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Letter
Tachosil: a new alternative for the treatment of non-traumatic corneal perforations
  1. M Hurtado-Sarrió1,
  2. A Duch-Samper2,
  3. A Cisneros-Lanuza1,
  4. M Díaz-Llopis1
  1. 1
    Ophthalmology Service, La Fe University Hospital, Valencia, Spain
  2. 2
    Ophthalmology Service, Arnau de Vilanova Hospital, Valencia, Spain
  1. Correspondence to Dr M Hurtado-Sarrió, Ophthalmology Service, La Fe University Hospital, Valencia, Spain, Esmeralda I, Casa 7, Mas Camarena, 46117 Betera, Valencia, Spain; hurtado_mer{at}gva.es

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TachoSil is a collagen sponge with human fibrinogen 5.5 mg, and human thrombin 2.0 IU.

Upon contact with physiological fluids or saline solution, the components of the coating dissolve and partly diffuse into the wound surface, creating a firm, mechanically stable network with good adhesive properties as well as sealing. Here we report the first case of the use of a collagen sponge combined with human fibrin sealant (TachoSil) in ophthalmology to patch a corneal perforation after infectious keratitis.

Case report

An 84-year-old Caucasian male with a history of heart disease treated with acenocoumarin and chronic obstructive pulmonary disease (COPD) reported to the emergency room with red eye, ocular pain, photophobia, decreased vision and discharge. At the slit-lamp examination, a large corneal stromal infiltrate with hypopyon was observed. A bacterial culture revealed Streptococcus pneumoniae. The keratitis responded to topical vancomycin, the stromal infiltrate decreased, and the hypopyon regressed, but the patient developed local corneal thinning that evolved towards manifest corneal perforation with anterior chamber bleeding (fig 1A).

Figure 1

(A) Corneal thinning with perforation and anterior chamber bleeding (see arrows). (B) Slit-lamp image at the moment of the procedure with the TachoSil patch. (C) Follow-up 3 weeks after the procedure. (D) Follow-up after 3 months, showing successful healing of the corneal perforation.

We decided to apply a patch of collagen sponge with human fibrin (TachoSil) at the site of the corneal perforation at the slit lamp, using topical anaesthesia (procaine). After removal of TachoSil from the sterile package, the sponge can be cut to the correct size, extending beyond the margins of the site of perforation. It is then premoistened in saline solution and applied immediately. The yellow, active side of the sponge is applied to the leaking surface and held against it for 3–5 min with forceps. This procedure enables easy adhesion of TachoSil (fig 1B). We patched the eye for 24 h. On the following day, a fine layer of fibrin and collagen remained on the cornea with no need for bandage contact lens. Three weeks (fig 1C) and 3 months after the procedure (fig 1D), successful healing of the corneal perforation was observed with no recurrence of the infectious process.

Discussion

Corneal perforation is an unfortunate sequel of infectious, sterile or inflammatory keratitis that requires urgent management to reduce subsequent ocular morbidity. Conjunctival flaps, amniotic membrane transplantation, tissue adhesives and penetrating keratoplasty have been advocated in its treatment.1234 The active side of TachoSil, which is coated with the fibrinogen and thrombin, is marked by a yellow colour. This is indicated for supportive treatment in surgery for improvement of haemostasia where standard techniques are insufficient but has also been used by surgeons in the management of cerebrospinal fluid leakage after the surgical removal of pituitary adenomas5 and to reduce pericardial effusions.6 Upon contact with physiological fluids or saline solution, the components of the coating dissolve and partly diffuse into the wound surface. This is followed by the fibrinogen–thrombin reaction, which initiates the last phase of physiological blood coagulation. Fibrinogen is converted into fibrin monomers which spontaneously polymerise to a fibrin clot, which holds the collagen sponge tightly to the wound surface. The fibrin is then cross-linked by endogenous factor XIII, creating a firm, mechanically stable network with good adhesive properties and provides sealing as well. Based on this mechanism of action, we have tried it with favourable results in our case.

We think TachoSil patching has its use in ophthalmology and may be regarded as an alternative to cyanoacrylate tissue adhesives, amniotic membrane transplantation and conjunctival flaps in the treatment of corneal perforations under 3 mm in size. TachoSil has the advantages of easy application at the slit lamp (obviating the need to use an operating room), patient comfort and good retention of the fibrin glue (which accelerates the corneal healing process) thanks to the collagen-sponge with no need for a bandage contact lens.

REFERENCES

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Footnotes

  • Competing interests None.

  • Provenance and Peer review Not commissioned; externally peer reviewed.

  • Ethics approval Ethics approval was provided by the Educational and Investigation Department of La Fe University Hospital, Valencia (Spain).

  • Patient consent Obtained.

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