Nonmechanical excimer laser penetrating keratoplasty for perforated or predescemetal corneal ulcers

OBJECTIVE: To review the authors' results using nonmechanical excimer laser trephination in penetrating keratoplasty for perforated or predescemetal corneal ulcers. DESIGN: Noncomparative, consecutive, interventional case series. PARTICIPANTS: Thirty-two patients with perforated (17) or deep (15) corneal ulcers (9 bacterial, 5 acanthamoebal, 10 herpetic, 3 associated with rheumatoid arthritis, 5 other) necessitating immediate tectonic keratoplasty. INTERVENTION: Penetrating tectonic keratoplasty with excimer laser trephination was performed along metal aperture masks in donor and recipient corneas. MAIN OUTCOME MEASURES: Clinical results including intraoperative and postoperative complications were evaluated. RESULTS: Trephination was possible in all eyes without perforation of predescemetal ulcers or extrusion of intraocular contents. No eyes with bacterial or acanthamoebal ulcers showed persistence or recurrence of infection. One eye showed recurrent epithelial herpetic keratitis. Best-corrected postoperative visual acuity ranged from 20/700 to 20/20 (median, 20/58), with 30 of 32 eyes achieving improvement of best visual acuity during follow-up (mean, 22.4 months) and with 12 of 32 eyes reaching a visual acuity of 20/40 or greater. Eyes with bacterial or acanthamoebal ulcers showed best results. Episodes of graft rejection occurred in nine eyes and resulted in irreversible opacity of the graft in seven cases. None of the eyes lost all vision, developed endophthalmitis, or had to be enucleated. CONCLUSIONS: Nonmechanical trephination is a useful technical refinement of tectonic penetrating keratoplasty à chaud for perforated or deep progressive corneal ulcers. This technique greatly facilitates exact trephination under these difficult surgical conditions and might possibly improve the prognosis of this procedure.