Financial Disclosure: None World Cornea Congress Boston, April 2010 Human Fibrin Tissue Adhesive for Sutureless Patch Graft in Post-Infectious Corneal Melting Noopur Gupta Ritika Sachdev Radhika Tandon Financial Disclosure: None R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences New Delhi, India

Introduction Corneal perforations demand prompt management to minimize ocular morbidity Infectious keratitis remains a common cause of corneal perforations The use of tissue adhesive has been advocated for perforations less than 2mm Larger perforations are not amenable to tissue adhesives alone Corneal patch grafts or multilayered amniotic membrane may be required

Purpose To determine whether fibrin tissue adhesive (Tisseel, Baxter AG, Vienna) can provide adequate adhesion of a full thickness corneal patch graft in large (>3mm) paracentral corneal melts following infectious keratitis

Advantages of a tissue adhesive over conventional suturing for patch grafts Tissue adhesive to replace sutures for paracentral patch grafts Quick and safe treatment modality Lesser induced astigmatism Increased patient comfort Sutures may encroach upon visual axis

Subjects: Clinical presentation 75-year-old male Primary open angle glaucoma with advanced glaucomatous cupping OU Alkali injury with secondary bacterial keratitis OD Pseudophakos OS VA: PL+ OD; 1/60 OS 48-year-old male Immature Senile Cataract OU Post-traumatic bacterial keratitis OD VA: 1/60 OD; 6/12 OS 73-year-old male Reis Buckler Dystrophy OU Bacterial keratitis with descemetocoele & Immature Senile Cataract OD VA: HMCF OD; 1/60 OS

Surgical Technique Intensive topical & systemic specific antimicrobial therapy initiated pre-operatively and continued post-operatively. Host preparation Dimensions of defect ascertained. Margins freshened with sloping stromal edges to accommodate the graft. Donor preparation Graft fashioned with dermal trephine & scissors. Lamellar trimming of the graft was done if required, to prevent over-riding. Glue application Tissue adhesive applied with duplojet system (slow setting mode) Donor tissue manipulated into position, left undisturbed for 2 minutes Bandage contact lens applied.

Postoperative treatment Post-operative medications included : Oral Vitamin C 500mg thrice daily Intensive Systemic & topical antibiotics Cycloplegic eye drops Lubricating eye drops Patients were examined daily for one week, weekly for one month and monthly thereafter Follow up ranged from 7-12 months

Post-operative outcome Case 1 Anterior chamber formed, healing adequate. VA PL+, limited due to near total glaucomatous cupping. Case 2 Anterior chamber formed, graft slightly ectatic BCVA 6/18 Case 3 Anterior chamber well formed, graft stable. BCVA 6/60

Case 1 pre-op Case 1 post op Case 2 pre-op Case 2 post-op pre-op Case 3 Case 3 post-op

Conclusion An innovative technique to seal large corneal melts is presented The sutureless patch graft appears to be a convenient and effective treatment modality for 3-5mm paracentral perforations following infectious keratitis Fibrin glue is an efficient substitute to conventional suturing This procedure may be adopted as a definitive or interim treatment to salvage the integrity of the globe following corneal perforations due to infectious keratitis