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BRIEF COMMUNICATION
Year : 2019  |  Volume : 26  |  Issue : 3  |  Page : 168-171  

Use of fibrin glue in the management of Descemet membrane perforation during deep anterior lamellar keratoplasty


1 Department of Ophthalmology, Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
2 Division of Ophthalmology, Department of Surgery, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia

Date of Submission07-Apr-2019
Date of Decision28-Aug-2019
Date of Acceptance15-Sep-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Saad S Alharbi
Department of Ophthalmology, Anterior Segment Division, King Khaled Eye Specialist Hospital, Orouba Street, Umm Al-Hamam Dist., P.O. Box 7191, Riyadh 11462
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.MEAJO_97_19

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   Abstract 


PURPOSE: To describe the use of fibrin glue to seal Descemet membrane (DM) microperforation and macroperforation during deep anterior lamellar keratoplasty (DALK).
METHODS: A retrospective chart review was performed on patients who had DM perforation managed by fibrin glue during DALK at King Khaled Eye Specialist Hospital (KKESH) between June 2014 and February 2019.
RESULTS: One thousand two hundred and eighty-eight DALK surgeries were performed at KKESH during the study period. Fibrin glue was used to seal DM perforations in four cases of DALK for keratoconus.
CONCLUSION: Fibrin glue is an effective method to seal DM microperforations and macroperforations during DALK, which reduces the rate of conversion to penetrating keratoplasty (PK), preserving the advantage of DALK over PK.

Keywords: Deep anterior lamellar keratoplasty, Descemet membrane, fibrin glue


How to cite this article:
Alharbi SS, Alameer A. Use of fibrin glue in the management of Descemet membrane perforation during deep anterior lamellar keratoplasty. Middle East Afr J Ophthalmol 2019;26:168-71

How to cite this URL:
Alharbi SS, Alameer A. Use of fibrin glue in the management of Descemet membrane perforation during deep anterior lamellar keratoplasty. Middle East Afr J Ophthalmol [serial online] 2019 [cited 2019 Nov 21];26:168-71. Available from: http://www.meajo.org/text.asp?2019/26/3/168/268254




   Introduction Top


Deep anterior lamellar keratoplasty (DALK) is often used as an alternative to penetrating keratoplasty (PK) for keratoconus and corneal stromal pathologies.[1],[2] A major advantage of DALK over PK is the reduced rate of graft rejection and endothelial cell loss.[2],[3],[4] However, Descemet's membrane (DM) perforation can occur during trephination, deep stromal injection of air, or dissection during big bubble DALK.[5] DM perforation is a major complication of DALK which has been reported to range from 4% to 39%.[6],[7],[8] Although DM perforation warrants conversion to PK, several techniques have been suggested to manage intraoperative DM perforation. Successful management of DM perforation reduces the rate of conversion to PK and hence preserves the advantages of DALK over PK. In literature, only two reports have been published of external application of fibrin glue for sealing DM microperforation during DALK. In this study, we described the use of fibrin glue to seal DM microperforation and macroperforation during DALK.


   Methods Top


A retrospective chart review was performed on patients who had DM perforation managed by fibrin glue (Tisseel fibrin sealant, Baxter Healthcare Corporation, Glendale, CA, USA) during DALK at King Khaled Eye Specialist Hospital (KKESH) in Riyadh, Saudi Arabia, between June 2014 and February 2019. Preoperative data collection included best-corrected visual acuity (BCVA), defined as either best-corrected Snellen vision with spectacles or pinhole vision; indication of surgery; and any coexisting ocular disease. Intraoperative data collection included the surgical technique, location of DM perforation, size of DM perforation (microperforation or macroperforation), and the stage of the surgery when the perforation occurred. Microperforation was defined as a small perforation that did not lead to consistent anterior chamber collapse, as compared to a macroperforation, in which a sizeable tear or gap in DM (>0.5 mm) resulted in persistent, complete collapse of the anterior chamber despite the use of air or balanced salt solution to reform the anterior chamber.[7] Postoperative data collection included BCVA, refraction, graft clarity, immediate or late DM detachment, and any possible complications. An anterior-segment consultant at KKESH performed all the surgeries using the “Big Bubble technique”[5] or manual layer-by-layer dissection.


   Results Top


One thousand two hundred and eighty-eight DALK surgeries were performed at KKESH between June 2014 and February 2019. Fibrin glue was used to seal DM perforation in four cases of DALK for keratoconus.

Case 1

A 21-year-old male presented with a DM macroperforation (4 mm at graft–host junction) during trephination. Deep manual dissection was carried out followed by intracameral air injection, and fibrin glue was applied over the stromal surface externally to seal the macroperforation before suturing the graft in place with 16 interrupted 10-0 nylon sutures [Figure 1]. Ten days later, the patient developed DM detachment which was managed by the injection of sulfur hexafluoride (SF6) 20% gas. DM reattached and remained attached thereafter.
Figure 1: (a) Intraoperative image showing the extent of Descemet membrane perforation (arrows). (b) Postoperative optical coherence tomography image showing attached Descemet membrane with fibrin glue (red star). (c) Day 10 postoperative image showing the interface haze which cleared after 4 weeks. (d) Day 10 postoperative optical coherence tomography image showing detached Descemet membrane

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Case 2

The case was a 48-year-old male who underwent a successful big bubble technique. However, central DM macroperforation (2 mm) was observed during the excision of deep stromal layer. Fibrin glue was applied externally between the host DM and the graft, and the patient did not develop any further complications over the duration of follow-up.

Case 3

A 25-year-old male presented with an inferior DM macroperforation (4 mm at graft–host junction) that was observed during the excision of deep stromal layer after successful big bubble formation. Fibrin glue was applied over the area of perforation prior to suturing the graft. Localized DM detachment was noted on the 1st postoperative day and reattached spontaneously within 2 days.

Case 4

A 22-year-old male presented with an inferior DM microperforation that was observed during the excision of deep stromal layer after successful big bubble formation. Fibrin glue was applied over the area of perforation followed by graft suturing. The patient developed localized DM detachment on the 1st postoperative day, which spontaneously reattached within 2 days without further intervention.

In all cases, air was injected intracamerally before the application of fibrin glue to stop fluid leakage and maintain the anterior chamber. At the last follow-up, all patients had a clear graft with no long-term sequelae related to fibrin glue. There were no traces of the glue by 10–14 days postoperatively. Examination findings at the last follow-up including BCVA, refraction, and graft clarity are summarized in [Table 1].
Table 1: Examination at the last follow-up

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   Discussion Top


Fibrin glue is a human plasma-derived product that has been used widely in ophthalmology, mainly for its adhesive properties. One of the advantages of fibrin glue over the synthetic adhesive (e.g., cyanoacrylate) is its biodegradability and the minimal inflammation, making it a good choice for application under a superficial covering layer (e.g., conjunctiva, amniotic membrane).[9]

Anwar et al. described the use of fibrin glue to seal DM perforation in DALK.[10] They reported two cases of peripheral DM microperforation and concluded that the use of fibrin glue may reduce the need for air tamponade and subsequent awkward postoperative positioning.[10] In our series, we used fibrin glue to seal DM macroperforations up to 4 mm. Fibrin glue is considered a superior alternative to air tamponade in sealing DM macroperforations or any inferior DM perforations. Although superior and central DM perforations can be managed by air tamponade only, this measure carries the risks of pupillary block with high intraocular pressure, postoperative fixed dilated pupil, cataract, and posterior synechia formation. Leaving air in the anterior chamber at the end of the surgery with head positioning will promote the tamponade of DM, but intraocular pressure should be monitored closely after the surgery to avoid the abovementioned complications. Alternatively, inferior peripheral iridectomy will help to prevent pupillary block. When air is injected into the anterior chamber, we should avoid overinflation which may extend DM break further. It is advised to inject the air after securing the graft with four cardinal sutures to avoid enlarging the rupture site. If a DM perforation is encountered during trephination, a suture can be used to close the site of perforation and stromal dissection can be attempted from the opposite direction. The use of fibrin glue in this situation (case 1) will prevent rolling of the DM tear edge and minimize postoperative problems. Fibrin glue is a biodegradable material; hence, it gradually becomes translucent with time with no infiltration, inflammation, or vascularization. Furthermore, fibrin glue has been applied in the stromal interface of the donor cornea to facilitate adhesion during DALK without interface complications postoperatively.[11],[12],[13]

DM detachment is a possible complication after DALK, and its occurrence increases with DM perforation.[6] Air or expandable gas such as SF6 can be used to reattach DM. In our series, two patients developed DM detachment on the 1st postoperative day but spontaneously reattached within 2 days, whereas DM detachment occurred in one patient at 10 days postoperatively which was managed successfully with SF6 gas tamponade. No long-term complications associated with fibrin glue have been observed. Corneal vascularization developed in the fourth case secondary to a loosened suture 6 months postoperatively. Good visual acuity was achieved in our series of patients, which was comparable to other DALK patients without DM perforation. However, the fourth patient had some degree of amblyopia, which might explain his relatively poor BCVA.

To the best of our knowledge, external fibrin glue use in DM perforation has been reported only in two cases of peripheral microperforation during DALK. In our study, we reported its use in microperforation and macroperforation in addition to central and inferior perforations. In conclusion, fibrin glue is an effective method to seal DM micro\macroperforations during DALK, which reduces the rate of conversion to PK, preserving the advantage of DALK over PK.

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 Top

1.
Henein C, Nanavaty MA. Systematic review comparing penetrating keratoplasty and deep anterior lamellar keratoplasty for management of keratoconus. Cont Lens Anterior Eye 2017;40:3-14.  Back to cited text no. 1
    
2.
Keane M, Coster D, Ziaei M, Williams K. Deep anterior lamellar keratoplasty versus penetrating keratoplasty for treating keratoconus. Cochrane Database Syst Rev 2014;22:CD009700.  Back to cited text no. 2
    
3.
Watson SL, Ramsay A, Dart JK, Bunce C, Craig E. Comparison of deep lamellar keratoplasty and penetrating keratoplasty in patients with keratoconus. Ophthalmology 2004;111:1676-82.  Back to cited text no. 3
    
4.
Morris E, Kirwan JF, Sujatha S, Rostron CK. Corneal endothelial specular microscopy following deep lamellar keratoplasty with lyophilised tissue. Eye (Lond) 1998;12(Pt 4):619-22.  Back to cited text no. 4
    
5.
Anwar M, Teichmann KD. Deep lamellar keratoplasty: Surgical techniques for anterior lamellar keratoplasty with and without baring of Descemet's membrane. Cornea 2002;21:374-83.  Back to cited text no. 5
    
6.
Karimian F, Feizi S. Deep anterior lamellar keratoplasty: Indications, surgical techniques and complications. Middle East Afr J Ophthalmol 2010;17:28-37.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Huang OS, Htoon HM, Chan AM, Tan D, Mehta JS. Incidence and outcomes of intraoperative Descemet membrane perforations during deep anterior lamellar keratoplasty. Am J Ophthalmol 2019;199:9-18.  Back to cited text no. 7
    
8.
Leccisotti A. Descemet's membrane perforation during deep anterior lamellar keratoplasty: Prognosis. J Cataract Refract Surg 2007;33:825-9.  Back to cited text no. 8
    
9.
Rajesh S, Chandrashekhar K, Namrata S. Use of tissue adhesives in ophthalmology. Indian J Ophthalmol 2009;57:409-13.  Back to cited text no. 9
    
10.
Anwar HM, El-Danasoury A, Hashem AN. The use of fibrin glue to seal Descemet membrane microperforations occurring during deep anterior lamellar keratoplasty. Cornea 2012;31:1193-6.  Back to cited text no. 10
    
11.
Heshemi H, Dadgostar A. Automated lamellar therapeutic keratoplasty. Am J Ophthalmol 2007;143:750-4.  Back to cited text no. 11
    
12.
Agarwal T, Bandivadekar P, Sharma N, Sagar P, Titiyal JS. Sutureless anterior lamellar keratoplasty with phacoemulsification. Cornea 2015;34:615-20.  Back to cited text no. 12
    
13.
Narendran N, Mohamed S, Shah S. No sutures corneal grafting – A novel use of overlay sutures and fibrin glue in deep anterior lamellar keratoplasty. Cont Lens Anterior Eye 2007;30:207-9.  Back to cited text no. 13
    


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