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Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 33-34

Penetrating keratoplasty following Tenon's patch graft: A clinicopathological correlation

1 Department of Cornea and Anterior Segment, Eye Life; Department of Cataract and Refractive Surgery, Netra Mandir, Mumbai, Maharashtra, India
2 Consultant Pathologist, Accura Healthcare and Diagnostics, Mumbai, Maharastra, India
3 Department of Cataract and Refractive Surgery, Netra Mandir, Mumbai, Maharashtra, India
4 Department of Vitreo-Retina and Uveitis, Eye Life, Mumbai, Maharashtra, India

Date of Submission03-May-2022
Date of Acceptance30-Aug-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Sushmita G Shah
Department of Cornea and Anterior Segment, Eye Life, 204 Ram Krishna Chambers, Linking Road, Khar West, Mumbai - 400 103, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1098_22

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This report aims to describe the histopathological changes in the cornea following Tenon's patch graft. A 51-year-old male underwent Tenon's patch graft (TPG) for corneal perforation following Therapeutic penetrating keratoplasty which was performed twice for non-resolving microbial keratitis and graft infiltrate, respectively. The infection resolved following TPG resulting in formation of a vascularised scar. An Optical penetrating keratoplasty was performed six months after the TPG. Postoperative period was uneventful. Histo-pathological evaluation of the excised corneal tissue revealed excellent integration of the tenon tissue with the surrounding corneal stromal collagen. Histo-pathological evidence suggests that, tenon's tissue integrates well with surrounding corneal stromal collagen and is probably capable of regenerating new collagen and thus aid in corneal wound healing

Keywords: Autologous fibroblasts, corneal perforation, corneal wound healing, penetrating keratoplasty, Tenon's patch graft

How to cite this article:
Shah SG, Pandey V, Shah YC, Shah GY. Penetrating keratoplasty following Tenon's patch graft: A clinicopathological correlation. Indian J Ophthalmol Case Rep 2023;3:33-4

How to cite this URL:
Shah SG, Pandey V, Shah YC, Shah GY. Penetrating keratoplasty following Tenon's patch graft: A clinicopathological correlation. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:33-4. Available from: https://www.ijoreports.in/text.asp?2023/3/1/33/368124

The role of Tenon's patch graft (TPG) in the management of corneal perforations has been well described in literature.[1],[2] We report a case of optical penetrating keratoplasty following a TPG and its clinicopathological correlation.

  Case Report Top

A 51-year-old male with corneal perforation after undergoing therapeutic penetrating keratoplasty twice, for nonresolving polymicrobial keratitis and graft infiltrate, respectively, underwent a Tenon's patch graft. Tenon's tissue was excised from the inferior bulbar conjunctiva and secured with 10-0 nylon radial as well as overlay sutures to seal the perforation. A bandage contact lens was placed. The infection resolved completely and a vascularized corneal scar was noted [Figure 1]. After 6 months, optical penetrating keratoplasty with cataract extraction and intraocular lens implantation was performed. His postoperative period was uneventful.
Figure 1: Clinical photograph of the left eye under diffuse illumination showing a vascularized corneal scar

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Histopathology of the excised corneal tissue revealed corneal epithelial morphology with edematous corneal stroma underlying it. Short and haphazardly arranged collagen fibers with blood vessels suggestive of Tenon's tissue with an adjoining area of irregularly arranged stromal collagen suggestive of scarring were also noted [Figure 2]a and [Figure 2]b. Masson trichrome staining confirmed the presence of Tenon's tissue along with scarred corneal stromal collagen [Figure 2]c.
Figure 2: Photomicrograph showing stratified squamous epithelium with thick, richly vascularized irregularly arranged collagen suggestive of Tenon's tissue (blue asterisk), lamellar arrangement of avascular corneal collagen (black asterisk) was noted in the intervening area between the epithelium and Tenon's tissue, fragmented Descemet's membrane is seen as an eosinophilic thread-like structure (short arrow) with an adjoining area of irregularly arranged collagen suggestive of scar tissue (white asterisk); hematoxylin and eosin stain, 40× Digital Scanner Magnification, (2a), Tenon's tissue well integrated within the corneal stroma (blue asterisk) along with regularly arranged collagen overlying it (black asterisk); hematoxylin and eosin stain, 100× Digital Scanner Magnification, (2b), increased collagen of Tenon's graft (blue asterisk), and scar tissue (white asterisk); Masson trichrome stain, 40× Digital Scanner Magnification (2c).

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  Discussion Top

Tenon's patch graft using Tenon's tissue has multiple advantages, which include easy availability, no immunological reaction due to its autologous nature, and no dependence on corneal tissue in perforations ≥3 mm. Korah et al.[1] have described the technique of TPG in eyes with corneal perforation of size 3 mm to 6 mm in which Tenon's tissue was secured using cyanoacrylate glue and bandage contact lens. In their series comprising 27 eyes with corneal perforation, successful globe preservation was noted in 20 eyes. Sharma et al.[2] have described the technique of tuck-in TPG, which involves creating a 360-degree stromal pocket around the area of perforation and tucking in the Tenon's tissue into the pocket.[3] Twenty-seven out of 31 eyes in their series have shown successful healing of the perforation with the formation of a leucomatous scar. Chaudhary et al.[3] have reported successful outcome following TPG in an eye with corneal perforation due to active Herpes Zoster Ophthalmicus wherein the TPG was secured using fibrin glue and bandage contact lens. The patient subsequently underwent successful phacoemulsification in that eye. Our patient showed a successful outcome following TPG, which was secured using 10-0 nylon sutures. Excellent integration of the TPG with the surrounding stromal tissue was noted on histopathology. This case provides histopathological evidence in support of the postulate that Tenon's tissue contains autologous fibroblasts that help in its integration into corneal stroma[1] and that, it also acts as a scaffold for the corneal epithelium to grow over it.[3]

Fibroblasts play a critical role in immune response and wound healing in the eye. Interleukin (IL)-1β, a proinflammatory cytokine produced by corneal epithelial cells and macrophages stimulate increased production of cytokines like IL-6 and IL-8, vascular endothelial growth factor (VEGF), cyclooxygenase (Cox)-2, and prostaglandin (PG) E2 by fibroblasts, thus modulating corneal wound healing and scarring.[4] However, the same study reports some differences in the inflammatory cytokine expression by ocular fibroblasts obtained from Tenon's capsule, cornea, and lacrimal gland based on their tissue of origin. Furthermore, Módulo et al.[5] have reported transforming growth factor (TGF)-β mediated activation of Tenon's capsule fibroblasts resulting in conversion of these fibroblasts to myofibroblasts, both of which then aid in collagen production and extracellular matrix remodeling. This response of the Tenon's capsule fibroblasts in eyes that have undergone trabeculectomy surgery is contributory to the pathogenesis of scarring of glaucoma filtration bleb leading to bleb failure. In a review by Kate and coworkers,[6] integration of the Tenon's tissue within the corneal stroma with pseudocornea formation has been described. Interestingly, we also noted the presence of collagen underlying the epithelium and over the Tenon's tissue in our specimen, which points toward the possibility that the autologous fibroblasts present in the Tenon's tissue are capable of laying down a new collagen matrix.

  Conclusion Top

In conclusion, histopathological analysis following Tenon's patch graft demonstrates excellent integration of Tenon's tissue with surrounding corneal stromal collagen. It also demonstrates the possibility of regeneration of new collagen matrix by the autologous fibroblasts present in the Tenon's tissue, thus aiding in corneal wound healing. Larger studies are warranted.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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. 1
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. 2
Chaudhary S, Basu S, Donthineni PR. Long-term outcome of Tenon's patch graft in corneal perforation secondary to neurotrophic keratitis: A case report on a 4-year anatomical functional outcome. Int J Surg Case Rep 2021;83:106046. doi: 10.1016/j.ijscr. 2021.106046.  Back to cited text no. 3
Xi X, McMillan DH, Lehmann GM, Sime PJ, Libby RT, Huxlin KR, et al. Ocular fibroblast diversity: Implications for inflammation and ocular wound healing. Invest Ophthalmol Vis Sci 2011;52:4859-65.  Back to cited text no. 4
Módulo CM, Ferreira LD, Silva LECMD, Frade MAC, Reinach PS, Rocha EM, et al. Anti-fibrotic effects of rosmarinic acid on Tenon's capsule fibroblasts stimulated with TGF-β: therapeutic potential in ocular surgery. Arq Bras Oftalmol 2020;83:305-11.  Back to cited text no. 5
Kate A, Vyas S, Bafna RK, Sharma N, Basu S. Tenon's Patch Graft: A review of indications, surgical technique, outcomes and complications [published online ahead of print, 2021 Dec 21]. Semin Ophthalmol 2021;1-9.  Back to cited text no. 6


  [Figure 1], [Figure 2]


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