Role of AS-OCT in Assessment of Healing of Thin or Perforated Cornea Treated by Amniotic Membrane Graft and PRP Clot

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Abdelghany, Jorge L. Alio, Ahmed A. Abdelmonem, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7083809/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Dec, 2025 Read the published version in BMC Ophthalmology → Version 1 posted 12 You are reading this latest preprint version Abstract Background: The purpose of the study is to evaluate the role of anterior segment optical coherence tomography in the assessment of the healing of corneal perforation after surgical treatment by amniotic membrane graft and platelet-rich plasma clot. Methods: Prospective, consecutive clinical series of cases. 13 eyes of 13 patients with small corneal perforation or thinning were included in the study. The patients were surgically treated with an amniotic membrane graft (AMG) and a platelet-rich plasma (PRP) clot, and the anterior chamber was reformed using air. Anterior segment optical coherence tomography (AS-OCT) was performed 1 week and 1 month after the surgery to confirm corneal healing and to assess the anterior chamber. Results: All cases demonstrated the formation of the anterior chamber and adequate intraocular pressure digitally during the follow-up period, and all cases showed complete healing of the corneal perforation by AS-OCT within the 4-week follow-up period. Conclusion AS-OCT is an essential tool to confirm healing of the corneal perforation surgically treated by amniotic membrane graft and platelet-rich plasma clot. Trial registration: The study was registered in ClinicalTrials.gov on May 20, 2024, with NCT06422897. The study was approved by the Ethics Committee, Faculty of Medicine, Minia University, El-Minya, Egypt (No. 1133/04/2024). This study adhered to the principles outlined in the Declaration of Helsinki. Corneal Perforation Amniotic membrane Platelet-rich plasma clot Anterior segment optical coherence tomography Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Corneal thinning or even perforation may follow corneal infection if not adequately treated. Ulcerations or even perforations may negatively affect the visual abilities of the affected eye, causing what is called corneal blindness. [ 1 ] Infectious keratitis (IK) has been considered the most common cause of corneal blindness, with higher incidence in developing countries, causing thinning or even perforation of the cornea, especially with low socioeconomic status [ 1 ]. The incidence ranges between 2.5 to 799 per 100,000 population per year. It is a painful and potentially blinding ocular disease that may require hospital admission. The main causative microorganisms are bacteria and fungi (especially in rural areas), followed by viruses and parasites. In mild and moderate cases, broad-spectrum topical antimicrobial therapy is effective alone, but in severe and resistant cases, other additive procedures may be needed, such as corneal cross-linking, corneal gluing, amniotic membrane grafting (AMG), and finally therapeutic keratoplasty [ 2 – 5 ]. Other causes of corneal ulcerations and perforations include autoimmune disorders, ocular surface diseases, and penetrating trauma. Autoimmune disorders and ocular surface diseases usually cause perforations associated with secondary infectious keratitis [ 1 ]. Urgent management with surgical intervention of complicated ulcers or perforations is necessary to save the eye. Treatment modalities prescribed before with good results are amniotic membrane graft (AMG) and platelet-rich plasma (PRP) clot [ 5 , 6 ]. The aim of this study is to assess the healing of corneal perforations or thinning by the use of anterior segment optical coherence tomography (AS-OCT) in a consecutive series of cases. PATIENTS AND METHODS This study was a prospective consecutive interventional non-randomized clinical series of cases. 13 cases were included (8 males and 5 females), and the study was conducted from the 15th of April 2024 to the 5th of September 2024. 10 eyes of 10 patients were presented with corneal perforations of different sizes and locations, with lost anterior chamber, and 3 eyes of another 3 patients (the last 3 in Table 1 ) were presented with severe corneal thinning (deep resistant corneal ulcers). Clinical evaluation was done with slit-lamp examination, and both Seidel and fluorescein tests were performed (in small perforations and deep ulcers), and intraocular infection was excluded; then AS-OCT was done for all cases. Emergency surgeries within 24 hours for perforations were scheduled, while cases with thin corneas were prepared to be performed within 48 hours of examination and decision. To prepare AMG, the placentas were obtained after elective cesarean section from mothers who had been tested as negative for human immunodeficiency virus (HIV), syphilis, hepatitis B virus (HBsAg), hepatitis C virus (HCV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The amniotic membrane was prepared from a fresh placenta under sterile conditions. The placenta was taken under a laminar flow hood with all sterile precautions. Blood clots are removed by rinsing them with a balanced salt solution (BSS), which contains 100 µg/ml of neomycin, 50 µg/ml of penicillin, 50 µg/ml of streptomycin, and 2.5 µg/ml of amphotericin B. AMG was placed in tissue culture and glycerol at a ratio of 1:1. To prepare PRP clots, 60 ml of blood from patients was sent to the laboratory, where the blood sample was divided into two tubes and sodium citrate was added to prevent coagulation. At 5˚C, centrifugation was done for about 10 minutes. After plasma separation, the lower part is used and divided into two parts to create the clot and the eye drops. The part for the clot is placed in tissue culture plates, and after adding 10% calcium chloride, the plates are incubated for 30 min at 37˚C.. The clot was transferred directly for use in the surgical operation room [ 7 ]. All patients were administered moxifloxacin HCL 0.5% ophthalmic solution (Vigamox, ALCON, Egypt) every 1 hour till starting the procedure. Surgeries were performed by (AMK). Most surgeries were performed under general anesthesia (10 patients) and (3 cases) under surface anesthesia in the form of Benoxinate hydrochloride 0.4% eye drops. Surgical procedure : Under complete aseptic conditions, sterilization of the eyelids and conjunctival sac was done using 10% povidone-iodine aqueous solution. A wire speculum was used for proper exposure of the eye. Removal of any necrotic tissue was done. The AMG was fashioned in a proper circular or oval shape with a diameter of at least 2 mm larger than that of the corneal perforation or targeted thin area, then 10 − 0 nylon sutures were used to fix the AMG to the underlying corneal or limbal tissue leaving upper gap window from where the PRP clot was introduced under the AMG then the last upper suture was done. Using a 27-gauge air-filled syringe, the anterior chamber was formed in cases of corneal perforation (Fig. 1), then a contact lens was applied. Post-operative treatment was moxifloxacin HCL 0.5% ophthalmic solution (Vigamox, Alcon Co.) 5 times daily for all patients, doxycycline hydrochloride 100mg capsules (Vibramycin, Pfizer Co.), acetazolamide 250mg tablets (Cidamex, CID co.) twice daily for patients after intracameral air injection, and preservative free lubricant eye drops in the form of sodium hyaluronate 1 mg, carboxymethylcellulose 5 mg, glycerin 9 mg (polyfresh extra single dose units, Orchidia) [ 6 ]. Follow-up visits were done on day 1 and 3 postoperative then weekly for 4 weeks and in each visit slit lamp examination was done, and AS-OCT was performed 1 week and 1 month after surgery. AS-OCT Examination The anterior segment imaging was performed by using spectral-domain optical coherence tomography (SD-OCT) (RTVue model-RT100 CAM System, version 6.2; Optovue, Inc., Fremont, CA), after applying the cornea/anterior module (CAM) lens. The CAM lens has a 10-mm working distance and is a wide-angle, high-magnification lens. With this method, the scan beam had a wavelength of 840 to 10 nm, an axial resolution of 5 µm, and a lateral resolution of 8 µm. The scanning protocol was a line scan at the center of the corneal lesion. At each visit, high-resolution AS-OCT scans were performed through the same region. The main study outcome was assessment of healing of corneal perforation or thinning and confirmation of anterior chamber reformation by AS-OCT. RESULTS The study included 13 patients (8 males and 5 females) aged 33–72 years. All cases were regular in their follow-up visits; slit lamp examination showed formation of the anterior chamber in all cases and intraocular pressure was digitally formed. Despite successful separation of the iris from the cornea with the intracameral injection of air at the end of surgery (Fig. 1), 3 cases with previous paracentral and peripheral corneal perforations show focal peripheral anterior synechia. Intraocular pressure was digitally high in the 1st postoperative day in 5 patients with intracameral air injection, and acetazolamide 250mg tablets (Cidamex, CID, Egypt) prescription was elevated to became 4 times daily and in all 5 cases it returns to normal on the 3rd day post-operative with small intracameral air bubble in 2 cases of them. There was no evidence of corneal infection or intraocular inflammation. Regarding visual acuity as shown in Table 1 , cases show the same preoperative visual acuity, and 1 case (case 3) with a peripheral perforated ulcer that showed a decrease in visual acuity may be due to added astigmatism. All patients suffered different degrees of foreign body sensation and lacrimation, which disappeared after 1 week. AMG was dissolved within 4 weeks of surgery, leaving clean corneal scarring at the site of perforation or thinning (Fig. 2). The nylon sutures were removed after 1 month of surgery. AS-OCT was done in all cases on the 1st and 4th weeks of follow-up and confirmed complete healing of the corneal perforation or ulceration (Figs. 3, 4). Two of the included cases in this study (till now) underwent penetrating keratoplasty with satisfying visual results, and 9 other cases are on the waiting list, while two of them are not in need (peripheral perforation). Table 1 Clinical data and post-operative outcomes Case number Gender Age (year) Corneal pathology Etiological factor Preoperative visual acuity (Snellen) Postoperative visual acuity (Snellen) Healing by AS-OCT 1 M 69 perforation Fungal HM HM complete 2 F 63 perforation Fungal HM HM complete 3 F 42 perforation immunologic 0.8 0.7 complete 4 M 72 perforation Bacterial HM HM complete 5 F 45 perforation Fungal HM HM complete 6 M 33 perforation Traumatic CF CF complete 7 M 59 perforation Fungal HM HM complete 8 M 57 perforation Bacterial HM HM complete 9 M 47 perforation Fungal HM HM complete 10 F 68 perforation Fungal CF CF complete 11 M 56 thinning Fungal CF CF complete 12 F 41 thinning immunologic 0.6 0.6 complete 13 M 69 thinning neurotrophic HM HM complete HM: Hand movement, CF: Counting fingers, M: Male, F: Female, ASOCT: Anterior segment optical coherence tomography. DISCUSSION The amniotic membrane is the innermost layer of the placenta, consisting of a single epithelial layer that is metabolically active with an underlying thick basement membrane and an avascular stromal matrix. AMG is usually used in combination with the standard antimicrobial treatment as a second-line therapy in infectious keratitis, promoting corneal healing [ 5 ]. Platelet-rich plasma (PRP) is rich with growth factors after filtering out leukocytes and has wound-healing and biological properties. PRP clot acts as cement to seal corneal perforations. Combination of AMG and PRP clots may help in cases with corneal perforations through sealing of the perforation and promoting healing [ 6 , 8 ]. Assessment of the healing process using anterior segment optical coherence tomography (AS-OCT) is helpful as a quantitative method, especially with the presence of amniotic membrane graft and platelet-rich plasma clot, which can obscure full clinical evaluation [ 9 , 10 ]. Size and site of corneal perforation or thinning are the main factors in the decision of management. According to size, perforations can be classified into small (less than 2.5 mm), which is the target perforation of this case series, large (more than 5 mm), and medium in between. According to the site, they can be classified into central within a circle around the visual axis of 5 mm diameter, paracentral extending to an 8 mm circle diameter, and peripheral reaching and including the limbus. Regarding these classifications, the treatment modality can be chosen. For large perforations, penetrating keratoplasty was the preferred surgical approach. Small and medium perforations and deep corneal ulcers can be treated with corneoscleral patch graft, AMG, or autologous plasma rich in growth factors, fibrin membrane (mPRGF). For peripheral perforations, a tight conjunctival flap and the previous modalities can be used. Anterior lamellar keratoplasty can be used to treat deep ulcers and leaking descemetoceles. AMG and plasma rich in growth factors, when available, are preferred in all corneal defects. [ 11 – 13 ] AMG has many advantages, including a lack of graft rejection, availability, and its desired biological properties, including wound healing, antimicrobial activity, anti-inflammatory activity, and anti-angiogenic properties. [ 14 ] Platelet-rich plasma clot has two benefits, one of them is mechanical and physical with its clot form, which helps sealing in case of perforations till healing takes place, and the second is biological as Platelets can promote healing of epithelial and stromal tissues with their high content of growth factors. [ 15 ] Regarding corneal perforations, previous studies have used autologous fibrin membrane and bovine pericardium membrane with PRP, and the results were comparable with the advantage of AMG over them being rapidly and easily prepared with the progress in its preservation and not expensive as the bovine pericardium and so it may be a good choice in urgent cases. Another study included 15 eyes with different ocular surface pathologies including corneal perforations underwent successful placement of autologous plasma rich in growth factors fibrin membrane (mPRGF) with total healing of the corneal defects in 13/15 (86.7%) and the other 2 cases was partially healed which is also comparable with this case series and the difference of total healing percentage may be due to superiority of this combination of AMG and PRP clot or the variety of diseases treated with mPRGF. Another comparable study used synthetic AMG and PRP clot in corneal perforations, only with excellent results, which support the results of this series. [ 6 , 11 , 16 , 17 ] A bandage contact lens was applied at the end of the procedure to decrease irritation symptoms and to protect the AMG. Doxycycline hydrochloride was prescribed postoperatively as it has anti-matrix metalloproteinase activity. [ 16 ] OCT is a noncontact in vivo ocular imaging technology that uses low-coherence interferometry. Several corneal parameters can be quantitatively evaluated by AS-OCT because of its noncontact, high-resolution, and cross-sectional examination [ 18 ]. Anterior segment OCT (AS-OCT) can efficiently image different corneal pathologies with ultra-high-resolution images, which can be described as an “optical biopsy.” This noninvasive and rapid technology is well-tolerated by patients. The role of AS-OCT in evaluating our cases was essential because the AMG is semi-opaque, especially with the underlying PRP clot, making this an invaluable diagnostic tool for monitoring the healing process in such cases. [ 19 ] Conclusion We can conclude that AS-OCT in the assessment of healing of resistant corneal defects and perforations with a combination of AMG and PRP clot is mandatory and that this surgery can provide an effective method as a primary management. Abbreviations AMG: Amniotic membrane graft AS-OCT: Anterior segment optical coherence tomography BSS: Balanced salt solution CAM: Cornea/anterior module CF: Counting fingers F: Female HBV: Hepatitis B virus HCV: Hepatitis C virus HM: Hand movement HIV: Human immunodeficiency virus IK: Infectious keratitis M: Male PRP: Platelet-rich plasma SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2 SD-OCT: Spectral-domain optical coherence tomography Declarations Ethical approval : The study was approved by the Ethics Committee, Faculty of Medicine, Minia University, El-Minya, Egypt (No. 1133/04/2024). The study was registered in Clinical Trials.gov with NCT06422897. This study adhered to the principles outlined in the Declaration of Helsinki. Consent to participate: All patients signed informed consent after explaining the eye condition, and the importance of the procedure and associated risk or complications. Consent to publish: Not applicable Availability of data and materials : The data sets used and/or analyzed during the current study are included in the manuscript and available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: No funding Authors' contributions: AMK Conception and design of the study Surgical intervention Data collection Analysis and interpretation of data Writing the manuscript Critical revision of the article Final approval of the article Provision of materials Literature search AAA Conception and design of the study Data collection Analysis and interpretation of data Critical revision of the article Final approval of the article Provision of materials Literature search JA Conception and design of the study Critical revision of the article Final approval of the article AA Conception and design of the study Critical revision of the article Final approval of the article MS Conception and design of the study Data collection Analysis and interpretation of data Critical revision of the article Final approval of the article Provision of materials Literature search References Deshmukh R, Stevenson LJ, Vajpayee R. Management of corneal perforations: An update. Indian Journal of Ophthalmology. 2020 Jan;68(1):7. Ting DS, Ho CS, Deshmukh R, Said DG, Dua HS. Infectious keratitis: an update on epidemiology, causative microorganisms, risk factors, and antimicrobial resistance. Eye. 2021 Apr;35(4):1084-101. Lin L, Duan F, Yang Y, Lou B, Liang L, Lin X. Nine-year analysis of isolated pathogens and antibiotic susceptibilities of microbial keratitis from a large referral eye center in southern China. Infection and Drug Resistance. 2019 May;15:1295-302. Khoo, P., Cabrera-Aguas, M. P., Nguyen, V., Lahra, M. M. & Watson, S. L. Microbial keratitis in Sydney, Australia: risk factors, patient outcomes, and seasonal variation. Graefes Arch. Clin. Exp. Ophthalmol. 2020; 258 (8), 1745–1755. Liu J, Li L, Li X. Effectiveness of cryopreserved amniotic membrane transplantation in corneal ulceration: a meta-analysis. Cornea. 2019 Apr 1;38(4):454-62. Abdelghany AA, Bahrawy ME, Alio JL. Combined platelet rich plasma and amniotic membrane in the treatment of perforated corneal ulcers. European Journal of Ophthalmology. 2022 Jul;32(4):2148-52. Jorge L. Alió, Francisco Arnalich-Montiel, Alejandra E. Rodriguez. The Role of “Eye Platelet Rich Plasma” (E-Prp) for Wound Healing in Ophthalmology. Current Pharmaceutical Biotechnology, 2012, 13, 1257-1265. Anitua E, De la Fuente M, Muruzabal F, Riestra A, Merayo-Lloves J, Orive G. Plasma rich in growth factors (PRGF) eye drops stimulates scarless regeneration compared to autologous serum in the ocular surface stromal fibroblasts. Experimental eye research. 2015 Jun 1;135:118-26. Gupta N, Varshney A, Ramappa M, Basu S, Romano V, Acharya M, Gaur A, Kapur N, Singh A, Shah G, Chaudhary I. Role of AS-OCT in managing corneal disorders. Diagnostics. 2022 Apr 7;12(4):918. Abdelghany AA, Alio JL, AttaAllah HR. Role of Anterior Segment Optical Coherence Tomography in Staging and Evaluation of Treatment Response in Infectious Keratitis. Cornea. 2022 May 13:10-97. Sabater, A. L., Mousa, H. M., Quinones, X., Valenzuela, F., Sanchez Avila, R. M., Orive, G., ... & Perez, V. L. Use of autologous plasma rich in growth factors fibrin membrane in the surgical management of ocular surface diseases. International ophthalmology.2021; 41, 2347-2358. ‏ Krysik, K., Dobrowolski, D., Lyssek-Boron, A., Jankowska-Szmul, J., & Wylegala, E. A. Differences in surgical management of corneal perforations, measured over six years. Journal of ophthalmology. 2017(1), 1582532. ‏ Ting, D. S. J., Henein, C., Said, D. G., & Dua, H. S. Amniotic membrane transplantation for infectious keratitis: a systematic review and meta-analysis. Scientific Reports.2021; 11(1), 13007. ‏ Dua, H. S., Gomes, J. A., King, A. J., & Maharajan, V. S. The amniotic membrane in ophthalmology. Survey of ophthalmology .2004; 49 (1), 51-77. ‏ Nurden, A. T. Platelets, inflammation and tissue regeneration. Thrombosis and haemostasis .2011; 105 (S 06), S13-S33. ‏ Alio JL, Rodriguez AE and Martinez LM. Bovine pericardium membrane (tutopatch) combined With solid platelet-rich plasma for the management of perforated corneal ulcers. Cornea 2013; 32: 619–624. Alio JL, Rodriguez AE, Martinez LM, et al. Autologous fibrin membrane combined with solid platelet-rich plasma in the management of perforated corneal ulcers: a pilot study. JAMA Ophthalmol 2013 Jun; 131: 745–751. Wang SB, Cornish EE, Grigg JR, et al. Anterior segment optical coherence tomography and its clinical applications. Clin Exp Optom. 2019;102:195–207. Yim M, Galor A, Nanji A, et al. Ability of novice clinicians to interpret high-resolution optical coherence tomography for ocular surface lesions. Canadian Journal of Ophthalmology. 2018 Apr; 53(2):150-154. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Dec, 2025 Read the published version in BMC Ophthalmology → Version 1 posted Editorial decision: Revision requested 11 Oct, 2025 Reviews received at journal 21 Sep, 2025 Reviews received at journal 19 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviews received at journal 07 Sep, 2025 Reviewers agreed at journal 06 Sep, 2025 Reviewers invited by journal 04 Sep, 2025 Editor invited by journal 14 Aug, 2025 Editor assigned by journal 10 Jul, 2025 Submission checks completed at journal 10 Jul, 2025 First submitted to journal 09 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7083809","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512516631,"identity":"2ee221c8-2b70-4110-a2bc-cb587075ed8b","order_by":0,"name":"Ahmed M Khalafallah","email":"data:image/png;base64,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","orcid":"","institution":"Minia University","correspondingAuthor":true,"prefix":"","firstName":"Ahmed","middleName":"M","lastName":"Khalafallah","suffix":""},{"id":512516632,"identity":"897a2443-e30c-4e30-a43f-0fedde9911fd","order_by":1,"name":"Ahmed A. 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Abdelmonem","email":"","orcid":"","institution":"Minia University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"A.","lastName":"Abdelmonem","suffix":""},{"id":512516638,"identity":"a24db6ed-d61e-4b73-bff6-8e42b18a77b7","order_by":4,"name":"Mohamed Salah El-Din","email":"","orcid":"","institution":"Minia University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Salah","lastName":"El-Din","suffix":""}],"badges":[],"createdAt":"2025-07-09 12:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7083809/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7083809/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12886-025-04495-w","type":"published","date":"2025-12-01T15:58:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91076242,"identity":"b437086e-db80-4dd4-9dc7-a7337f8d1b7f","added_by":"auto","created_at":"2025-09-11 11:09:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":324301,"visible":true,"origin":"","legend":"\u003cp\u003eA case of central corneal perforation; preoperative (a), and immediately postoperative (b) with amniotic membrane and PRP clot underneath and anterior chamber formed with air.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7083809/v1/ee67af040059ccb11f5a60a5.png"},{"id":91076243,"identity":"6d877d69-2c40-4461-90b9-7e97d4b60c75","added_by":"auto","created_at":"2025-09-11 11:09:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":323943,"visible":true,"origin":"","legend":"\u003cp\u003eA case on the 4th postoperative week showing clean corneal scar by slit lamp examination (a), and Anterior segment OCT showing complete healing with a strong scar (b).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7083809/v1/7cca9ce83ecb22af02b88097.png"},{"id":91077976,"identity":"e896261a-c35d-4717-b241-6453757472df","added_by":"auto","created_at":"2025-09-11 11:17:19","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":155578,"visible":true,"origin":"","legend":"\u003cp\u003eAnterior segment OCT for a case with central traumatic corneal perforation; preoperative with lost anterior chamber (a), 1 week postoperative with partial corneal healing and formed anterior chamber (b). 1 month postoperative with complete corneal healing (c).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7083809/v1/5b89edc3999b9acb3684fa89.png"},{"id":91077978,"identity":"a4949bc2-52ca-4540-ade6-5bf21e000ad0","added_by":"auto","created_at":"2025-09-11 11:17:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":151449,"visible":true,"origin":"","legend":"\u003cp\u003eAnterior segment OCT for a case with central corneal perforation post infective keratitis; preoperative with lost anterior chamber (a), 1 week postoperative with partial corneal healing and formed anterior chamber (b). 1 month postoperative with complete corneal healing (c).\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7083809/v1/e1a9ac8856a8be4b5c318e2f.png"},{"id":97723929,"identity":"e95875cf-ec56-4d97-ba8d-ffdb1618e25c","added_by":"auto","created_at":"2025-12-08 16:09:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1501519,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7083809/v1/d10f3b44-9e5b-405b-84f3-3ecf8c37aabb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Role of AS-OCT in Assessment of Healing of Thin or Perforated Cornea Treated by Amniotic Membrane Graft and PRP Clot","fulltext":[{"header":"Background","content":"\u003cp\u003eCorneal thinning or even perforation may follow corneal infection if not adequately treated. Ulcerations or even perforations may negatively affect the visual abilities of the affected eye, causing what is called corneal blindness. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eInfectious keratitis (IK) has been considered the most common cause of corneal blindness, with higher incidence in developing countries, causing thinning or even perforation of the cornea, especially with low socioeconomic status [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The incidence ranges between 2.5 to 799 per 100,000 population per year. It is a painful and potentially blinding ocular disease that may require hospital admission. The main causative microorganisms are bacteria and fungi (especially in rural areas), followed by viruses and parasites. In mild and moderate cases, broad-spectrum topical antimicrobial therapy is effective alone, but in severe and resistant cases, other additive procedures may be needed, such as corneal cross-linking, corneal gluing, amniotic membrane grafting (AMG), and finally therapeutic keratoplasty [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOther causes of corneal ulcerations and perforations include autoimmune disorders, ocular surface diseases, and penetrating trauma. Autoimmune disorders and ocular surface diseases usually cause perforations associated with secondary infectious keratitis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUrgent management with surgical intervention of complicated ulcers or perforations is necessary to save the eye.\u003c/p\u003e\u003cp\u003eTreatment modalities prescribed before with good results are amniotic membrane graft (AMG) and platelet-rich plasma (PRP) clot [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe aim of this study is to assess the healing of corneal perforations or thinning by the use of anterior segment optical coherence tomography (AS-OCT) in a consecutive series of cases.\u003c/p\u003e"},{"header":"PATIENTS AND METHODS","content":"\u003cp\u003eThis study was a prospective consecutive interventional non-randomized clinical series of cases. 13 cases were included (8 males and 5 females), and the study was conducted from the 15th of April 2024 to the 5th of September 2024.\u003c/p\u003e\u003cp\u003e10 eyes of 10 patients were presented with corneal perforations of different sizes and locations, with lost anterior chamber, and 3 eyes of another 3 patients (the last 3 in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) were presented with severe corneal thinning (deep resistant corneal ulcers). Clinical evaluation was done with slit-lamp examination, and both Seidel and fluorescein tests were performed (in small perforations and deep ulcers), and intraocular infection was excluded; then AS-OCT was done for all cases. Emergency surgeries within 24 hours for perforations were scheduled, while cases with thin corneas were prepared to be performed within 48 hours of examination and decision.\u003c/p\u003e\u003cp\u003eTo prepare AMG, the placentas were obtained after elective cesarean section from mothers who had been tested as negative for human immunodeficiency virus (HIV), syphilis, hepatitis B virus (HBsAg), hepatitis C virus (HCV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The amniotic membrane was prepared from a fresh placenta under sterile conditions. The placenta was taken under a laminar flow hood with all sterile precautions. Blood clots are removed by rinsing them with a balanced salt solution (BSS), which contains 100 µg/ml of neomycin, 50 µg/ml of penicillin, 50 µg/ml of streptomycin, and 2.5 µg/ml of amphotericin B. AMG was placed in tissue culture and glycerol at a ratio of 1:1.\u003c/p\u003e\u003cp\u003eTo prepare PRP clots, 60 ml of blood from patients was sent to the laboratory, where the blood sample was divided into two tubes and sodium citrate was added to prevent coagulation. At 5˚C, centrifugation was done for about 10 minutes. After plasma separation, the lower part is used and divided into two parts to create the clot and the eye drops. The part for the clot is placed in tissue culture plates, and after adding 10% calcium chloride, the plates are incubated for 30 min at 37˚C.. The clot was transferred directly for use in the surgical operation room [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAll patients were administered moxifloxacin HCL 0.5% ophthalmic solution (Vigamox, ALCON, Egypt) every 1 hour till starting the procedure.\u003c/p\u003e\u003cp\u003eSurgeries were performed by (AMK). Most surgeries were performed under general anesthesia (10 patients) and (3 cases) under surface anesthesia in the form of Benoxinate hydrochloride 0.4% eye drops.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSurgical procedure\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eUnder complete aseptic conditions, sterilization of the eyelids and conjunctival sac was done using 10% povidone-iodine aqueous solution. A wire speculum was used for proper exposure of the eye. Removal of any necrotic tissue was done. The AMG was fashioned in a proper circular or oval shape with a diameter of at least 2 mm larger than that of the corneal perforation or targeted thin area, then 10 − 0 nylon sutures were used to fix the AMG to the underlying corneal or limbal tissue leaving upper gap window from where the PRP clot was introduced under the AMG then the last upper suture was done. Using a 27-gauge air-filled syringe, the anterior chamber was formed in cases of corneal perforation (Fig.\u0026nbsp;1), then a contact lens was applied. Post-operative treatment was moxifloxacin HCL 0.5% ophthalmic solution (Vigamox, Alcon Co.) 5 times daily for all patients, doxycycline hydrochloride 100mg capsules (Vibramycin, Pfizer Co.), acetazolamide 250mg tablets (Cidamex, CID co.) twice daily for patients after intracameral air injection, and preservative free lubricant eye drops in the form of sodium hyaluronate 1 mg, carboxymethylcellulose 5 mg, glycerin 9 mg (polyfresh extra single dose units, Orchidia) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFollow-up visits were done on day 1 and 3 postoperative then weekly for 4 weeks and in each visit slit lamp examination was done, and AS-OCT was performed 1 week and 1 month after surgery.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAS-OCT Examination\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe anterior segment imaging was performed by using spectral-domain optical coherence tomography (SD-OCT) (RTVue model-RT100 CAM System, version 6.2; Optovue, Inc., Fremont, CA), after applying the cornea/anterior module (CAM) lens. The CAM lens has a 10-mm working distance and is a wide-angle, high-magnification lens. With this method, the scan beam had a wavelength of 840 to 10 nm, an axial resolution of 5 µm, and a lateral resolution of 8 µm.\u003c/p\u003e\u003cp\u003eThe scanning protocol was a line scan at the center of the corneal lesion. At each visit, high-resolution AS-OCT scans were performed through the same region.\u003c/p\u003e\u003cp\u003eThe main study outcome was assessment of healing of corneal perforation or thinning and confirmation of anterior chamber reformation by AS-OCT.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study included 13 patients (8 males and 5 females) aged 33\u0026ndash;72 years. All cases were regular in their follow-up visits; slit lamp examination showed formation of the anterior chamber in all cases and intraocular pressure was digitally formed. Despite successful separation of the iris from the cornea with the intracameral injection of air at the end of surgery (Fig.\u0026nbsp;1), 3 cases with previous paracentral and peripheral corneal perforations show focal peripheral anterior synechia. Intraocular pressure was digitally high in the 1st postoperative day in 5 patients with intracameral air injection, and acetazolamide 250mg tablets (Cidamex, CID, Egypt) prescription was elevated to became 4 times daily and in all 5 cases it returns to normal on the 3rd day post-operative with small intracameral air bubble in 2 cases of them. There was no evidence of corneal infection or intraocular inflammation.\u003c/p\u003e\u003cp\u003eRegarding visual acuity as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, cases show the same preoperative visual acuity, and 1 case (case 3) with a peripheral perforated ulcer that showed a decrease in visual acuity may be due to added astigmatism.\u003c/p\u003e\u003cp\u003eAll patients suffered different degrees of foreign body sensation and lacrimation, which disappeared after 1 week. AMG was dissolved within 4 weeks of surgery, leaving clean corneal scarring at the site of perforation or thinning (Fig.\u0026nbsp;2). The nylon sutures were removed after 1 month of surgery. AS-OCT was done in all cases on the 1st and 4th weeks of follow-up and confirmed complete healing of the corneal perforation or ulceration (Figs.\u0026nbsp;3, 4). Two of the included cases in this study (till now) underwent penetrating keratoplasty with satisfying visual results, and 9 other cases are on the waiting list, while two of them are not in need (peripheral perforation).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical data and post-operative outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv 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colname=\"c6\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eperforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTraumatic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" 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colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eperforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBacterial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eperforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFungal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eperforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFungal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ethinning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFungal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ethinning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eimmunologic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ethinning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eneurotrophic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eHM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ecomplete\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHM: Hand movement, CF: Counting fingers, M: Male, F: Female, ASOCT: Anterior segment optical coherence tomography.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe amniotic membrane is the innermost layer of the placenta, consisting of a single epithelial layer that is metabolically active with an underlying thick basement membrane and an avascular stromal matrix. AMG is usually used in combination with the standard antimicrobial treatment as a second-line therapy in infectious keratitis, promoting corneal healing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePlatelet-rich plasma (PRP) is rich with growth factors after filtering out leukocytes and has wound-healing and biological properties. PRP clot acts as cement to seal corneal perforations. Combination of AMG and PRP clots may help in cases with corneal perforations through sealing of the perforation and promoting healing [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAssessment of the healing process using anterior segment optical coherence tomography (AS-OCT) is helpful as a quantitative method, especially with the presence of amniotic membrane graft and platelet-rich plasma clot, which can obscure full clinical evaluation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSize and site of corneal perforation or thinning are the main factors in the decision of management. According to size, perforations can be classified into small (less than 2.5 mm), which is the target perforation of this case series, large (more than 5 mm), and medium in between. According to the site, they can be classified into central within a circle around the visual axis of 5 mm diameter, paracentral extending to an 8 mm circle diameter, and peripheral reaching and including the limbus. Regarding these classifications, the treatment modality can be chosen. For large perforations, penetrating keratoplasty was the preferred surgical approach. Small and medium perforations and deep corneal ulcers can be treated with corneoscleral patch graft, AMG, or autologous plasma rich in growth factors, fibrin membrane (mPRGF). For peripheral perforations, a tight conjunctival flap and the previous modalities can be used. Anterior lamellar keratoplasty can be used to treat deep ulcers and leaking descemetoceles. AMG and plasma rich in growth factors, when available, are preferred in all corneal defects. [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAMG has many advantages, including a lack of graft rejection, availability, and its desired biological properties, including wound healing, antimicrobial activity, anti-inflammatory activity, and anti-angiogenic properties. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e\u003cp\u003ePlatelet-rich plasma clot has two benefits, one of them is mechanical and physical with its clot form, which helps sealing in case of perforations till healing takes place, and the second is biological as Platelets can promote healing of epithelial and stromal tissues with their high content of growth factors. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eRegarding corneal perforations, previous studies have used autologous fibrin membrane and bovine pericardium membrane with PRP, and the results were comparable with the advantage of AMG over them being rapidly and easily prepared with the progress in its preservation and not expensive as the bovine pericardium and so it may be a good choice in urgent cases. Another study included 15 eyes with different ocular surface pathologies including corneal perforations underwent successful placement of autologous plasma rich in growth factors fibrin membrane (mPRGF) with total healing of the corneal defects in 13/15 (86.7%) and the other 2 cases was partially healed which is also comparable with this case series and the difference of total healing percentage may be due to superiority of this combination of AMG and PRP clot or the variety of diseases treated with mPRGF. Another comparable study used synthetic AMG and PRP clot in corneal perforations, only with excellent results, which support the results of this series. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eA bandage contact lens was applied at the end of the procedure to decrease irritation symptoms and to protect the AMG. Doxycycline hydrochloride was prescribed postoperatively as it has anti-matrix metalloproteinase activity. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOCT is a noncontact in vivo ocular imaging technology that uses low-coherence interferometry. Several corneal parameters can be quantitatively evaluated by AS-OCT because of its noncontact, high-resolution, and cross-sectional examination [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Anterior segment OCT (AS-OCT) can efficiently image different corneal pathologies with ultra-high-resolution images, which can be described as an \u0026ldquo;optical biopsy.\u0026rdquo; This noninvasive and rapid technology is well-tolerated by patients. The role of AS-OCT in evaluating our cases was essential because the AMG is semi-opaque, especially with the underlying PRP clot, making this an invaluable diagnostic tool for monitoring the healing process in such cases. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe can conclude that AS-OCT in the assessment of healing of resistant corneal defects and perforations with a combination of AMG and PRP clot is mandatory and that this surgery can provide an effective method as a primary management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAMG: Amniotic membrane graft\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAS-OCT:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAnterior segment optical coherence tomography\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBSS: Balanced salt solution\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCAM: Cornea/anterior module\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCF: Counting fingers\u003c/p\u003e\n\u003cp\u003eF: Female\u003c/p\u003e\n\u003cp\u003eHBV: Hepatitis B virus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHCV: Hepatitis C virus\u003c/p\u003e\n\u003cp\u003eHM: Hand movement\u003c/p\u003e\n\u003cp\u003eHIV: Human immunodeficiency virus\u003c/p\u003e\n\u003cp\u003eIK: Infectious keratitis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eM: Male\u003c/p\u003e\n\u003cp\u003ePRP: Platelet-rich plasma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSARS-CoV-2: Severe acute respiratory syndrome coronavirus 2\u003c/p\u003e\n\u003cp\u003eSD-OCT: Spectral-domain optical coherence tomography\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eThe study was approved by the Ethics Committee, Faculty of Medicine, Minia University, El-Minya, Egypt (No. 1133/04/2024).\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eThe study was registered in Clinical Trials.gov with NCT06422897.\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eThis study adhered to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003eConsent to participate:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eAll patients signed informed consent after explaining the eye condition, and the importance of the procedure and associated risk or complications.\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003eConsent to publish:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eNot applicable\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eThe data sets used and/or analyzed during the current study are included in the manuscript and available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003eNo funding\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cem\u003e\u003cspan dir=\"LTR\"\u003eAuthors\u0026apos; contributions:\u003c/span\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003eAMK\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConception and design of the study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eSurgical intervention\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eData collection\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAnalysis and interpretation of data\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eWriting the manuscript\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eCritical revision of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eFinal approval of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eProvision of materials\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eLiterature search\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003eAAA\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConception and design of the study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eData collection\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAnalysis and interpretation of data\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eCritical revision of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eFinal approval of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eProvision of materials\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eLiterature search\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cstrong\u003e\u003cspan dir=\"LTR\"\u003eJA\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConception and design of the study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eCritical revision of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eFinal approval of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003eAA\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConception and design of the study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eCritical revision of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eFinal approval of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: left;\"\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eConception and design of the study\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eData collection\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eAnalysis and interpretation of data\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eCritical revision of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eFinal approval of the article\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eProvision of materials\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\" style=\"text-align: left;\"\u003e\u003cspan dir=\"LTR\"\u003eLiterature search\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDeshmukh R, Stevenson LJ, Vajpayee R. Management of corneal perforations: An update. Indian Journal of Ophthalmology. 2020 Jan;68(1):7.\u003c/li\u003e\n\u003cli\u003eTing DS, Ho CS, Deshmukh R, Said DG, Dua HS. Infectious keratitis: an update on epidemiology, causative microorganisms, risk factors, and antimicrobial resistance. Eye. 2021 Apr;35(4):1084-101.\u003c/li\u003e\n\u003cli\u003eLin L, Duan F, Yang Y, Lou B, Liang L, Lin X. Nine-year analysis of isolated pathogens and antibiotic susceptibilities of microbial keratitis from a large referral eye center in southern China. Infection and Drug Resistance. 2019 May;15:1295-302.\u003c/li\u003e\n\u003cli\u003eKhoo, P., Cabrera-Aguas, M. P., Nguyen, V., Lahra, M. M. \u0026amp; Watson, S. L. Microbial keratitis in Sydney, Australia: risk factors, patient outcomes, and seasonal variation. \u003cem\u003eGraefes Arch. Clin. Exp. Ophthalmol.\u003c/em\u003e2020; \u003cstrong\u003e258\u003c/strong\u003e(8), 1745\u0026ndash;1755.\u003c/li\u003e\n\u003cli\u003eLiu J, Li L, Li X. Effectiveness of cryopreserved amniotic membrane transplantation in corneal ulceration: a meta-analysis. Cornea. 2019 Apr 1;38(4):454-62.\u003c/li\u003e\n\u003cli\u003eAbdelghany AA, Bahrawy ME, Alio JL. Combined platelet rich plasma and amniotic membrane in the treatment of perforated corneal ulcers. European Journal of Ophthalmology. 2022 Jul;32(4):2148-52.\u003c/li\u003e\n\u003cli\u003e\u003cspan dir=\"LTR\"\u003e Jorge L. Ali\u0026oacute;, Francisco Arnalich-Montiel, Alejandra E. Rodriguez. The Role of \u0026ldquo;Eye Platelet Rich Plasma\u0026rdquo; (E-Prp) for Wound Healing in Ophthalmology. Current Pharmaceutical Biotechnology, 2012, 13, 1257-1265.\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAnitua E, De la Fuente M, Muruzabal F, Riestra A, Merayo-Lloves J, Orive G. Plasma rich in growth factors (PRGF) eye drops stimulates scarless regeneration compared to autologous serum in the ocular surface stromal fibroblasts. Experimental eye research. 2015 Jun 1;135:118-26.\u003c/li\u003e\n\u003cli\u003eGupta N, Varshney A, Ramappa M, Basu S, Romano V, Acharya M, Gaur A, Kapur N, Singh A, Shah G, Chaudhary I. Role of AS-OCT in managing corneal disorders. Diagnostics. 2022 Apr 7;12(4):918.\u003c/li\u003e\n\u003cli\u003eAbdelghany AA, Alio JL, AttaAllah HR. Role of Anterior Segment Optical Coherence Tomography in Staging and Evaluation of Treatment Response in Infectious Keratitis. Cornea. 2022 May 13:10-97.\u003c/li\u003e\n\u003cli\u003eSabater, A. L., Mousa, H. M., Quinones, X., Valenzuela, F., Sanchez Avila, R. M., Orive, G., ... \u0026amp; Perez, V. L. Use of autologous plasma rich in growth factors fibrin membrane in the surgical management of ocular surface diseases. International ophthalmology.2021; 41, 2347-2358.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eKrysik, K., Dobrowolski, D., Lyssek-Boron, A., Jankowska-Szmul, J., \u0026amp; Wylegala, E. A. Differences in surgical management of corneal perforations, measured over six years. Journal of ophthalmology. 2017(1), 1582532.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eTing, D. S. J., Henein, C., Said, D. G., \u0026amp; Dua, H. S. Amniotic membrane transplantation for infectious keratitis: a systematic review and meta-analysis. Scientific Reports.2021; 11(1), 13007.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eDua, H. S., Gomes, J. A., King, A. J., \u0026amp; Maharajan, V. S. The amniotic membrane in ophthalmology. \u003cem\u003eSurvey of ophthalmology\u003c/em\u003e.2004;\u003cem\u003e49\u003c/em\u003e(1), 51-77.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eNurden, A. T. Platelets, inflammation and tissue regeneration. \u003cem\u003eThrombosis and haemostasis\u003c/em\u003e.2011;\u003cem\u003e105\u003c/em\u003e(S 06), S13-S33.\u003cspan dir=\"RTL\"\u003e\u0026rlm;\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003eAlio JL, Rodriguez AE and Martinez LM. Bovine pericardium membrane (tutopatch) combined With solid platelet-rich plasma for the management of perforated corneal ulcers. Cornea 2013; 32: 619\u0026ndash;624.\u003c/li\u003e\n\u003cli\u003eAlio JL, Rodriguez AE, Martinez LM, et al. Autologous fibrin membrane combined with solid platelet-rich plasma in the management of perforated corneal ulcers: a pilot study. JAMA Ophthalmol 2013 Jun; 131: 745\u0026ndash;751.\u003c/li\u003e\n\u003cli\u003eWang SB, Cornish EE, Grigg JR, et al. Anterior segment optical coherence tomography and its clinical applications. Clin Exp Optom. 2019;102:195\u0026ndash;207.\u003c/li\u003e\n\u003cli\u003eYim M, Galor A, Nanji A, et al. Ability of novice clinicians to interpret high-resolution optical coherence tomography for ocular surface lesions. Canadian Journal of Ophthalmology. 2018 Apr; 53(2):150-154. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Corneal Perforation, Amniotic membrane, Platelet-rich plasma clot, Anterior segment optical coherence tomography","lastPublishedDoi":"10.21203/rs.3.rs-7083809/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7083809/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe purpose of the study is to evaluate the role of anterior segment optical coherence tomography in the assessment of the healing of corneal perforation after surgical treatment by amniotic membrane graft and platelet-rich plasma clot.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eProspective, consecutive clinical series of cases. 13 eyes of 13 patients with small corneal perforation or thinning were included in the study.\u003c/p\u003e\n\u003cp\u003eThe patients were surgically treated with an amniotic membrane graft (AMG) and a platelet-rich plasma (PRP) clot, and the anterior chamber was reformed using air. Anterior segment optical coherence tomography (AS-OCT) was performed 1 week and 1 month after the surgery to confirm corneal healing and to assess the anterior chamber.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll cases demonstrated the formation of the anterior chamber and adequate intraocular pressure digitally during the follow-up period, and all cases showed complete healing of the corneal perforation by AS-OCT within the 4-week follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAS-OCT is an essential tool to confirm healing of the corneal perforation surgically treated by amniotic membrane graft and platelet-rich plasma clot.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was registered in ClinicalTrials.gov on May 20, 2024, with NCT06422897.\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee, Faculty of Medicine, Minia University, El-Minya, Egypt (No. 1133/04/2024).\u003c/p\u003e\n\u003cp\u003eThis study adhered to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e","manuscriptTitle":"Role of AS-OCT in Assessment of Healing of Thin or Perforated Cornea Treated by Amniotic Membrane Graft and PRP Clot","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:09:14","doi":"10.21203/rs.3.rs-7083809/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-11T05:34:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T19:36:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T15:33:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281646792254172532978258622429372334031","date":"2025-09-13T15:39:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20628790041312759563689095411451579777","date":"2025-09-09T12:36:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T11:58:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313009392878551306342721894829617162811","date":"2025-09-06T09:49:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-04T08:54:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T06:56:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-10T12:17:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-10T12:15:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-07-09T12:14:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"69819418-f9ad-407d-bc79-874734e7e964","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:02:57+00:00","versionOfRecord":{"articleIdentity":"rs-7083809","link":"https://doi.org/10.1186/s12886-025-04495-w","journal":{"identity":"bmc-ophthalmology","isVorOnly":false,"title":"BMC Ophthalmology"},"publishedOn":"2025-12-01 15:58:01","publishedOnDateReadable":"December 1st, 2025"},"versionCreatedAt":"2025-09-11 11:09:14","video":"","vorDoi":"10.1186/s12886-025-04495-w","vorDoiUrl":"https://doi.org/10.1186/s12886-025-04495-w","workflowStages":[]},"version":"v1","identity":"rs-7083809","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7083809","identity":"rs-7083809","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}