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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 1 | Page : 30-32 |
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Tenon's graft melt: A case report
Venugopal Anitha1, Aditee Madkaikar2, Meenakshi Ravindran3
1 Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
2 Cornea and Refractive Surgery, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
3 Paediatric and Strabismus Surgery, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India
| Date of Submission | 14-Apr-2022 |
| Date of Acceptance | 26-Aug-2022 |
| Date of Web Publication | 20-Jan-2023 |
Correspondence Address:
Venugopal Anitha
Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, S.N High Road, Tirunelveli Junction – 627 001, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijo.IJO_967_22
A 48-year-old female underwent a Tenon's patch graft for a perforated ulcer done during coronavirus disease 2019 (COVID-19) times. Five months later, the patient presented to us with Tenon's graft melt due to the infection of the graft and the corneal stroma with Curvularia. The patient was successfully treated with appropriate topical, commonly used antifungal therapy with a good outcome. To our knowledge, this is the first documentation of case describing the predisposing factors, clinical features, and the management of autologous Tenon's graft infection with Curvularia fungus, a rare occurrence in literature.
Keywords: Corneal perforation, COVID-19 times, Curvularia keratitis, Tenon's graft infection
How to cite this article:
Anitha V, Madkaikar A, Ravindran M. Tenon's graft melt: A case report. Indian J Ophthalmol Case Rep 2023;3:30-2 |
Corneal perforations, if left untreated, lead to corneal iridic scar and vascularization or permanent corneal fistula leading to phthisis.[1] Techniques to seal the perforations are cyanoacrylate glue with bandage contact lens (BCL), multilayered amniotic membrane (AMG) with BCL, TPG with BCL, and corneal patch graft.[1]
During the pandemic, the acute crisis of donor corneas encouraged ophthalmologists to innovate, create novel ideas, and expand the indications of preexisting techniques in ophthalmology. In particular, Tenon's patch graft (TPG) was found to be increasingly used by corneal surgeons to seal large perforations instead of donor corneal tissues.[2] It is inexpensive, easily accessible, inciting minimal inflammation, no graft rejection or reaction, and has a fast learning curve.[2] It harbors autologous fibroblasts helping in easy incorporation to the surrounding host tissue without extensive scarring.[3] Albeit its advantages, postoperative complications, graft displacement, sterile melt, and pseudo ectasia exist in literature but not TPG infection. Interestingly, we report a rare late postoperative fungal infection of one half of the TPG done for corneal perforation and its management outcomes.
| Case Report | |  |
A 48-year-old female presented to us 6 months back with a history of injury with a cow's tail in the left eye (LE) for 4 days. On examination, her uncorrected distance visual acuity (UDVA) in both eyes was 6/12. Slit-lamp examination (SLE) revealed immature cataract in the right eye (RE). LE showed central full-thickness corneal infiltrate of 2 × 3 mm, with perforation, iris incarceration, and positive Seidel's. Corneal scraping was avoided due to perforation. She was started on topical preservative-free moxifloxacin 0.5%, voriconazole 1% hourly, and homatropine hydrobromide 2% BD. BCL was applied. After 10 days, the infiltrate appeared to be healing, and AC was formed with iris incarceration. BCL removal revealed a positive seidel. Hence, TPG with AMG was done as an emergency pandemic procedure.
Postoperative examination revealed central scarring, forming AC without iris incarceration [Figure 1]. Host tissue culture showed no growth. She was continued on Moxifloxacin 0.5% and Voriconazole 1% QID for 3 weeks. Her UDVA was 6/18 on day 18. She presented after 5 months again with a history of cow's tail injury 6 days back. UDVA was 6/36. SLE revealed diffuse circumciliary congestion, superficial infiltrate with pigmentations involving the TPG, one-half of the graft wholly melted, and trace hypopyon [Figure 2]a and [Figure 2]b. Microbiology for KOH and Grams revealed the presence of many fungal hyphae. Sabouraund's dextrose agar culture grew woolly, gray to black colonies on the seventh day, suggestive of Curvularia sp. The patient was started on hourly fortified Amphotericin B 0.5% and Voriconazole 1% eye drops. The infiltrate showed a healing response and resolved hypopyon within 1 week with a healthy, intact remaining half of the graft. For 4 weeks, she has been prescribed Itraconazole 1% eye ointment and Voriconazole 1% QID. UDVA was 6/36, pin-hole 6/12 in the last visit. She has advised close follow-up and exercise caution in the future [Figure 3]a and [Figure 3]b. | Figure 1: Postoperative image of Tenon's patch graft done for central corneal perforation
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 | Figure 2: (a) Right eye image showing pigmented fungal infection involving one half of the Tenon's patch graft before corneal scraping for microscopic examination. (b): Right eye image showing pigmented fungal infection involving one half of the Tenon's patch graft after corneal scraping
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 | Figure 3: (a and b) Image showing complete healing of the infiltrate with retained remnant of the graft post infection
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| Discussion | | |
Tenon's capsule consists of dense elastic fibrovascular connective tissue, provides an armor effect for the ocular coats, and regulates the tension of all the extraocular muscles.[2],[3],[4] An email survey conducted among eye bankers by Roy et al. revealed that 66.1% of the corneal surgeons did not perform keratoplasty between April and June 2020 and used alternative tectonic procedures.[5] Sharma et al. studied the results of TPG for corneal perforations of size 3–5 mm in 31 patients and achieved good results with a mean healing time of 25.7 ± 6.7 days in 27 cases.[6] Rahul et al. observed one case of graft pseudo ectasia due to increased graft thickness, supra-tenons hemorrhage, and thin graft leading to melting and Pseudopterygium formation each.[7] Korah et al.[2] did a retrospective review of 28 patients with TPG for corneal perforations of 6 years duration and noted successful outcomes in 74.1% of the patients.[3] Complications with TPG included defective vision due to leucomatous scar formation, sterile graft melt, displacement, and pseudo ectasia with conjunctivalization.[1],[2],[3],[4],[5],[6] Etiology in our case was trauma with the cow's tail and delayed presentation. Since TPG is an autologous tissue, there is less possibility of microbial infection.[1],[2],[3],[4],[5],[6],[7],[8] Perhaps, ours is the first documentation of TPG melt due to infective etiology. Curvularia is a hyphomycete fungus, a facultative pathogen causing superficial feathery infiltration with visible pigmentation and suppuration. It constitutes 6%–8% of the fungal keratitis preceded by Aspergillus, Fusarium in Saudi Arabia, Bangladesh, and India.[8] To date, only one Indian case series of 97 patients with Curvularia keratitis has been studied by Khurana et al., reporting sugarcane leaf injury (66.1%) as the most common cause of infection; commonly used antifungals included Natamycin and Voriconazole, surgical treatment in 5.2% with one recurrence after 45 days and medical therapy in 42.3%.[9]
In a case report, Pitchaimuthu et al. successfully treated Curvularia keratitis with Amphotericin B and Fluconazole[10] while Kumar et al. reported resolution with topical Natamycin.[11] Our patient responded well to Voriconazole, Amphotericin B, and Itraconazole. Natarajan et al.[3] studied the efficacy of TPG in Mooren's ulcer, leaking cicatrix, persistent epithelial defects, and perforation for 6 months with no intra/postoperative complications. Prompt PKP is indicated in cases involving the visual axis for early visual rehabilitation. In our patient, the Curvularia keratitis healed completely with antifungals. However, PKP was delayed for 6 months due to the risk of reinfection (occupational hazard).
| Conclusion | | |
Although rare, infection of TPG and its melt can occur in patients when used to seal infective corneal perforations. Therefore, close monitoring and follow-up with prompt medical or surgical therapy, early visual rehabilitation, and patient education regarding avoidance of recurrent trauma are imperative.
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 | | |
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| 2. | Anitha V, Ghorpade A, Ravindran M. A modified Tenons sling annular graft for advanced peripheral ulcerative keratitis with an hourglass cornea. Indian J Ophthalmol 2022;70:655-7. [ PUBMED] [Full text] |
| 3. | Korah S, Selvin SST, Pradhan ZS, Jacob P, Kuriakose T. Tenons Patch Graft in the Management of Large Corneal Perforations. Cornea 2016;35:696-9. |
| 4. | Natarajan R, Nagpal N. Tectonic Tenon transplants for four different corneal melts. Indian J Ophthalmol Case Rep 2022;2:59-60. [Full text] |
| 5. | Roy A, Das S, Chaurasia S, Fernandes M, Murthy S. Corneal transplantation and eye banking practices during COVID-19-related lockdown period in India from a network of tertiary eye care centers. Indian J Ophthalmol. 2020;68:2368-71. |
| 6. | Sharma N, Singhal D, Maharana PK, Vajpayee RB. Tuck-In Tenon Patch Graft in Corneal Perforation. Cornea. 2019;38:951-4. |
| 7. | Kate A, Vyas S, Bafna RK, Sharma N, Basu S. Tenon's Patch Graft: A Review of Indications, Surgical Technique, Outcomes and Complications, Seminars in Ophthalmology2022;37:462-70 |
| 8. | Bafna RK, Kalra N, Rathod A, Asif MI, Lata S, Parmanand K, et al. Hitch suture assisted tuck in Tenon's Patch Graft for management of Corneal Perforations. Eur J Ophthalmol 2022:11206721221078682. Epub ahead of print. |
| 9. | Khurana A, Chanda S, Bhagat P, Aggarwal S, Sharma M, Chauhan L. Clinical characteristics, predisposing factors, and treatment outcome of Curvularia keratitis. Indian J Ophthalmol 2020;68:2088-93. [ PUBMED] [Full text] |
| 10. | Pitchaimuthu J, Nadarajah G, Mohd Salleh M, Mustakim S. A case report of Curvularia fungal keratitis. International Journal of Infectious Diseases.101 (S1)(2021)159-79. |
| 11. | Kumar A, Khurana A. Bilateral Curvularia Keratitis. J Ophthalmic Vis Res. 2020;15:574-5. |
[Figure 1], [Figure 2], [Figure 3]
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