July2019 1195Case Reports

Mushroom keratoplasty and contact lens applicat ion: Strategy for management of a pediatric eye injury

Saverio V Luccarelli1, Stefano Lucentini1, Francesco Bonsignore1, Paolo Nucci1,2

We show the challengingvisual rehabilitation of a penetratingeyeinjuryinachildwithwidecentralcornealscarandaphakia.A 9‑year‑old male patient underwent combined surgery,includingmembranectomywith pupilloplasty andmushroompenetrating keratoplasty. Corneal transparency was restored;aphakia and irregular astigmatismwere corrected first with arigid gas‑permeable contact lens (CL) and then, successfully,withhybridCL.WediscussthesurgicaltreatmentusedtorestorecornealtransparencyandthechoiceofthebestCLtoovercomeirregularastigmatismandaphakia.

Key words: Aphakia, contact lenses, corneal transplantation,pediatriceyeinjury

Ocular injury is one of the primary causes ofmonocularblindnessworldwide,especiallyindevelopingcountries.Mostpediatriccasesderivefromsharpobjectpenetrationcausingopenglobeinjuries.Theprimaryaimoftreatmentistorestoretheintegrityofocularstructuresthroughemergencysurgeryandtopreventinfections.[1] Managementofresidualrefractiveerrors,however,ismorechallenging.

Cornealscarsandaphakiaarefrequentsequelae,resultinginirregularastigmatismandlossofaccommodativefunction.Optionsforrestoringvisionvaryfromsurgerywithintraocularlens(IOL)implantation,[2]tononsurgicaltreatmentwithcontactlens(CL).[3]Particularattentionshouldbepaidtocornealscarsinvolvingthevisualaxisofchildrentopreventamblyopia.[4]

We show the challenging management and visualrehabilitationofapenetratingeyeinjuryinayoungboywithcentralcornealscarandaphakia.

Case ReportA9‑year‑oldmalepatientpresentedwithapenetratingocularrighteye(RE)traumaoccurred4monthsearlier.Hesufferedafull‑thicknesscorneallacerationwithlensdislocationcausedby

1EyeClinicSanGiuseppeHospital,Milan, 2DepartmentofClinicalScienceandCommunityHealth,UniversityofMilan,Italy

Correspondenceto:Dr.SaverioVLuccarelli,ViaSanVittore12,20123,Milano,Italy.E‑mail:saverio.luccarelli@gmail.com

Manuscriptreceived:4.10.18;Revision accepted:18.01.19

Cite this article as: Luccarelli SV, Lucentini S, Bonsignore F, Nucci P. Mushroom keratoplasty and contact lens application: Strategy for management of a pediatric eye injury. Indian J Ophthalmol 2019;67:1195-7.

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aglassbottleexplosion.HewaspromptlytreatedwithcornealsuturingandlensextractioninEgypt.VisualacuitywaslightperceptioninREand20/20inlefteye.Orthopticsevaluationshowedafixed right exotropia,probablybecauseofvisualdeprivation. Slit‑lamp examination revealed awide linearcornealscar(9.00mm)throughthevisualaxisandaphakia.Thepupilhadaninferiordecentralizationduetothepresenceof a thick retropupillarymembraneandanterior synechiaebetweenthepupillaryedgeandtheiridocornealangle.Anteriorchamberwasclear,andintraocularpressure(IOP)wasdigitallynormal.B‑scanshowedanintactretinawithoutpathologicalfindingsorforeignintraocularbodies.

One year after the trauma,weperformed a combinedprocedure includingmembranectomywith pupilloplastyandmushroompenetratingkeratoplasty(MR‑PK);themainsurgicalstepsareillustratedinFig. 1.MushroomkeratoplastywasperformedusingProf.Busin’sstandardtechnique.[5] The hostcorneawastrephinedtoapproximately200µm in depth and9.00mmdiameterusinga suction trephine (HessburgBarronTrephine,Altomed,TyneandWear,UK),andthenananteriormanualpartialstromectomywasperformed.

Thegraftwaspreparedbythelocaleyebank(MonzaEyeBank,Monza,Italy)usingasingle‑donorcorneasplitintoananterior andposterior lamellae by amicrokeratome set at250µmdepth(ALTK;MoriaSA,Antony,France).Theanteriorlamellawasthenpunchedto9.00mmandtheposteriorlamellato6.50mm(BarronDonorCornealPunch,Altomed,TyneandWear,UK).Thenextstepwasthefull‑thicknesstrephinationofthehostcorneausinga6.50‑mmtrephinecenteredoverthepupil,obtainingahostcornealbuttonwhichwasremovedandreplacedbythe6.50‑mmposteriordonorlamella,the“stem.”Theanteriordonorlamella,the“hat,”wasthenplacedoverthe“stem.”The“hat”waslastlysuturedtothehostcornea[Fig.2].

One‑monthfollow‑upshowedaclearcornealgraft.Best‑correctedvisualacuity(BCVA)was20/400witha+12.00Dspherespectaclescorrection. Fundus examinationwas unremarkable. Theretropupillarymembranewasstillpresenteven if reduced indimensionsandIOPwas15mmHg.Loosesutureswereremoved.At2monthsoffollow‑up,BCVAbecame20/200withpinholeandthecorneahadhealedenoughforCLfitting.

ThefirstattemptofCLcorrectionwasmadewitharigidgas‑permeable (RGP) inversegeometry lens SanalensRoseK2 IC (Sanalens, Pisa, Italy) 7.55/+10.00/10.60 to evaluatethe visual potential in a condition of low and irregularastigmatism [Fig.3].

Therewasaproperlensfittingandanoptimalfluoresceinpattern,buttheBCVAwasonly20/200.Thisfunctionalresultwasconsideredinsufficientconsideringthecornealcondition

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1196 Indian Journal of Ophthalmology Volume67Issue7

andtheretinastatus,togetherwiththeobservationthatthechildhadanabnormalheadposture.Theredreflex,assessedatslitlamp,suggestedthatresidualpupillarymembranemasked

thevisualaxis.AnND:YAGlaserpupillarymembranotomywasperformedtoenlargethepupil.

Considering the discomfort with the RGP lenses, aHybridCLSynergEyesA(SynergEyes,Carlsbad,CA,USA)7.50/8.50/+10.25/14.5wasusedtotrytoincreasecomfortandthus compliance to correction [Fig. 4]. Thefitting comfortwasexcellent,noairbubblewaspresent, and theclearancewasoptimal.BCVAwas20/100.Thepatientwasprescribedfull‑timeCLwear.

Figure 2: Spectral Domain OCT showing the structure of the mushroom shaped graft, the superior 9.00mm "hat" (*) and the inferior 6,50mm "stem" (#)

Figure 4: Corneal topography (Pentacam HR, Oculus Inc., Arlington, WA, USA) shows -3.50D slightly irregular astigmatism

Figure 3: Slit lamp examination at one‑month follow‑up with the overlay of the margins of the 6.50 mm stem (blue dashes) and the 9,00 mm hat (black dashes)

Figure 1: Surgical steps of membranectomy, pupilloplasty and mushroom keratoplasty. Anterior synechiotomy using a 27g sharp blade (a), membranotomy with a 25g vitrectome (b). Trephination was of 9.00 mm diameter and approximately 250 µm depth, centered in relation to the limbus (c). Manual superficial stromectomy (d) and 6.50 mm central full‑thickness host trephination centered on the pupil (e), posterior button is removed with scissors (f). Placement of donor posterior lamella with 6.50 mm (e). Anterior 9.00 mm donor lamellar placed and sutured in place (f) and final appearance (g)

d

h i

c

g

b

f

a

e

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July2019 1197Case Reports

At 5 of months follow‑up, BCVA was 20/60 withCL correct ion; the exotropia became intermittentand disappeared with CL fitted. At the 18 th month postoperatively,BCVAwas20/30andtheendothelialcellcountwas1600cells/mm2.

DiscussionThefirst stepwas toperform the aforementioned surgicalproceduretorestoretransparencyandanatomyoftheanteriorsegment,sincethecornealscarandthepupillarymembranewereonthevisualaxis.MR‑PKwasdescribedtobeaneffectiveprocedureinpediatriccases.[5]Therationaleistocombinetherefractiveadvantagesofawidesuperiorhat(9.00mm),togetherwiththesmalldiameteroftheinferiorstem(6.50mm).Thistechniqueshouldminimizesutures’impactonthevisualaxisandreducethenumberofendothelialcellstransplanted,giventhechanceoftransplantrejection.[5]

AphakiawasnotcorrectedinthefirstsurgeryconsideringintraoperativerisksandtheimpossibilityofapreciseIOLpowercalculationbeforekeratoplasty.CLshavebeen successfullyusedtorepairpediatricaphakiainmultiplereports.[6]

RGP lenswas attempted first, because of the presenceof irregularastigmatismof−3.50D,[7]withabetterVAoverspectaclecorrection.Studiesindicateashighasa36.8%dropoutrateofRGPwearduetodiscomfort[8] despite the improvement inBCVA,asinthiscase.

HybridCLwasaviableoptionbecause it combined thesuperior comfort over theRGP lens,[9] essential for good compliance,with theopticofRGP lens.ThedisadvantagesofhybridCLare the increasedcostcomparedwithGPandthemore frequent replacement. There are some concernsaboutconsideringsecondaryIOLimplantinthefuture:evenifitwasabletocorrectthesphericalametropia,theirregularastigmatismwouldprobablystillneedaCLcorrection.

ConclusionWe report the complex and integratedmanagement of apediatric ocular trauma. Surgical (MR‑PK)andnonsurgicaltreatments(ND:YAGlaserandCLs)werecombinedtopromotethebestrestorationofocularstructures.ThefinaluseofhybridCL allowed obtaining good‑quality vision and tolerance,reducingresidualametropiaandavoidingtheunpredictable

refractiveresultandsurgicalriskslinkedtoIOLimplantationatthisage.

Declaration of patient consentTheauthors certify that theyhaveobtainedall appropriatepatient consent forms. In the form thepatient(s) has/havegivenhis/her/theirconsentforhis/her/theirimagesandotherclinicalinformationtobereportedinthejournal.Thepatientsunderstandthattheirnamesandinitialswillnotbepublishedanddue effortswill bemade to conceal their identity, butanonymitycannotbeguaranteed.

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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5. BusinM,BeltzJ,ScorciaV.Mushroomkeratoplastyinpediatricpatients.SaudiJOphthalmol2011;25:269‑74.

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