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Lamellar keratoplasty and intracorneal inlay: An alternative to corneal tattooing and contact lenses for disfiguring corneal scars

Hollick EJ(1), Coombes A(2), Perez-Santonja JJ(3), Dart JKG(3)

1King’s College Hospital NHS Trust, London, UK
2Barts and The London NHS Trust, London, UK
3Moorfields Eye Hospital NHS Trust, London, UK

Correspondence: Emma J Hollick, Department of Ophthalmology, King’s College Hospital, Denmark Hill, London, SE5 9RS

Date of acceptance: 25th August 2005

 

Lamellar keratoplasty and intracorneal inlay for a disfiguring corneal scar in a blind eye of a 32 year-old woman. The central 6.5 mm anterior lamella was removed and the edges undermined. Next, a black Hydrogel lens was cut and placed onto the stromal bed. A full thickness donor cornea was trephinated to 6.75 mm in diameter, Descemet’s membrane was removed, and the donor was placed over the inlay onto the stromal bed. This was sutured in place using 4 cardinal sutures and a 16 bite continuous 10/0 nylon suture.

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Introduction

We present a previously unreported surgical technique to treat poor cosmesis due to corneal scarring. A 32 year old female was first seen at the age of 3 with a right convergent squint due to sensory deprivation caused by a juxtapapillary white mass in her right eye, thought to be due to either toxocara or a congenital abnormality. This eye became blind and cosmetically poor due to corneal scarring, a dislocated cataractous lens and posterior segment fibrosis. She was unable to tolerate a cosmetic contact lens. Seven years ago she had corneal surface tattooing to produce a dark pupil. This faded and she had the tattooing repeated 3 years later, which was complicated by a persistent epithelial defect postoperatively, and failed to produce a good cosmetic result. She developed more corneal scarring as the epithelial defect healed (figure 1a). She underwent lamellar grafting with an intracorneal inlay of a black hydrogel contact lens to mimic a dark pupil (figure 1b). She has had yearly follow up and continues to have a good cosmetic result (figure 1c ).

Figure 1: Preoperative image of the patient's eye showing corneal scarring and leucocoria (1a). One year postoperative image with the graft sutures still in situ (1b). Two years postoperatively all the sutures have been removed, and the patient continues to have a good cosmetic result (1c)

Technique

The surgical technique for lamellar keratoplasty with intracorneal hydrogel inlay is an extension of an old technique to correct myopia.[1] The center of the cornea was marked with a 6.5 mm corneal trephine. A calibrated diamond knife set at 400 μm was used to cut around this trephination mark. Blunt lamellar dissection with Morlet dissector across the central 7mm was performed. The central 6.5 mm anterior lamella was removed using graft scissors and the edges were undermined. A black Hydrogel lens was cut with a 4 mm diameter skin punch, and placed onto the stromal bed. A full thickness donor cornea was trephinated to 6.75 mm in diameter. Descemet’s was removed, and the donor was placed over the inlay onto the stromal bed. This was sutured in place using 4 cardinal sutures and a16 bite continuous 10/0 nylon suture.

Discussion

There are three options to improve cosmesis for disfigured corneas and/ or leucocoria in blind eyes. The easiest is the use of a soft cosmetic contact lens to produce a black pupil. The commonest problem with this is intolerance. The second option is corneal tattooing to give the appearance of a dark pupil.[2] The most frequent problems with tattooing are ocular discomfort, conjunctival injection and mild keratitis. Persistent epithelial defects, corneal ulceration, uveitis, endophthalmitis have been reported.[3] Tattooing is impermanent with the tattoo may eventually fade. Disturbance of the corneal lamellae with subsequent superficial scar formation can disrupt the tattoo. The use of a hydrogel inlay underneath lamellar graft is the third, previously unreported, option. The surgery is relatively time consuming, but no more so than corneal tattooing using skin tattooing techniques. The requirement for donor material could be cited as a disadvantage, but material suitable for lamellar corneal grafting only is more readily available. The long-term results were good in our patient. Eyes with corneal scarring intolerant of contact lenses and other prosthetic devices, may benefit from this technique. For corneal scars this technique is preferable when penetrating keratoplasty carries a high risk of rejection and failure. Leucocoria is probably better treated with a cataract extraction and a black implant (Morcher GmbH, Stuttgart, Germany). However corneal surgery for leucocoria may be preferred in eyes with no visual potential, where the lens and pupil are very disorganised, precluding a safe cataract procedure, or when such surgery carries an unreasonable risk of sympathetic ophthalmicus and phthsis bulbi.


References

    • Synthetic keratophakia. Chapter 36. In Corneal Surgery. F S Brightbill. Published C V Mosby 1986.
    • Mannis MJ, Eghbali K, Schwab IR. Keratopigmentation: A reeview of corneal tattooing. Cornea 1999; 18 (6): 633-37.
    • Gifford SR, Steinberg A. Gold and silver impregnation of the cornea for cosmetic purposes. Am J Ophthalmol 1927; 10: 240-47.