One Donor Cornea For Three Corneal Transplants, Including A Novel Combined Tight Suturing To Reduce And Crescentic Lamellar Grafting To Strengthen Terrien’S Marginal Degeneration.

We successfully used one good quality donor cornea for 3 patients; a crescentic lamellar Keratoplasty (CrLK) for Terrien’s marginal degeneration (TMD), a Descemet membrane endothelial Keratoplasty (DMEK) for Fuchs endothelial dystrophy (FECD) and a deep anterior lamellar Keratoplasty (DALK) for an advanced keratoconus.  In the case of TMD that had severe corneal ectasia, a novel combination of existing 2 surgical techniques were successfully combined: tight sutures for ectasia reduction and CrLK for tissue strengthening. We hope that sharing our outcome would be beneficial to corneal surgeons at large.

The first patient, 61 year old male with 20 years of defective vision, worsened in right eye for 6 months and referred for TMD surgical intervention. The second patient, a 75 year old male with 2 years of diminution of vision in right eye, diagnosed as FECD with significant cataract and referred for DMEK with phacoemulsification. The third patient, 13 year old boy with 2 months of blurry vision, a habitual eye rubber, diagnosed advanced keratoconus in the right eye and refered for DALK.

All 3 grafts were from a single donor, prepared during the first surgery for TMD. TMD ectasia reduction was as follows: epithelial delamination using 20% ethanol, ledge creation at corneal and scleral sides, bites from corneal ledge, through stromal bed and scleral ledge tied tightly to reduce ectasia. Next, the donor graft preparation started with donor Descemet’s (DM) stripping up to ¾^th, an L mark directly on the folded DM, refloated the DM and punched eccentrically 8 mm creating DMEK and DALK grafts and was kept aside. The remaining graft was punched with 11 mm trephine to a ring, with central eccentric 8 mm hole. This graft was sutured with radial bites onto the reduced stromal bed of TMD, along with manual graft trimming to tailor fit it to the host bed dimensions. On another day, both the DMEK graft for FECD and DALK graft for keratoconus patients were used. For the DMEK, manual DM stripping, loading and injecting with glass injector system, tapping for unfolding and air injection for graft attachment were used. For DALK, manual dissection and graft anchoring with combined interrupted and continuous sutures were used. Uneventful post-op was for TMD and keratoconus patients, while FECD patient showed graft separation needing a single air injection. Until, the recent follow up of 6 months, the best corrected vision improved from LogMAR 1.00 to 0.30 for TMD patient, was maintained at LogMAR 1.00 in DMEK and improved from LogMAR 1.00 to 0.18 in DALK patient.     

The combination of CrLK with DMEK and DALK from a single donor cornea has not been published so far, to the best of our knowledge. Maximal usage of good quality donor cornea is beneficial in reducing burden on the eye banks. In peripheral ectatic conditions, the central cornea is clear but distorted due to ectasia. Reducing the ectasia with tight sutures, used in the early stages, will restore the central corneal curvature. Lamellar grafts add tissue to the thinned stroma and are used for stromal strengthening at later stages. Combining these two techniques in our case has given good outcome. If proven beneficial on studies with larger sample size, this method can be used for other forms peripheral ectasia.