with rigid contact lenses, one had a peripheral lesion and one is awaiting optical keratoplasty.

We used fibrin glue instead of cyanoacrylate to attach the TPG as it gives a smoother surface and avoids the need for removal later. Care should be taken not to spill over into the anterior chamber as it causes inflammation. A BCL with or without a small amniotic membrane overlay on the TPG promotes epithelization. The graft integrates with the host cornea with minimal vascularization if the primary disease is controlled. The resultant whitish scar-like appearance fades over time and may lend to a rigid contact lens trial for visual rehabilitation.[7]

The supero-temporal quadrant is the best site for Tenon's harvest as the tissue is lax, thick, and easily accessible.[1] The donor site should be closed meticulously to avoid infection or necrosis of underlying episclera.[8] When sealing a corneal perforation, the spongy Tenon's tissue may later swell up due to contact with the aqueous. To avoid this, a larger graft with low cautery is applied to shrink the air spaces and “cross-linking” prevents fluid imbibition from the perforation.

TPG is a valuable resource for patching different corneal melts, especially during a shortage in pandemic times.[9]


  Conclusion Top


Tenon's tissue can be safely used in various cases of corneal thinning, as a tissue-building agent. TPG is easy to perform and provides good tectonic outcomes not only in small corneal perforations but also in corneal melts due to other infective, immune, and toxic conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kakizaki H, Takahashi Y, Nakano T, Asamoto K, Ikeda H, Ichinose A, et al. Anatomy of Tenons capsule. Clin Exp Ophthalmol 2012;40:611-6.  Back to cited text no. 1
    
2.
Peng WY, He LW, Zeng P, Chen DC, Zhou SY. Tenonplasty combined with amniotic membrane transplantation for patients with severe ocular burns induced anterior segment necrosis. J Burn Care Res 2020;41:668-73.  Back to cited text no. 2
    
3.
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. 3
    
4.
Deshmukh R, Stevenson LJ, Vajpayee R. Management of corneal perforations: An update. Indian J Ophthalmol 2020;68:7-14.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
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. 5
    
6.
Malhotra C, Jain AK. Human amniotic membrane transplantation: Different modalities of its use in ophthalmology. World J Transplant 2014;4:111-21.  Back to cited text no. 6
    
7.
Sultana N, Chaurasia S, Ramappa M. High-resolution optical coherence tomography in a case of descemetocele managed with amniotic membrane transplantation. Indian J Ophthalmol 2018;66:315-7.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Ruiz-Lozano RE, Garza-Garza LA, Davila-Cavazos O, Foster CS, Rodriguez-Garcia A. The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review. Surv Ophthalmol 2021;66:594-611.  Back to cited text no. 8
    
9.
Sharma S, Rathi A, Murthy SI, Trivedi M, Patel C, Mohamed A, et al. Outcomes of penetrating and lamellar corneal patch grafts. Cornea 2021;40:618-23.  Back to cited text no. 9
    


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