Techniques
 
Surgical Technique for Managing Deep Corneal Hematoma following Penetrating Keratoplasty
 

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Kulbhushan P Chaudhary, Vinay Gupta
Department of Ophthalmology, Indira Gandhi Medical college,
Shimla (H.P.) 17100 India.


Corresponding Author
: Dr. Vinay Gupta
E-Mail : drvinay66@gmail.com


Abstract

We report a surgical technique to manage deep corneal hematoma following penetrating Keratoplasty.A 30 year old male patient with subtotal vascularized corneal opacity in right eye with adherent leucoma underwent penetrating Keratoplasty. Donor corneal graft of 7.5mm was sutured with 16 10-0 monofilament nylon suture. Post operative period was uneventful and the best corrected visual acuity (BCVA) was 6/24 at 6 weeks follow up. Patient presented 22 weeks after penetrating Keratoplasty with sudden diminution of vision with deep corneal hematoma and blood vessels at 5.30, 6.30, 9.30 and 11.30 positions. Cauterization of vessels was done with drainage of hematoma from 7 o`clock position through host graft junction and wash with BSS solution was done. Patients graft became clear with resolution of hematoma and regression of vessels. Patients BCVA 10 weeks post drainage was 6/12. Deep corneal hematoma is a rare complication after penetrating Keratoplasty and not been reported in literature. The refractory cases can be managed by cauterization & drainage of deep corneal hematoma.

Corneal hematoma is a rare complication and has been reported after different surgical procedures like cataract surgery, is associated with Moorens ulcer, spontaneously and after canaloplasty in Glaucoma.[1,2,3,4] Deep corneal hematoma after penetrating Keratoplasty has not been reported in literature. We hereby report a case of deep corneal hematoma following penetrating Keratoplasty and a surgical technique to manage the case.

Surgical Technique

A 30 year male with subtotal vascularized corneal opacity in right eye underwent penetrating keratoplasty. (Figure 1 & 2) Twenty two weeks post operatively, the patient presented with sudden diminution of vision. Best corrected visual acuity (BCVA) was 2/60 on examination. Patients IOP was 14mm of Hg. On Slit lamp biomicroscopic examination, there was a deep corneal hematoma in lower half of the graft, with deep vascular arcade and corneal edema and blood vessels at limbus entering graft at 5.30, 6.30, 9.30 and 11.30 o’clock positions (Figure 3). Drainage of hematoma was planned. The patient was evaluated on the slit lamp and feeder vessels were marked. The size of hematoma was also marked which was 3?4 mm. After performing local peritomy and partial thickness sclerotomy, both ends of the deep feeder vessels were cautrized with wet field diathermy (Figure 4 a). The next day, size of vessels had regressed but the size of hemetoma had increased to 4?5 mm and large epithelial bullae were noted at 7 ’O’ clock position in front of the hematoma (Figure 4 b). The patient was operated under peribulbar anesthesia. A 150 blade was used to enter the graft host junction at the site of most dense hematoma i.e 7 o’clock position. The entry was extended up to the central part of the hematoma at supra descemet’s location (Figure 4 c). Using a 26 gauge canula, (Figure 4 d) the hematoma was drained and washed with balanced salt solution (BSS). The feeder vessels were again cauterized and subconjunctival dexamethasone was given at the site of blood vessels.











Result

At first post-operative day, there was minimal hematoma in deep corneal location (Figure 4 E). One week post drainage the hematoma had resolved, corneal edema had decreased, the blood vessels had regressed and bullae had resolved. The patient was discharged on 14th day post operative on oral & topical steroids, cyclosporine eye drop, antibiotics and artificial tear drops. Ten months post drainage, patient had a vision of 6/12 with +1D cylinder at 112 degrees with clear corneal graft and no blood vessels entering the graft (Figure 5).


Discussion

Corneal hematoma is a rare complication of penetrating Keratoplasty. Young and D ‘ombrain5 reported a 72 years old lady with high IOP (90 mm Hg) in both eyes and hematoma in right eye around limbus & around arcus senilis region. It was postulated that since this zone was without conjunctival support, degenerative and friable condition of tissue & blood vessels led to bleed in a sharply defined line. In 1984, Scarl SS et al[1] described two cases of corneal hematoma following cataract surgery.Initially the cases manifested as corneal blood staining and were complicated by the presence of persistent epithelial defect and stromal thinning. Scanning electron and light microscopic examination of the second case demonstrated a loss of keratocyte, stromal collagen breakdown and epithelial cells degeneration over the centre of hematoma. In 2000, Wagoner et al[2] reported a case of 81 year old man with bilateral Moorens ulcer complicated with intracorneal hemorrhage in right eye secondary to peripheral corneal neovascularisation and was followed by slow resolution over a 3 year period. The patient had undergone penetrating Keratoplasty. Histopathological examination demonstrated the association between the stromal neovascularisation and residual interlamellar hemorrhage showing phagocytosis of residual hemosiderin by macrophages. Kachi S et al[3] demonstrated the importance of ultrasonographic biomicroscopy for following the clinical course of an intracorneal hematoma of unknown origin. The hematoma occurred in 64 years old woman at predescemets’ membrane level without any obvious cause and was classified as spontaneous. The hematoma had almost resolved 2.5 years after the onset, and the visual acuity improved to 20/30.









Gismondi et al4 described a case of an intracorneal hematoma after canaloplasty in left eye in a 45 year old male with uncontrolled pigmentary open angle glaucoma. During surgery while doing catheterization, there was probably a limited detachment of descemets membrane. Slit lamp biomicroscopy showed a large intracorneal hematoma that threatened the visual axis. A partial thickness paracentesis was performed without interrupting the the descemets membrane to remove the hematoma.



In the present case deep stromal hematoma developed 22 weeks following a penetrating Keratoplasty. After starting oral and topical steroids, cyclosporine drops and cauterization, the vessels had regressed slightly but the size of hematoma and corneal edema had increased and a bulla had appeared in front of denser part of hematoma.Corneal hematoma leads to loss of keratocytes & stromal collagen breakdown. Large hematoma may cause epithelial degeneration by functioning as a barrier to nutrients and metabolic factors from anterior chamber. Unlike corneal blood staining, conservative treatment is often insufficient therapy for corneal hematoma with associated persistent epithelial defect1, hence the surgical option as described in this case had to be exercised. After the drainage of hematoma the corneal edema had disappeared and vessels regressed, host graft junction became firm, which would act as a potential barrier for the growth of vessels into the donor graft. Graft remained clear and the chances of graft failure decreased. So if we observe a complication of corneal hematoma in high risk cases and if hematoma is not likely to be resolved by conservative methods, we should exercise the surgical option of draining the hematoma.

References
  1. Searl SS, Croll SD, Boruchoff SA, Albert DM. Corneal hematoma. Arch Ophthalmol 1984; 102(11):1647-9.
  2. Michael D Wagoner, Sara I Islam, Fenwick Riley. Intracorneal hematoma in Mooren ulceration. Am J Ophthalmol. 2000; 129(2):251-3.
  3. Kachi S, Hirano K. Ultrasonographic biomicroscopic study of an intracorneal hematoma. Cornea 2002; 21(4):421-3.
  4. Maurizio G, Paolo B. Intracorneal hematoma after Canaloplasty in Glaucoma. Cornea 2011; 30(6):718-9.
  5. Young G, D’ombrain AW. Haematoma of the Cornea. A clinical note. Br J Ophthalmol. 1925; 9(6):299-300.