Use of Fibrin Glue

1
Use of Fibrin Glue with ALK in Peripheral
Corneal Melts (Terrien's Pellucid) and
Alphacor Artificial Cornea
ASCRS MEETING 2007 SAN DIEGO, CA
Thomas John, MD Clinical Associate
Professor Loyola University at Chicago Maywood,
Illinois USA
2
John T Use of Fibrin Flue with ALK in Peripheral
Corneal Melts Terriens Pellucid and AlphaCor
Artificial Cornea

• PURPOSE To report the combined use of fibrin
  glue and anterior lamellar keratoplasty (ALK) in
  Terriens and Pellucid marginal degeneration and
  in AlphaCor artificial cornea.
• SETTING/VENUE This study was performed in the
  office setting in Tinley Park, Illinois and
  Merrillville, Indiana.
• METHODS Anterior lamellar keratopplasty
  techniques with fibrin glue were utilized in 5
  eyes, 7 procedures, as follows (a) Terriens
  marginal degeneration with Descematocele
  formation and impending perforation (n1 eye, 2
  procedures due to recurrent melt), (b) Pellucid
  marginal degeneration, inferior corneal melt
  corneal perforation OS ODPMD with
  descemetocele (n2), and (c) AlphaCor artificial
  cornea and superior corneal melt with exposure of
  the clear optic and the opaque skirt (n2 eyes, 3
  procedures).
• RESULTS There were a total of 5 eyes with 7 ALK
  procedures. Terriens marginal degeneration
  healed with a subsequent melt requiring a second
  ALK with fibrin glue. All eyes healed with
  stabilization of the cornea. There were no
  interface opacities, inflammation, and no
  additional neovascularization, in any of the eyes
  studied. There was good integration of the
  donor-host tissues. Fibrin glue showed no
  deleterious effects on the AlphaCor in these
  eyes.
• CONCLUSIONS ALK with fibrin glue appears to be a
  safe and effective surgical procedure in
  peripheral corneal melts in Terriens and
  Pellucid marginal degeneration of the cornea and
  in AlphaCor artificial cornea.
• FINANCIAL DISCLOSURE John, T None

3
(A) Terriens Marginal Degeneration
Surgical 8-16-2004 Sutureless ALK with
fibrin glue OS for Terriens with Descemetocele
OS ALK Automated Moria LSK Unit mickrokeratome
350 µm head Moria ALTK system used (artificial
AC) 12-01-2004 Corneal argon laser
photocoagulation for neovascularization with
lipid keratopathy OS 2-15-06 ALK sutureless
with fibrin glue OS for recurrent Terriens with
Descemetocele OS
John, T

• Clinical 8-15-2004
• 67-yo CM presented with Terriens marginal
• degeneration descemetocele formation
• (impending perforation) OS
• Feb 14, 2006 Recurrence of Terriens with
• descemetocele. BSCVA 20/200 PH 20/40-1.
• Post-operatively Confoscan showed
• activated keratocytes adjacent to
• host-donor interface (2004 2006).
• July 18, 2006 ALK stable. No melting.
• No recurrence of Terriens. BSCVA 20/25

Pre-op Wavefront
6-days Post-op Wavefront
Terrien's Marginal Degeneration
Stable 6 months post Repeat-ALK
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Surgical 5-20-2005 Sutureless ALK OS with
fibrin glue Amniotic Membrane Transplant for
PMD with Corneal Perforation 4-20-2006 -
Sutureless ALK with fibrin glue for PMD
Descemetocele OD ALK OU Manual dissection
Moria artificial AC
John, T
(B) Pellucid Marginal Degeneration (PMD)
Clinical 5-19-2005 62-yo-AAF with PMD
OU, descemetocele perforatioon (arrow in fig.)
OS. BSCVA 20/50 OD, 20/200 OS. Seidel test ve
OS. 6-26-2006 BSCVA 20/40 OD, 20/30
OS Post-operatively Confoscan showed activated
keratocytes adjacent to host-donor interface.
Endothelial cell count OD2351 OS1669/mm2
Confoscan Interface
1 year post-op
OS
OS
Fibrin Glue
-gt
OD
Activated keratocytes
Adjacent to interface
ALK with Fibrin Glue POD 1
ALK
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(C) AlphaCor Artificial Cornea (AAC) Peripheral
Melt
Case 1 65-yo-CF with diabetes mellitus,
5-previously failed corneal grafts (PKPs), and
pre-operative BSCVA CF OD, underwent AlphaCor
Artificial Cornea OD on March 17, 2005.
Post-operative meds Pred Forte 1, Zymar
Medroxyprogesterone (MPG) QID. 8 months post
first stage surgery patients UCVA20/40, hence
2nd stage surgery was not performed. Jan 25,
2006, underwent automated ALK (Moria ALTK
system), fibrin glue, for superior corneal melt.
Cornea stabilized (Figures). August 22, 2006,
Recurrent melt with exposure of AlphaCor skirt
superior cornea (Figures). Area of melt covered
by upper eyelid, no exposure, on MPG eye
drops.August 24, 2006, Repeat ALK with 200 µm
microkeratome head and Moria ALTK system, fibrin
glue, and partial conjunctival flap. Condition
stabilized (2 weeks follow-up).
Interface learly visible
S/P first ALK, Fibrin Glue
Recurrent Melt
Automated Technique
Skirt exposure
Sutureless ALK
Case 2 56-yo-AAM, with 3-previously failed
corneal grafts (PKPs) and a pre-operative vision
of LP OD, underwent AlphaCor artificial cornea,
and Gunderson flap under MAC with peribulbar
block anesthesia on September 10, 2003. Stage II
surgery on December 15, 2003. Post-operative
VaHM secondary to traumatic macular scar.
Post-operative meds Pred Forte 1, MPG, and
Zymar QID OD. Superior corneal melt with
AlphaCor skirt exposure on April 16, 2006. April
17, 2006, underwent ALK with fibrin glue OD.
Cornea stabilized, VaLP.
John, T
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Peripheral Corneal Melts
ALK With FibrinGlue
appears to be safe effective in
Terrien's marginal degeneration
Pellucid marginal degeneration
AlphaCor Artificial Cornea with melt
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Use of Fibrin Glue with ALK in Peripheral
Corneal Melts (Terrien's Pellucid) and
Alphacor Artificial Cornea
ASCRS MEETING 2007 SAN DIEGO, CA
Thomas John, MD Clinical Associate
Professor Loyola University at Chicago Maywood,
Illinois USA