1. Management of corneal perforations and deep ulcers with patch grafts Dariusz Dobrowolski¹, Edward Wylęgała¹ ׳ ², Dorota Tarnawska¹, Dominika Janiszewska¹ ׳ ² ¹ Department of Ophthalmology, District Railway Hospital, Katowice, Poland ² Department of Nursing and Social Medical Issues, Health Care Division, Silesian Medical University, Katowice, Poland Authors have no financial interest in this presentation

2. Purpose To present management of corneal ulcers and perforations Indications for closing corneal ulcers and perforations with corneal grafts Advantages & disadvantages of the surgery Complications in particular cases Outcomes of small diameter keratoplasty in corneal perforations and deep ulcers

3. Material & methods 108 procedures: 77 in corneal perforations and 31 in deep ulcers) were performed between 2001 and June 2007 102 patients (follow-up at least 6 months) 68 men and 34 women, mean age 48,8±14,92 years We applied grafts with diameter from 2,5 to 5 mm with oversize of 0,5 – 1 mm Single sutures were used in all cases Lens status: 65 phakic eyes, 38 pseudophakic (37 with PC IOLs, 1 with AC IOL), 3 aphakic eyes

4. The technique Removing of the necrotic or infected tissue to healthy margins Removing of the epithelium surrounding ulcer margins to promote reepithelialisation Only single sutures Oversize of the graft: 0,5-1,0 mm because of tissue swelling in ulcer margins Avoiding flattening of the cornea Antiinflammatory and immunosuppresive treatment

5. The primary disease Dry eye syndrome74,5% Infection 41,1% Autoimmune diseases31,3% Neurotrophic ulcers13,7% Corneal trauma7,8% Acne rosacea1,9% Ocular pemphigus1,9% Unknown7,8%

6. Results Morphologic outcomes: 103 eyes restored stable corneal surface, 2 grafts failed due to graft melting, 2 eyes developed the phthisis, one eye was eviscerated due to fungal endophthalmitis Visual outcomes: VA improvement of was achieved in 41 eyes without any additional procedure (gain 2 lines), 47 required further procedures of penetrating keratoplasty or cataract surgery

7. Results BCVA > 0,86,4% BCVA > 0,514,8% BCVA > 0,212,9% After additional procedure BCVA > 0,82,7% BCVA > 0,58,3% BCVA > 0,215,7%

8. Failures Corneal melting were connected with poor prognosis for good vision and required tarsoraphy or conjuctival flap 18 eyes due to severe dry eye syndrome, loss of light localization or retinal detachment (2 eyes) were disqualified to other procedures

9. Complications Graft edema Anterior synechiae Suture loosening Corneal vascularization Corneal surface irregularity Corneal melting Uncontroled infection Intraocular complications

10. Alternative management Bandage contact lens Amniotic membrane application (multilayer AM – sandwich technique) Autologous serum drops in dry eye Systemic immunosupression Conjunctival flaps Tarsoraphy Botulin toxin induced ptosis Primary keratoplasty

11. Conclusions Small diameter grafts are useful to restore corneal integrity Improve prognosis if further treatment needed ( PK or cataract removal ) Additional time for ocular surface healing