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Fibrin Glue–Assisted Closure of Macroperforation in Predescemetic Deep Anterior Lamellar Keratoplasty With a Donor Obtained From Small Incision Lenticule Extraction

Jacob, Soosan, MS, FRCS, DNB*,†; Dhawan, Pallavi, MS*,†; Tsatsos, Michael, MD, PhD‡,§; Agarwal, Amar, MS, FRCS, FRCO; Narasimhan, Smita, MBBS, FERC; Kumar, Arun, BE, MBA*,†

doi: 10.1097/ICO.0000000000001918

Purpose: To report a case with multiple macroperforations and a double anterior chamber (AC) after predescemetic deep anterior lamellar keratoplasty.

Methods: A patient was referred after undergoing complicated excision of pseudopterygium that extended onto the cornea. At presentation, an eccentric lamellar patch graft extending over the pupillary axis with a double AC was seen. Surgical intervention showed a predescemetic plane of dissection with 2 macroperforations and iris plugging of the peripheral perforations. Suturing and fibrin glue alone did not seal the macroperforation, and a donor lenticule from small incision lenticule extraction (SMILE) was used to close the larger perforation using fibrin glue. A trephine was then used to mark a larger area of predescemetic dissection that included the original patch graft. A donor corneal graft was sutured after stripping Descemet membrane (DM).

Results: Postoperatively, the double AC resolved, and vision improved to 0.50 decimal equivalent (20/40) by 3 weeks. At 18-month postoperative follow-up, corrected distance visual acuity (CDVA) was 0.67 (20/30). The donor graft remained clear, and the SMILE lenticule with underlying sutures could be visualized.

Conclusions: A donor lenticule from SMILE surgery is a useful adjunct to seal macroperforations in deep anterior lamellar keratoplasty because the thin uniform lamellar tissue is easily applied using fibrin glue and gives uniform and good apposition on both host and donor sides. It can be used immediately without further preparation unlike hand-fashioned patch grafts.

*Dr. Agarwal's Refractive and Cornea Foundation (DARCF), Chennai, India;

Dr. Agarwal's Group of Eye Hospitals, Chennai, India;

Aristotle University of Thessaloniki, Thessaloniki, Greece; and

§Dorset County Hospital, Dorchester, UK.

Correspondence: Amar Agarwal, MS, FRCS, FRCO, Dr. Agarwal's Eye Hospital and Eye Research Centre, 19 Cathedral Road, Chennai 600 086, India (e-mail:

The authors have no funding or conflicts of interest to disclose.

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Received December 20, 2018

Received in revised form January 03, 2019

Accepted January 23, 2019

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