1. 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

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

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

10. 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