Outcome of Sclerokeratoplasty in Devastating Sclerocorneal Infections

Successful Management of a Refractory Scedosporium (Pseudallescheria) boydii Keratitis With Sclerokeratoplasty

Here, we present the successful sclerokeratoplasty surgery in resistant Scedosporium (Pseudallescheria) boydii keratitis. A 47-year-old male patient presented with complaints of 4-mm corneal infiltration and 1-mm hypopyon after an eye injury with organic material. Topical treatments with vancomycin (50 mg/mL), ceftazidime (50 mg/mL), voriconazole (10 mg/mL), and amphotericin B (0.5 mg/mL) were started hourly. Because of the significant progression despite the treatment, emergency therapeutic penetrating keratoplasty was performed. In this patient, in whom Scedosporium boydii growth was detected in mycological examination, although the infection appeared under control after keratoplasty, recurrence occurred on day 30. Hence, because of the rapid progression of the infection to the corneoscleral junction despite intensive treatment, emergency sclerocorneal transplant was performed. Globe integrity was preserved, and the patient had no recurrence in the 5-month follow-up. In severe S. boydii keratitis that causes infiltration up to the limbus border, removal of infected corneal tissue by wide excision and sclerocorneal transplant along with medical treatment may offer a successful treatment option. To the best of our knowledge, this is the first case in which sclerokeratoplasty was performed to successfully treat S. boydii keratitis.

Modified tectonic corneoscleral graft technique for treating devastating corneoscleral infections

BACKGROUND

This study aims to evaluate the clinical outcomes and efficacy of a modified tectonic corneoscleral graft (TCG) in patients suffering from devastating corneoscleral infections.

METHODS

Thirty-eight eyes from 38 patients who underwent the modified TCG were included in this study. The outcomes measured were recurrence rates, best-corrected visual acuity (BCVA), ocular surface stability, postoperative complications, and graft survival.

RESULTS

Among the 38 patients, 23 had fungal infections, 9 had bacterial infections and 6 had Pythium insidiosum infections. At the final follow-up, with an average duration of 25.1 ± 8.6 months, the rate of monocular blindness decreased from 100 to 58%. Significant improvements in LogMAR BCVA were observed from preoperative to postoperative measurements (P < 0.001). Thirty-two eyes (84.2%) maintained a stable ocular surface. The survival rate of ocular surface stability was 84.2%±5.9% at one year and 57.7%±9.7% at three years post-surgery. Twenty eyes (52.6%) retained a clear graft, with a survival rate for graft clarity was 81.6%±6.3% at one year and 36.0%±10.8% at three years post-surgery. The incidence of immune rejection was 36.8%. Corneal epithelial defects were observed in ten patients, and choroidal detachment occurred in four patients. No cases of elevated intraocular pressure were detected.

CONCLUSIONS

The modified TCG is effective in eradicating infections, preserving the eyeball, and maintaining useful vision in cases of devastating corneoscleral infections. Regular use of tacrolimus, timely administration of glucocorticoids, and good patient compliance can help mitigate postoperative challenges.

The Use of Corneoscleral Grafts to Maintain Tectonic Stability in Severe Keratolysis

Severe corneal ulcerations, causing major keratolysis with large perforation of the cornea or extending to the limbal region, are an ophthalmic emergency. In these cases, a larger corneoscleral graft can be transplanted to restore tectonic integrity, alleviate pain, save vision, and prevent loss of the eye. Chart review of 34 patients with a corneoscleral graft ≥9.5 mm was conducted. Primary endpoints of the study were tectonic stability defined as no need for another keratoplasty or enucleation. In addition, visual acuity, postoperative complications, and secondary procedures were analyzed. In total, 12 patients (35%) were female. The mean age at transplantation was 65 ± 19 years. The underlying disease was a perforated infectious corneal ulcer in 30 cases (88%). Mean follow up was 675 ± 789 days. Tectonic stability at the end of the follow-up was maintained with a probability of 56% in a Kaplan-Meier analysis. Another penetrating keratoplasty was necessary in six cases (17%) and enucleation in five cases (15%). A corneoscleral transplant remains a viable treatment option to prevent enucleation in severe keratolysis. In our study, this was possible in about half of the cases. Postoperative complications, secondary surgeries, and markedly reduced visual acuity put the advantages into perspective.