Reconstructing the anterior segment

Strategies for saving vision in trauma cases

Dermot McGrath

Posted: Thursday, December 3, 2020

Claus Cursiefen MD, PhD, FEBO

A variety of different surgical strategies can be successfully deployed in the reconstruction of the anterior segment to save vision and obtain satisfactory functional and anatomical results in challenging cases of traumatic or chemical injury, according to Claus Cursiefen MD, PhD, FEBO.
“There are options available for these complex cases involving post-traumatic corneal oedema and scars, iris defects, cyclodialysis with hypotony and epithelial invasion, among others,” he said.
Speaking at the joint ESCRS-EuCornea symposium held during the 38th Congress of the ESCRS, Dr Cursiefen, Chairman and Professor of the Department of Ophthalmology at the University of Cologne, Germany, gave a broad overview of various techniques that could be applied to different repair scenarios.
In cases of post-traumatic corneal oedema, Descemet membrane endothelial keratoplasty (DMEK) is the first-choice surgical option, said Dr Cursiefen.
“We can try Descemet stripping automated endothelial keratoplasty (DSAEK) if DMEK is not possible, for example in cases of poor visibility where no intraoperative OCT is available or in eyes with very irregular posterior surface. The next option is penetrating keratoplasty but only if corneal scarring and severe corneal neovascularisation is present,” he said.
DMEK may also prove helpful in vascularised high-risk eyes with stromal oedema, said Dr Cursiefen. He cited a retrospective study carried out using data taken from Cologne’s database of more than 5,000 different DMEK cases between 2011 and 2020.
Of 24 vascularised high-risk eyes with stromal oedema identified, DMEK was shown to be a viable treatment option.
“Significant regression of corneal neovascularisation was observed. The final visual acuity was relatively worse than in normal DMEK and we had a graft rejection in one eye (4.2%), which is also higher than for normal DMEK,” he said. “Nonetheless, safety and efficacy is much better compared to penetrating keratoplasty in vascularised high-risk eyes!”
For eyes with large iris defects, Dr Cursiefen noted that DMEK combined with a safety suture has been successfully employed in severe trauma cases to avoid dislocation of the graft. In cases of post-traumatic scar with no visual acuity and where it is not possible to wear an iris print lens, intrastromal corneal tattooing may provide a cosmetically acceptable result, he said.
In cases of post-traumatic hypotony due to cyclodialysis, Dr Cursiefen advised firstly adopting a “watch and wait” policy treating with cycloplegics and topical steroids. The indications for direct cycloplexy surgery include cyclodialysis of more than 60% circumference, with hypotony persisting for more than six weeks, beginning functional changes and morphologic changes such as macular folds, cystoid macular oedema and papilloedema.
Success rates of around 80% success can be expected for direct cycloplexy, with re-interventions more common in larger cleft defects, he said. Care has to be taken with early postoperative pressure spikes.
Although epithelial invasion is a common complication after trauma, block excision with tectonic corneoscleral grafting is an effective treatment in cases of cystic and/or diffuse sheet-like epithelial ingrowth, he concluded.
Claus Cursiefen: