Year : 2003 | Volume
: 51 | Issue : 3 | Page : 259--260
Traumatic Wound Dehiscence 14 Years following Penetrating Keratoplasty.
S Maheshwari, M Saswade, A Thool
Shri Ganapati Netralaya, Jalna, India
Shri Ganapati Netralaya, Jalna
Penetrating keratoplasty eyes are at greater risk of laceration than intact corneas due to persistent wound weakness, even years after surgery. We report a case of traumatic wound dehiscence by fingertip injury 14 years following penetrating keratoplasty.
|How to cite this article:|
Maheshwari S, Saswade M, Thool A. Traumatic Wound Dehiscence 14 Years following Penetrating Keratoplasty. Indian J Ophthalmol 2003;51:259-260
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Maheshwari S, Saswade M, Thool A. Traumatic Wound Dehiscence 14 Years following Penetrating Keratoplasty. Indian J Ophthalmol [serial online] 2003 [cited 2020 Feb 24 ];51:259-260
Available from: http://www.ijo.in/text.asp?2003/51/3/259/14671
A 55-year-old male patient presented at our institute in March 2001 complaining of trauma to the left eye caused by the fingertip approximately 10 hours earlier, followed by diminished vision and pain. He had received penetrating keratoplasty (PK) in the left eye 14 years earlier. He had been blind in the right eye since early childhood and was a known diabetic for the last 10 years, on irregular treatment.
On examination vision in the right eye was no light perception (NLP) and left eye was counting fingers at 2 meters. The right eye was phthisical. The left eye revealed 5 clock hours of dehiscence in the nasal half at the graft-host junction, a shallow anterior chamber, sector iridectomy, aphakia and posterior capsular rent with vitreous in the pupillary area.
He underwent wound repair with anterior vitrectomy in the left eye. Postoperatively he was started on topical corticosteroids tapered gradually over a period of 4 months and cycloplegics. Three week post-wound repair best corrected visual acuity (BCVA) was 6/60, the graft had epithelial oedema, the anterior chamber was deep and applanation intraocular pressure (IOP) was 38 mmHg. Fundus evaluation showed a cup-disc ratio of 0.5 with intact neuro-retinal rim, temporal pallor and attached retina. With a diagnosis of secondary glaucoma, he was put on systemic carbonic anhydrase inhibitors and topical beta-blockers. One month post-wound repair BCVA was 6/18p, graft was compact and clear, and the IOP was 12 mmHg. The systemic carbonic anhydrase inhibitor was discontinued and he was continued on topical beta-blocker only. Three months post-wound repair visual acuity reduced to 6/36, the graft was clear and compact, and IOP was 6 mm Hg. Fundus examination showed partial rhegmatogenous retinal detachment in the infero-temporal quadrant with pigmented lattice. He underwent scleral buckling for the same. At last follow-up, 13 months post-wound repair, BCVA was 6/24, graft was compact and clear and IOP was 16 mmHg with topical beta-blockers. Fundus evaluation showed a cup-disc ratio of 0.6, intact neuro-retinal rim, temporal pallor, an attached retina and no evidence of diabetic retinopathy.
Traumatic wound dehiscence following PK is not a rare event. The incidence of wound dehiscence is reported to vary from 1.28% to 2.5%.,, In the present case the dehiscence occurred in the nasal half at the graft-host junction due to the force inflicted from the temporal side. Obviously, the direction and the nature of trauma are the determining factors. The graft-host interface in corneal graft is the primary site of rupture following trauma. ,,,,,, Using holographic stress analysis, Calkins et al have demonstrated that graft-host junction continues to be a potentially weak area even a year after PK. Several other factors lead to weakness of the wound like avascular central cornea, use of 10.0 nylon suture and prolonged use of topical corticosteroids.
The duration between initial surgery and wound dehiscence reported in various series ranges from 3 days to 13 years.,,,,,, Friedman has reported two cases of traumatic wound dehiscence 4 and 5 years after surgery. Tseng et al and Farley et al have reported keratoplasty wound dehiscence 13 years after initial surgery. In our case it was noted 14 years following initial PK.
The force of the trauma seems to be the most significant factor affecting the outcome. The visual outcome depends on the integrity of the posterior segment as noted in various reports., In the present case partial rhegmatogenous retinal detachment occurred 3 months after primary repair. Hence all cases of wound dehiscence should be followed up closely with frequent fundus evaluation.
Our case indicates that the corneal graft wound continues to be weak and vulnerable to trivial ocular trauma even years after keratoplasty. Emphasis on the lifelong use of protective eyewear during day and eye shield at night would be useful for PK patients. The patient should be instructed about longterm vulnerability of the graft wound and dire consequences of trauma to the eye.
|1||Agrawal V, Wagh M, Krishnamachary M, Rao G, Gupta S. Traumatic wound dehiscence after penetrating keratoplasty. Cornea 1995;14:601-3.|
|2||Tseng SH, Lin SC, Chen FK. Traumatic wound dehiscence after penetrating keratoplasty: clinical features and outcome in 21 cases. Cornea 1999;18:553-58.|
|3||Rehany U, Rumelt S. Ocular trauma following penetrating keratoplasty: incidence outcome, and postoperative recommendations. Arch Ophthalmol 1998;116:1282-86.|
|4||Raber IM, Arentsen JJ, Laibson PR. Traumatic wound dehiscence after penetrating keratoplasty. Arch Ophthalmol 1980;98:1407-9.|
|5||Friedman A. Late traumatic wound rupture following successful partial penetrating keratoplasty. Am J Ophthalmol 1973;75:117-19.|
|6||Topping TM, Stark WJ, Maumenee E, and Kenyon KR. Traumatic wound dehiscence following penetrating keratoplasty. Br J Ophthalmol 1982;66:174-78.|
|7||Farley MK, Pettit TH. Traumatic wound dehiscence after penetrating keratoplasty. Am J Ophthalmol 1987;104:44-49.|
|8||Calkins JL, Hochheimer BF, Stark WJ. Corneal wound healing: holographic stress-test analysis. Invest Ophthalmol Vis Sci 1981;21:322-34.|