Outcomes of Sclerokeratoplasty in Severe Ocular Surface Disease

Outcomes of Sclerokeratoplasty in Severe Ocular Surface Disease | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Outcomes of Sclerokeratoplasty in Severe Ocular Surface Disease Denise Loya-Garcia, David Jimenez-Collado, Aida Jimenez-Corona, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4573181/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Oct, 2024 Read the published version in Scientific Reports → Version 1 posted 12 You are reading this latest preprint version Abstract Sclerocorneal grafts are procedures considered in cases with extensive corneal and scleral tissue destruction. The study aims to describe sclerokeratoplasty outcomes in severely diseased eyes. We performed a retrospective review of clinical records. Demographic characteristics, medical history, surgical indications, aetiology of perforation, visual outcomes, complications associated with the surgical procedure, and ocular integrity at the end of the follow-up were obtained. Wilcoxon-signed rank tests and Mann-Whitney tests were used to compare complications between groups and outcomes at final follow-up. Survival analysis was performed to analyse vision preservation and global integrity and presented in Kaplan-Meier curves. 40 eyes from 40 patients with a mean age of 48.83 ± 18.85 years and a mean follow-up of 21.13 ± 33.92 months were included in the study. Median corrected visual acuity before and after the procedure remained at 2.8 logMAR. Twenty-seven eyes presented complications. The most common complications were a persistent epithelial defect in 11, hypertension in 10, and perforation in 8 eyes. More than half of the eyes (67.5%) presented with either one or more of all complications after corneoscleral graft. No significant differences were found regarding age, gender, or DM history. Concerning perforation, a significant difference was found between infectious and non-infectious only in the presentation of ocular hypertension (p = 0.048). Vision was preserved in 72.5% of the eyes, with a median survival probability of 4.12 years. Preservation of the ocular integrity was achieved in 85% of the eyes, with a median survival probability of 12 years. Sclerokeratoplasty despite being challenging and technically demanding followed by defiant complications, in some situations such as infectious keratitis and autoimmune diseases, is likely a procedure that salvages the eye and preserves vision. Health sciences/Diseases/Eye diseases/Corneal diseases Health sciences/Diseases/Eye diseases/Conjunctival diseases Sclerokeratoplasty Ocular Surface Disease Ocular Perforation Corneal Transplantation Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Complex corneal and ocular surface disorders presenting as keratitis with corneal ulceration, keratolysis, and corneal perforation attributable to infection, systemic diseases, and ocular trauma, are considered important causes of ocular morbidity. They not only threaten the vision but jeopardize the integrity of the globe. Often, emergency measures and radical techniques like corneoscleral grafts are mandatory to remove and replace the diseased tissue, eliminate, and prevent the posterior spreading of infection and preserve the structural integrity of the globe 1–4 . Causes of corneal and adjacent tissue destruction can be classified in infectious (i.e., bacterial, fungal, and viral diseases) and non-infectious pathologies (ocular trauma, autoimmune background diseases) 5–7 . Diverse types of surgical and non-surgical procedures have been described for the treatment of corneal perforation including the use of therapeutic contact lenses, topical biological adhesives (i.e., fibrin glue, cyanoacrylate), conjunctival flap, multilayer amniotic membrane graft and corneal transplant 5–7 . The choice of the procedure should be individualized and is usually based on the size, depth, location of the perforation and/or affected tissue along with the underlying disease 2 . Progress in pharmacological and surgical techniques has decreased the need for extreme and complex procedures to save ocular integrity. However, despite treatment, some conditions may need to be treated with sclerokeratoplasty to attempt to control disease progression and preserve the integrity of the globe 3 . Sclerocorneal grafts are considered in cases with severe compromise of corneal and scleral tissue. Hence, a high rate of complications such as recurrence of the underlying disorder, anatomical alteration of the iridocorneal angle and anterior segment (secondary glaucoma), persistent ocular surface and intraocular inflammation amongst others 2,8 . The purpose of this study is to describe sclerokeratoplasty outcomes in grievously diseased or severely perforated eyes. METHODS A retrospective review of clinical records of patients who underwent sclerocorneal keratoplasty for the treatment of severe ocular disease, perforation, and corneal melt between 2001 and 2020 at a specialized ophthalmological centre were included. The study was approved by the Ethics and Research Committees of our institution, Institute of Ophthalmology “Conde de Valenciana” (CONBIOETICA − 09-CEI-023-20160830), following the tenets of the Declaration of Helsinki, all patients were informed about the risks and benefits of the surgical management and provided written informed consent. The analysed data included demographic characteristics, medical history, surgical indications, aetiology of the perforation (infectious and non-infectious), visual outcomes, complications associated with the surgical procedure, and ocular integrity at the end of the follow-up. Patients were always evaluated by a cornea specialist, they underwent a complete medical history and a complete ophthalmic examination that included visual acuity, intraocular pressure measured with tonopen (Reichert TM Tono-Pen AVIA® Tonometer) and ocular hypertension (OHT) was defined as an intraocular pressure greater than 21 mmHg, biomicroscopic examination of the anterior segment and when possible, fundoscopy was performed. Patients received treatment according to the specific aetiology, when patients presented with infectious keratitis, corneal scrapes were performed, sent for culture, and broad-spectrum antibiotic, antifungal, and/or antiviral therapy was started, and then adjusted in accordance to stains and cultures in each specific case 9 . In the case of autoimmune disease, patients were handled in alliance with a rheumatology specialist. If present, oral doxycycline was given for the management of keratolysis. Indications for sclerokeratoplasy were severe infectious keratitis/scleritis, autoimmune disease and ocular trauma with extensive sclerocorneal damage and the main goal of the treatment was the total removal of the diseased tissue, restoration, and maintenance of the ocular integrity. Surgical technique varied widely based on the underlying disease, the indication and extent of the ocular process but overall surgeries were performed under general anaesthesia and a 360-degree peritomy along the keratolimbus in the recipient’s eye and the conjunctiva was undermined from the sclera. Subjacent bleeding was cauterized to achieve haemostasis. A 14 mm annular mark when possible was then made over the sclera around the limbus, excision of the affected tissue including a minimum of 1 mm of non-affected tissue with a freehand trephine blade to incise the sclera to approximately 50% of depth overseeing to avoid any damage to the iridocorneal angle structures. The size ranged from 10–14 mm based on the extent of the disease infiltration, necrosis, and melting of the adjacent tissue, the ideal size of the graft was determined by measuring the affected area either with a calliper or by placing various size trephines ensuring to include the diseased tissue. A lamellar dissection of the corneoscleral tunnel was done circumferentially through 360º and the anterior chamber was entered with a blade anterior to the limbus. If inflammatory membranes were present on the iris surface, they were carefully removed. The donor graft was oversized 0.5-1mm and placed over the recipient window over a viscoelastic cushion and sutured with a 10 − 0 nylon interrupted suture into the recipient sclerocorneal bed, a sealed wound was verified, and all knots were buried when possible. Postoperative care consisted of intensive and individualized management for the primary ocular pathology and continued. In case of infectious keratitis, antibiotic, antifungal and/or antiviral medications were adjusted accordingly. Topical and oral steroids were prescribed on an individual basis. Whenever possible topical steroids were started immediately after surgery and tapered over the next 6 months. When contraindicated topical steroids were substituted for topical cyclosporine. Oral steroids were prescribed in alliance with the immunologist/rheumatologist. Cycloplegics and ocular hypotensive medication were given accordingly if necessary. If a recurrence of infection was present or perforation was persistent, required additional surgery was performed. Statistical analysis Statistical analysis was performed with SPSS software version 28 for Windows. Descriptive statistics were obtained. The Shapiro-Wilks test was used to evaluate data normality. Initial and final CDVA in logarithm of minimum angle of resolution (logMAR) were analysed through Wilcoxon signed-rank test. Patients were grouped into two categories based on their predisposing condition: infectious and non-infectious. Mann-Whitney test was used with continuous variables, and chi-square tests were performed for all categorical surgery-related complications. Preservation of integrity was explored through survival analysis and presented in Kaplan-Meier curves with the analysis performed in R version 4.0.2. Results are expressed as mean and standard deviation. A value of p < 0.05 was considered statistically significant. RESULTS A total of 40 eyes from 40 patients (23 men and 17 women) with a mean follow-up of 21.13 ± 33.92 months were included. Their mean age was 48.83 ± 18.85 years (Range: 3–82). The most common systemic comorbidities were autoimmune diseases in 7 patients (17.5%), diabetes mellitus and systemic hypertension in 4 (10%) and 3 patients (7.5%) respectively. Regarding their ophthalmic predisposing condition, of the 40 eyes, twenty-six (65%) had an infectious background and fourteen eyes (35%) had a non-infectious aetiology, among these, autoimmune keratitis was the most frequent (9 eyes). The aetiologies and main causes for sclerocorneal graft are included in Table 1 . Of the 40 eyes, 13 of them (32.5%) had a history of a previous surgical procedure including amniotic membrane graft, therapeutic keratoplasty and or corneal patch. After sclerokeratoplasty 50% required at least one of these surgical procedures, during follow-up. Table 1 Primary aetiology in patients who underwent Sclerocorneal Keratoplasty Group Diagnosis Frequency (%) Infectious Bacterial keratitis 2 ( 5 ) Fungal keratitis 6 ( 15 ) Mixed keratitis 2 ( 5 ) Viral keratitis 2 ( 5 ) Non specified 16 (40) Non-infectious Autoimmune a) Rheumatoid arthritis 5 (12.5) b) Granulomatosis with polyangiitis 1 (2.5) c) Severe atopic dermatitis 1 (2.5) d) Pemphigoid 1 (2.5) Trauma 2 ( 5 ) Chemical burn 1 (2.5) B-cell lymphoma 1 (2.5) Regarding visual acuity, median corrected distance visual acuity (CDVA) before the surgical procedure was 2.8 logMAR (Perceives light / Discriminates colours), with 21 eyes (52.5%) with this initial visual acuity, followed by 10 eyes (25%) with 2.3logMAR (Detects hand movement) initial CDVA. Median CDVA in the final assessment remained at 2.8 logMAR (Perceives light / Discriminates colour), however, 11 eyes (27.5%) presented 2.8 and 3.0 logMAR (No light perception) CDVA respectively. Vision remained stable after sclerokeratoplasty since no statistical difference was found between initial and final CDVA (p = 0.537). Twenty-seven eyes presented complications after sclerokeratoplasty. Described complications were persistent epithelial defect in 11 eyes (27.5%), ocular hypertension in 10 eyes (25%), perforation in 8 eyes (20%), wound dehiscence with leakage in 6 eyes (15%), anterior synechiae in 6 eyes (15%), choroidal detachment in 5 eyes (12.5%), and retinal detachment in 2 eyes (5%). More than two-thirds of the eyes (67.5%) presented with either one or more of these complications after corneoscleral graft. Figure 1 Complications are depicted in Table 2 . When comparing those eyes that presented any complication with those that did not, no significant difference was found regarding age (p = 0.564), sex (p = 0.298), or DM history (p = 0.431). For analytical purposes, every complication was rated by comparing sex, DM history and perforation cause (infectious and non-infectious). Anterior synechiae formation and secondary perforation were more commonly seen in women (p = 0.028, p = 0.038, respectively). Secondary perforation and ocular hypertension showed a statistically significant difference, being more common in the non-infectious group. (p = 0.048). The rest of the complications were not significantly different. Table 2 Comparative analysis of corneoscleral graft complications Sex DM history Perforation cause Complication M F p Yes No p Infectious Non-infectious p Choroidal detachment 2 3 0.397 1 4 0.426 4 14 0.452 Retinal detachment 1 1 0.826 0 2 0.629 1 1 0.648 Ocular hypertension 7 3 0.356 0 10 0.224 3 7 0.007 Synechiae 1 5 0.028 1 5 0.555 4 2 0.926 Persistent epithelial defect 5 6 0.343 2 9 0.288 6 5 0.393 Wound dehiscence with leakage 5 1 0.165 0 6 0.376 4 2 0.926 Perforation 2 6 0.038 1 7 0.792 2 6 0.008 Visual function defined as visual acuity of 2.8 logMAR or better, was maintained in 29 eyes (72.5%), with survival analysis showing a median functional vision probability of 4.12 years (Fig. 2 ). On the other hand, preservation of the ocular integrity was achieved in 34 eyes (85%), with a median survival probability of 12 years (Fig. 3 ). Regardless of several procedures (ranging from 2 to 4) in 6 eyes ocular integrity was not possible. No statistical significance was observed between the infectious and non-infectious groups regarding either visual function (p = 0.173) or anatomical survival (p = 0.112). Characteristics of patients with loss of ocular integrity are described in Table 3 . Table 3 Characteristics of the patients with loss of ocular integrity Gender Age range Aetiology Total surgical procedures Complications 1 M 1s Trauma 3 PED/glaucoma/perforation 2 F 60s Viral keratitis 4 PED/infection recurrence/perforation 3 F 50s Rheumatoid arthritis 4 Perforation 4 F 60s Rheumatoid arthritis 3 PED/glaucoma/synechiae 5 F 60s Pemphigoid 2 PED/choroidal thickening 6 M 60s Infection 2 Infection recurrence DISCUSSION Severe ocular surface alterations involving corneal and scleral tissue in the setting of infectious keratitis, autoimmune perforations and ocular trauma can create a variety of complex and overwhelming situations difficult to manage medically and surgically since these situations produce urgent and extensive graft requirements. Total penetrating keratoplasty has been reported since 1920 by several authors including Burke, Filatov and Schimanowski as a treatment for extensive areas of unhealthy tissue involving the cornea and adjacent sclera with donor tissue 10 . Later on, Barraquer et al. 11 adopted the term reconstructive keratoplasty and better defined it as the treatment which has as its final purpose to restore de ocular integrity by eliminating the damaged areas. Sclerokeratoplasty consists of the replacement of the anterior third of the ocular globe with a full thickness of variable size corneoscleral graft to provide tectonic support and stabilize eyes with severe corneal and anterior segment diseases 3,12,13 . Thereafter, very few studies have been conducted for severe sight-threatening corneoscleral diseases 14–17 . The literature reported so far includes from case reports to case series 1,14,16 we describe one of the largest series of penetrating sclerokeratoplasty reported to date. More than half of the patients had an infectious aetiology. This is in accordance with data from other authors describing keratitis as the most frequent indication for sclerokeratoplasty 2,18 . After unspecified keratitis, fungal keratitis was the most common cause of keratitis with a filamentous fungi predominance, results that are similar to other studies of being the most common pathogens in the developing world. Fungal keratitis treatment is challenging, the limited antifungal therapy availability, high costs and poor ocular penetration, resistance to antifungal medication, and tendency to recur, therapeutic penetrating keratoplasties (PKP) are often needed. Some authors have described the use of corneoscleral transplantation as a useful option for better control of the infection particularly when it has reached adjacent and internal ocular structures 2,14–16,19 . Panda et al described the use of sclerokeratoplasty in infectious keratitis resistant to treatment and impending perforation and performed a comparison between SKP and PKP. In this study from a total of 20 eyes, 10 eyes per group reported better anatomical and visual outcomes with SKP 4 . Similarly, Jonas and associates reported the outcomes of tectonic sclerokeratoplasty and tectonic penetrating keratoplasty for the treatment of impending or perforated corneas. Unlike our results, the main reason for corneal ulceration in their study was rheumatoid arthritis. In their case series, SKP and keratoplasty showed similar anatomical and visual outcomes, suggesting SPK as an acceptable alternative in patients with severe peripheral corneal disorders 1 . In the autoimmune scenario such as rheumatoid arthritis, Wegener granulomatosis, pemphigoid, and systemic lupus erythematosus the inflammation is due to a local imbalance of a specific collagenase, and its tissue inhibitor 6 . Pharmacological systemic treatment is imperative as an initial management to be able to control underlying disease and it attributes to surgical success. Even though this technique is often used as a therapeutic approach, some reports suggest that satisfactory visual results can be achieved and maintained after SKP 4,14 . We did not observe a significant difference between initial and final CDVA, however in agreement with the available literature, performing SKP even under emergency conditions can result in preventing the loss of the globe and visual prognosis can be preserved, as can be seen in the functional preservation and globe preservation survival analysis. In the presence of severely damaged and inflamed eyes, the use of large grafts is mandatory to preserve the integrity of the eye. Therefore, anatomical disturbance of the anterior segment and iridocorneal angle is expected. The build-up of inflammatory elements in the trabeculum and secondary edema of the meshwork have also been described in association with severe infectious keratitis, which in addition to the need for intensified and prolonged use of topical steroids to control severe inflammation and prevent graft rejection, making ocular hypertension and glaucoma a common scenario in these cases 20–22 . Chronic inflammation is also likely to develop anterior synechiae, membrane overgrowth in the anterior chamber or scar formation leading to angle closure. Panda et al 17 , compared therapeutic sclerokeratoplasty versus therapeutic penetrating keratoplasty (PK) in refractory corneal ulcers, and despite larger grafts being related to greater IOP complications, the incidence of IOP elevation was significantly higher in the PK group. When performing sclerokeratoplasty, peripheral lamellar dissection is advised to preserve the angle structures to avoid intraocular pressure-related complications. Besides anterior chamber angle preservation, the use of through-and-through support mattress sutures in SKP has been described for preventing secondary angle closure glaucoma and achieving long-term IOP stability within normal ranges 22 . Liesenborghs et al 23 , analysed the risk factors for ocular hypertension development after keratoplasty, finding a definite association between pre-existing glaucoma, high preoperative IOP and triple procedure surgery. None of the eyes in our study had combined surgery and no data of preexisting glaucoma was reported. However, we found that a quarter of the patients presented with intraocular hypertension after a corneoscleral graft. Several factors can lead to glaucoma after penetrating keratoplasty, some of them can be attributed to the strong anterior chamber inflammatory response, angle, and trabecular meshwork distortion, peripheral anterior synechiae formation and prolonged use of systemic and topical steroids 24–26 . In accordance with our results, a moderate association between regrafting and post-penetrating keratoplasty glaucoma has been described by Wu et al 27 . Ocular hypertension was a complication present in 50% of the patients with autoimmune diseases in contrast with other authors, where they found that a high incidence of secondary ocular hypertension was associated in eyes with moderate to severe infectious keratitis 26 however, severe intraocular inflammation seems to be the main risk factor. Following other authors 16 , no additional surgical treatment was needed to control intraocular pressure, it was successfully managed and controlled with topical medication. The technique, preserving the angle structures, with the possibility of a subtotal cyclodialysis, a partial ciliary body disinsertion, or the likelihood that the transplanted tissue including the trabecular meshwork may be functional can perhaps explain our results. Just over a quarter of the patients in this study presented with wound healing impairment in the manner of persistent epithelial defects as compared with Hirst et al, reporting an incidence of 52% in their series, all of them requiring a partial tarsorrhaphy to manage epithelialization 16 . The persistence of the corneal defect could be explained due to an alteration or loss of the patient´s limbal stem cells, or because of rejection of the donor graft stem cells, but most likely in consequence of a large corneoscleral graft, total corneal denervation befalls. The loss of the sensory innervation of the cornea decreases the number of corneal stem cells, lessens metabolic and mitotic rates in the corneal epithelium and reduces acetylcholine and choline acetyltransferase concentrations, resulting in the development of persistent epitheliopathy 16 . The nature and chronicity of the epithelial breakdown can induce progressive stromal thinning and subsequent corneal perforation. It appears that performing a partial tarsorrhaphy prophylactically or after epithelium malfunction seems to be a beneficial tool to prevent further and devastating complications, some authors report an 80–100% success rate for re-epithelization in non-healing epithelium after tarsorrhaphy 16,28 . In the present work, in similarity with other studies 1,14 ) successful anatomical restoration was achieved within 85% of the eyes treated. Limitations of the present study are those related to its retrospective nature, a relatively small sample size, and the lack of a control group. However, sclerokeratoplasty is a rare procedure even in the busiest corneal clinics. The aetiology behind the procedure varies widely and so does the surgical technique and preoperative and postoperative medical regime. Therefore, conducting a prospective clinical trial to compare both procedures (PKP and SCK) may result increasingly difficult for most clinical settings. It is worth mentioning that a more profound analysis regarding the responsible infectious organism and its relation to visual prognosis and complications was not possible mainly because of culture-negative scrapes as these patients are almost invariably treated with an intense antibiotic regime before presenting to our clinic. Despite the limitations, this study remains one of the largest in size to this day and offers insight into the main indications and prognosis of patients requiring SCK. In conclusion, sclerokeratoplasty is a challenging and technically demanding procedure followed by defiant complications, sometimes the only achievable treatment option in complex situations such as perforated corneal ulcers, impeding perforation or refractory infections. However, as shown in this study, it is likely this procedure salvages the eye and even preserves vision. Declarations Competing interests The authors declare that they have no competing interests. Ethics approval and consent to participate The study was approved by the Ethics and Research Committees of our institution, Institute of Ophthalmology “Conde de Valenciana” (CONBIOETICA − 09-CEI-023-20160830), following the tenets of the Declaration of Helsinki, all patients were informed about the risks and benefits of the surgical management and provided written informed consent. Funding This research received no specific grant from any funding agency. Author Contribution D.L.G. and E.O.G.H. conceptualized and designed the work, monitored data collection and drafted and revised the paper. D.J.C and A.J.C designed the statistical design plan, analysed, interpreted the data collected, and analysed the paper. L.P.A. and N.M. conceptualized the work and monitored data collection. J.E.V.G., A.N. and E.O.G.H. revised the work and gave final approval for publication. Acknowledgements Not applicable Data Availability The datasets used and analysed during the current study are available from the corresponding author upon reasonable request. References Jonas, J. B., Rank, R. M. & Budde, W. M. Tectonic sclerokeratoplasty and tectonic penetrating keratoplasty as treatment for perforated or predescemetal corneal ulcers. American Journal of Ophthalmology 132, 14–18 (2001). https://doi.org:10.1016/s0002-9394(01)00874-1 Krysik, K., Wroblewska-Czajka, E., Lyssek-Boron, A., Wylegala, E. A. & Dobrowolski, D. Total Penetrating Keratoplasty: Indications, Therapeutic Approach, and Long-Term Follow-Up. Journal of Ophthalmology 2018, 1–6 (2018). https://doi.org:10.1155/2018/9580292 Taylor, D. M. & Stern, A. L. Reconstructive Keratoplasty in the Management of Conditions Leading to Corneal Destruction. Ophthalmology 87, 892–904 (1980). https://doi.org:10.1016/s0161-6420(80)35151-8 Panda, A., Sharma, N., Angra, S. K. & Singh, R. Therapeutic sclerokeratoplasty versus therapeutic penetrating keratoplasty in refractory corneal ulcers. Aust N Z J Ophthalmol 27, 15–19 (1999). https://doi.org:10.1046/j.1440-1606.1999.00141.x Bouazza, M. et al. [Non-traumatic corneal perforations: Therapeutic modalities]. J Fr Ophtalmol 38, 395–402 (2015). https://doi.org:10.1016/j.jfo.2014.11.012 Jhanji, V. et al. Management of corneal perforation. Surv Ophthalmol 56, 522–538 (2011). https://doi.org:10.1016/j.survophthal.2011.06.003 Yokogawa, H., Kobayashi, A., Yamazaki, N., Masaki, T. & Sugiyama, K. Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital. Clin Ophthalmol 8, 2165–2170 (2014). https://doi.org:10.2147/OPTH.S71102 Cellini, M., Fresina, M., Strobbe, E., Gizzi, C. & Campos, E. C. Corneoscleral graft in Mooren's ulcer: a case report. Cases Journal 2, 180 (2009). https://doi.org:10.1186/1757-1626-2-180 Hernandez-Camarena, J. C. et al. Trends in Microbiological and Antibiotic Sensitivity Patterns in Infectious Keratitis: 10-Year Experience in Mexico City. Cornea 34, 778–785 (2015). https://doi.org:10.1097/ICO.0000000000000428 Burke, J. W. Total Keratoplasty. Trans Am Ophthalmol Soc 18, 440–447 (1920). Barraquer, J. Total Penetrating Keratoplasty. Proceedings of the Royal Society of Medicine 54, 1116–1118 (1961). https://doi.org:10.1177/003591576105401220 Girard, L. Penetrating Sclerokeratoplasty. Cornea 1, 45–52 (1982). Ticho, U. & Ben-Sira, I. Total keratoplasty. Arch Ophthalmol 90, 104–106 (1973). https://doi.org:10.1001/archopht.1973.01000050106006 Donaldson, K. E., Dubovy, S. R. & Forster, R. K. Corneoscleral block excision grafts: indications, techniques, and outcomes. Cornea 30, 1277–1285 (2011). https://doi.org:10.1097/ICO.0b013e3182114124 Gao, H. et al. Conjunctival Flap Covering Combined with Antiviral and Steroid Therapy for Severe Herpes Simplex Virus Necrotizing Stromal Keratitis. The Scientific World Journal 2015, 1–6 (2015). https://doi.org:10.1155/2015/565964 Hirst, L. W. & Lee, G. A. Corneoscleral transplantation for end stage corneal disease. Br J Ophthalmol 82, 1276–1279 (1998). https://doi.org:10.1136/bjo.82.11.1276 Panda, A. Lamellolamellar sclerokeratoplasty. Where do we stand today? Eye (Lond) 13 (Pt 2), 221–225 (1999). https://doi.org:10.1038/eye.1999.55 Burk, R. O. W. & Joussen, A. M. Corneoscleroplasty with maintenance of the angle in two cases of extensive corneoscleral disease. Eye 14, 196–200 (2000). https://doi.org:10.1038/eye.2000.53 Barbany, M., Gris, O. & Guell, J. L. Therapeutic sectorial full-thickness sclero-keratoplasty for recurrent fungal keratitis. Arch Soc Esp Oftalmol 90, 385–388 (2015). https://doi.org:10.1016/j.oftal.2014.04.024 Bodh, S. A., Kumar, V., Raina, U. K., Ghosh, B. & Thakar, M. Inflammatory glaucoma. Oman J Ophthalmol 4, 3–9 (2011). https://doi.org:10.4103/0974-620X.77655 Castroviejo, R. Total penetrating keratoplasty; a preliminary report. Am J Ophthalmol 34, 1697–1706 (1951). https://doi.org:10.1016/0002-9394(51)90035-9 Cobo, M., Ortiz, J. R. & Safran, S. G. Sclerokeratoplasty with maintenance of the angle. Am J Ophthalmol 113, 533–537 (1992). https://doi.org:10.1016/s0002-9394(14)74725-7 Liesenborghs, I. et al. Risk Factors for the Development of Ocular Hypertension After Keratoplasty: A Systematic Review. Cornea 39, 394–402 (2020). https://doi.org:10.1097/ICO.0000000000002209 Phulke, S., Kaushik, S., Kaur, S. & Pandav, S. S. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma Pract 11, 67–72 (2017). https://doi.org:10.5005/jp-journals-l0028-1226 Roozbahani, M., Hammersmith, K. M., Nagra, P. K., Ma, J. F. & Rapuano, C. J. "Therapeutic Penetrating Keratoplasty: A Retrospective Review". Eye Contact Lens 44 Suppl 2, S433-S441 (2018). https://doi.org:10.1097/ICL.0000000000000522 Sakiyalak, D. & Chattagoon, Y. Incidence of and risk factors for secondary ocular hypertension in moderate to severe infectious ulcerative keratitis. Clinical Ophthalmology Volume 12, 2121–2128 (2018). https://doi.org:10.2147/opth.s169280 Wu, S. & Xu, J. Incidence and risk factors for post-penetrating keratoplasty glaucoma: A systematic review and meta-analysis. PLOS ONE 12, e0176261 (2017). https://doi.org:10.1371/journal.pone.0176261 Cosar, C. B. et al. Tarsorrhaphy: clinical experience from a cornea practice. Cornea 20, 787–791 (2001). https://doi.org:10.1097/00003226-200111000-00002 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Oct, 2024 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 01 Aug, 2024 Reviews received at journal 18 Jul, 2024 Reviews received at journal 04 Jul, 2024 Reviews received at journal 30 Jun, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers agreed at journal 24 Jun, 2024 Reviewers invited by journal 24 Jun, 2024 Editor assigned by journal 24 Jun, 2024 Editor invited by journal 24 Jun, 2024 Submission checks completed at journal 24 Jun, 2024 First submitted to journal 12 Jun, 2024 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-4573181","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":326840416,"identity":"a4338ac7-f72e-4523-9d97-65a113e9a578","order_by":0,"name":"Denise Loya-Garcia","email":"","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":false,"prefix":"","firstName":"Denise","middleName":"","lastName":"Loya-Garcia","suffix":""},{"id":326840417,"identity":"e385f34f-4593-4a66-b273-f9472656d27f","order_by":1,"name":"David Jimenez-Collado","email":"","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Jimenez-Collado","suffix":""},{"id":326840419,"identity":"72d3e026-15c5-46e2-b868-3bc070d79d9e","order_by":2,"name":"Aida Jimenez-Corona","email":"","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":false,"prefix":"","firstName":"Aida","middleName":"","lastName":"Jimenez-Corona","suffix":""},{"id":326840420,"identity":"916d8a1c-0651-4270-8d4f-92effee7fa26","order_by":3,"name":"Lucero Pedro-Aguilar","email":"","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":false,"prefix":"","firstName":"Lucero","middleName":"","lastName":"Pedro-Aguilar","suffix":""},{"id":326840422,"identity":"36fbd5c1-66f2-4713-98f0-08660873e924","order_by":4,"name":"Norma Morales","email":"","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":false,"prefix":"","firstName":"Norma","middleName":"","lastName":"Morales","suffix":""},{"id":326840426,"identity":"fee00c16-4784-4d9c-b8e6-fb544352d169","order_by":5,"name":"Alejandro Navas","email":"","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":false,"prefix":"","firstName":"Alejandro","middleName":"","lastName":"Navas","suffix":""},{"id":326840427,"identity":"4ef65764-43c0-4528-944c-78890eea3865","order_by":6,"name":"Jorge E. Valdez-Garcia","email":"","orcid":"","institution":"Monterrey Institute of Technology and Higher Education","correspondingAuthor":false,"prefix":"","firstName":"Jorge","middleName":"E.","lastName":"Valdez-Garcia","suffix":""},{"id":326840428,"identity":"5f14d679-e8da-4ba5-b529-065ed384b094","order_by":7,"name":"Enrique O Graue-Hernández","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYPCCA3Jg8gEpWozBZAIpWhIbQBRRWvj51z78zFNxJ31+2OGHQFvs5HQbCGiRnPHcWJrnzLPcjbfTDIBako3NDhDQYnDjGIM0b9vh3I2zE0BaDiRuI6TF/sYx5t+8/w6nG85O/0CcFgP+NjZp3obDCfLSOUTaInGDjc1yzrHDhhukcwoOJBgQ4Rf+/mPMN97UHJaXn52++cOHCjs5gloYJBKgLgSrNCCkHGwN1FD5BmJUj4JRMApGwYgEAM7+SQFYg/LxAAAAAElFTkSuQmCC","orcid":"","institution":"Instituto de Oftalmología “Fundación Conde de Valenciana IAP”","correspondingAuthor":true,"prefix":"","firstName":"Enrique","middleName":"O","lastName":"Graue-Hernández","suffix":""}],"badges":[],"createdAt":"2024-06-13 03:08:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4573181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4573181/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-76033-5","type":"published","date":"2024-10-16T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60618181,"identity":"78c5edaa-2c26-4f7d-b70b-ca326a022bc3","added_by":"auto","created_at":"2024-07-18 20:35:11","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":396175,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e Representative slim-lamp photograph of postoperative complications showing a rejected graft with vascularization and a central persistent epithelial defect, \u003cstrong\u003eB:\u003c/strong\u003e successful anatomical restoration with graft failure. \u003cstrong\u003eC:\u003c/strong\u003e Clear graft after a primary sclerokeratoplasty \u003cstrong\u003eD: \u003c/strong\u003eClear graft as a second procedure after initial sclerokeratoplasty.\u003c/p\u003e","description":"","filename":"floatimage1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4573181/v1/732a9e813c18a0a95c988656.jpg"},{"id":60619231,"identity":"fc716de4-077c-49f6-8803-ce2c67c8b433","added_by":"auto","created_at":"2024-07-18 20:43:11","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":83327,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve showing functional vision probability. Dotted line shows median survival.\u003c/p\u003e","description":"","filename":"floatimage2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4573181/v1/b0b5c853595049138cf6bcd2.jpg"},{"id":60618183,"identity":"3a0b73e8-3ebe-49c3-8fe6-9b1c12e2035d","added_by":"auto","created_at":"2024-07-18 20:35:11","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":88407,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve showing ocular integrity probability. Dotted line shows median survival.\u003c/p\u003e","description":"","filename":"floatimage3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4573181/v1/19bf012c1195a4c3de10b236.jpg"},{"id":67149228,"identity":"07dc6b84-118c-476c-bccd-7ed2acc5620b","added_by":"auto","created_at":"2024-10-21 16:12:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1033420,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4573181/v1/deb950e3-5092-4d3b-8929-0adaab24a865.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcomes of Sclerokeratoplasty in Severe Ocular Surface Disease","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eComplex corneal and ocular surface disorders presenting as keratitis with corneal ulceration, keratolysis, and corneal perforation attributable to infection, systemic diseases, and ocular trauma, are considered important causes of ocular morbidity. They not only threaten the vision but jeopardize the integrity of the globe. Often, emergency measures and radical techniques like corneoscleral grafts are mandatory to remove and replace the diseased tissue, eliminate, and prevent the posterior spreading of infection and preserve the structural integrity of the globe\u003csup\u003e1\u0026ndash;4\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCauses of corneal and adjacent tissue destruction can be classified in infectious (i.e., bacterial, fungal, and viral diseases) and non-infectious pathologies (ocular trauma, autoimmune background diseases)\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e. Diverse types of surgical and non-surgical procedures have been described for the treatment of corneal perforation including the use of therapeutic contact lenses, topical biological adhesives (i.e., fibrin glue, cyanoacrylate), conjunctival flap, multilayer amniotic membrane graft and corneal transplant\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e. The choice of the procedure should be individualized and is usually based on the size, depth, location of the perforation and/or affected tissue along with the underlying disease\u003csup\u003e2\u003c/sup\u003e. Progress in pharmacological and surgical techniques has decreased the need for extreme and complex procedures to save ocular integrity. However, despite treatment, some conditions may need to be treated with sclerokeratoplasty to attempt to control disease progression and preserve the integrity of the globe\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSclerocorneal grafts are considered in cases with severe compromise of corneal and scleral tissue. Hence, a high rate of complications such as recurrence of the underlying disorder, anatomical alteration of the iridocorneal angle and anterior segment (secondary glaucoma), persistent ocular surface and intraocular inflammation amongst others\u003csup\u003e2,8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe purpose of this study is to describe sclerokeratoplasty outcomes in grievously diseased or severely perforated eyes.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e A retrospective review of clinical records of patients who underwent sclerocorneal keratoplasty for the treatment of severe ocular disease, perforation, and corneal melt between 2001 and 2020 at a specialized ophthalmological centre were included. The study was approved by the Ethics and Research Committees of our institution, Institute of Ophthalmology \u0026ldquo;Conde de Valenciana\u0026rdquo; (CONBIOETICA \u0026minus;\u0026thinsp;09-CEI-023-20160830), following the tenets of the Declaration of Helsinki, all patients were informed about the risks and benefits of the surgical management and provided written informed consent.\u003c/p\u003e \u003cp\u003eThe analysed data included demographic characteristics, medical history, surgical indications, aetiology of the perforation (infectious and non-infectious), visual outcomes, complications associated with the surgical procedure, and ocular integrity at the end of the follow-up. Patients were always evaluated by a cornea specialist, they underwent a complete medical history and a complete ophthalmic examination that included visual acuity, intraocular pressure measured with tonopen (Reichert TM Tono-Pen AVIA\u0026reg; Tonometer) and ocular hypertension (OHT) was defined as an intraocular pressure greater than 21 mmHg, biomicroscopic examination of the anterior segment and when possible, fundoscopy was performed. Patients received treatment according to the specific aetiology, when patients presented with infectious keratitis, corneal scrapes were performed, sent for culture, and broad-spectrum antibiotic, antifungal, and/or antiviral therapy was started, and then adjusted in accordance to stains and cultures in each specific case\u003csup\u003e9\u003c/sup\u003e. In the case of autoimmune disease, patients were handled in alliance with a rheumatology specialist. If present, oral doxycycline was given for the management of keratolysis. Indications for sclerokeratoplasy were severe infectious keratitis/scleritis, autoimmune disease and ocular trauma with extensive sclerocorneal damage and the main goal of the treatment was the total removal of the diseased tissue, restoration, and maintenance of the ocular integrity.\u003c/p\u003e \u003cp\u003eSurgical technique varied widely based on the underlying disease, the indication and extent of the ocular process but overall surgeries were performed under general anaesthesia and a 360-degree peritomy along the keratolimbus in the recipient\u0026rsquo;s eye and the conjunctiva was undermined from the sclera. Subjacent bleeding was cauterized to achieve haemostasis. A 14 mm annular mark when possible was then made over the sclera around the limbus, excision of the affected tissue including a minimum of 1 mm of non-affected tissue with a freehand trephine blade to incise the sclera to approximately 50% of depth overseeing to avoid any damage to the iridocorneal angle structures. The size ranged from 10\u0026ndash;14 mm based on the extent of the disease infiltration, necrosis, and melting of the adjacent tissue, the ideal size of the graft was determined by measuring the affected area either with a calliper or by placing various size trephines ensuring to include the diseased tissue. A lamellar dissection of the corneoscleral tunnel was done circumferentially through 360\u0026ordm; and the anterior chamber was entered with a blade anterior to the limbus. If inflammatory membranes were present on the iris surface, they were carefully removed. The donor graft was oversized 0.5-1mm and placed over the recipient window over a viscoelastic cushion and sutured with a 10\u0026thinsp;\u0026minus;\u0026thinsp;0 nylon interrupted suture into the recipient sclerocorneal bed, a sealed wound was verified, and all knots were buried when possible. Postoperative care consisted of intensive and individualized management for the primary ocular pathology and continued. In case of infectious keratitis, antibiotic, antifungal and/or antiviral medications were adjusted accordingly. Topical and oral steroids were prescribed on an individual basis. Whenever possible topical steroids were started immediately after surgery and tapered over the next 6 months. When contraindicated topical steroids were substituted for topical cyclosporine. Oral steroids were prescribed in alliance with the immunologist/rheumatologist. Cycloplegics and ocular hypotensive medication were given accordingly if necessary. If a recurrence of infection was present or perforation was persistent, required additional surgery was performed.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed with SPSS software version 28 for Windows. Descriptive statistics were obtained. The Shapiro-Wilks test was used to evaluate data normality. Initial and final CDVA in logarithm of minimum angle of resolution (logMAR) were analysed through Wilcoxon signed-rank test. Patients were grouped into two categories based on their predisposing condition: infectious and non-infectious. Mann-Whitney test was used with continuous variables, and chi-square tests were performed for all categorical surgery-related complications. Preservation of integrity was explored through survival analysis and presented in Kaplan-Meier curves with the analysis performed in R version 4.0.2. Results are expressed as mean and standard deviation. A value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 40 eyes from 40 patients (23 men and 17 women) with a mean follow-up of 21.13\u0026thinsp;\u0026plusmn;\u0026thinsp;33.92 months were included. Their mean age was 48.83\u0026thinsp;\u0026plusmn;\u0026thinsp;18.85 years (Range: 3\u0026ndash;82). The most common systemic comorbidities were autoimmune diseases in 7 patients (17.5%), diabetes mellitus and systemic hypertension in 4 (10%) and 3 patients (7.5%) respectively. Regarding their ophthalmic predisposing condition, of the 40 eyes, twenty-six (65%) had an infectious background and fourteen eyes (35%) had a non-infectious aetiology, among these, autoimmune keratitis was the most frequent (9 eyes). The aetiologies and main causes for sclerocorneal graft are included in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 40 eyes, 13 of them (32.5%) had a history of a previous surgical procedure including amniotic membrane graft, therapeutic keratoplasty and or corneal patch. After sclerokeratoplasty 50% required at least one of these surgical procedures, during follow-up.\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\u003e\u003cb\u003ePrimary aetiology\u003c/b\u003e in patients who underwent Sclerocorneal Keratoplasty\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eInfectious\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBacterial keratitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFungal keratitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMixed keratitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eViral keratitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon specified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNon-infectious\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ea) Rheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eb) Granulomatosis with polyangiitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ec) Severe atopic dermatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ed) Pemphigoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChemical burn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB-cell lymphoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.5)\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\u003eRegarding visual acuity, median corrected distance visual acuity (CDVA) before the surgical procedure was 2.8 logMAR (Perceives light / Discriminates colours), with 21 eyes (52.5%) with this initial visual acuity, followed by 10 eyes (25%) with 2.3logMAR (Detects hand movement) initial CDVA. Median CDVA in the final assessment remained at 2.8 logMAR (Perceives light / Discriminates colour), however, 11 eyes (27.5%) presented 2.8 and 3.0 logMAR (No light perception) CDVA respectively. Vision remained stable after sclerokeratoplasty since no statistical difference was found between initial and final CDVA (p\u0026thinsp;=\u0026thinsp;0.537).\u003c/p\u003e \u003cp\u003eTwenty-seven eyes presented complications after sclerokeratoplasty. Described complications were persistent epithelial defect in 11 eyes (27.5%), ocular hypertension in 10 eyes (25%), perforation in 8 eyes (20%), wound dehiscence with leakage in 6 eyes (15%), anterior synechiae in 6 eyes (15%), choroidal detachment in 5 eyes (12.5%), and retinal detachment in 2 eyes (5%). More than two-thirds of the eyes (67.5%) presented with either one or more of these complications after corneoscleral graft. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComplications are depicted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. When comparing those eyes that presented any complication with those that did not, no significant difference was found regarding age (p\u0026thinsp;=\u0026thinsp;0.564), sex (p\u0026thinsp;=\u0026thinsp;0.298), or DM history (p\u0026thinsp;=\u0026thinsp;0.431). For analytical purposes, every complication was rated by comparing sex, DM history and perforation cause (infectious and non-infectious). Anterior synechiae formation and secondary perforation were more commonly seen in women (p\u0026thinsp;=\u0026thinsp;0.028, p\u0026thinsp;=\u0026thinsp;0.038, respectively). Secondary perforation and ocular hypertension showed a statistically significant difference, being more common in the non-infectious group. (p\u0026thinsp;=\u0026thinsp;0.048). The rest of the complications were not significantly different.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative analysis of corneoscleral graft complications\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eDM history\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e \u003cp\u003ePerforation cause\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eInfectious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNon-infectious\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChoroidal detachment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetinal detachment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.629\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.648\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOcular hypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSynechiae\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.555\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePersistent epithelial defect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.393\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound dehiscence with leakage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerforation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.792\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\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\u003eVisual function defined as visual acuity of 2.8 logMAR or better, was maintained in 29 eyes (72.5%), with survival analysis showing a median functional vision probability of 4.12 years (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). On the other hand, preservation of the ocular integrity was achieved in 34 eyes (85%), with a median survival probability of 12 years (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Regardless of several procedures (ranging from 2 to 4) in 6 eyes ocular integrity was not possible. No statistical significance was observed between the infectious and non-infectious groups regarding either visual function (p\u0026thinsp;=\u0026thinsp;0.173) or anatomical survival (p\u0026thinsp;=\u0026thinsp;0.112). Characteristics of patients with loss of ocular integrity are described in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the patients with loss of ocular integrity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge range\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAetiology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal surgical procedures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTrauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePED/glaucoma/perforation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eViral keratitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePED/infection recurrence/perforation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePerforation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRheumatoid arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePED/glaucoma/synechiae\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePemphigoid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePED/choroidal thickening\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=\"left\" colname=\"c3\"\u003e \u003cp\u003e60s\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInfection recurrence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSevere ocular surface alterations involving corneal and scleral tissue in the setting of infectious keratitis, autoimmune perforations and ocular trauma can create a variety of complex and overwhelming situations difficult to manage medically and surgically since these situations produce urgent and extensive graft requirements.\u003c/p\u003e \u003cp\u003eTotal penetrating keratoplasty has been reported since 1920 by several authors including Burke, Filatov and Schimanowski as a treatment for extensive areas of unhealthy tissue involving the cornea and adjacent sclera with donor tissue\u003csup\u003e10\u003c/sup\u003e. Later on, Barraquer et al.\u003csup\u003e11\u003c/sup\u003e adopted the term reconstructive keratoplasty and better defined it as the treatment which has as its final purpose to restore de ocular integrity by eliminating the damaged areas. Sclerokeratoplasty consists of the replacement of the anterior third of the ocular globe with a full thickness of variable size corneoscleral graft to provide tectonic support and stabilize eyes with severe corneal and anterior segment diseases\u003csup\u003e3,12,13\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThereafter, very few studies have been conducted for severe sight-threatening corneoscleral diseases\u003csup\u003e14\u0026ndash;17\u003c/sup\u003e. The literature reported so far includes from case reports to case series\u003csup\u003e1,14,16\u003c/sup\u003e we describe one of the largest series of penetrating sclerokeratoplasty reported to date.\u003c/p\u003e \u003cp\u003eMore than half of the patients had an infectious aetiology. This is in accordance with data from other authors describing keratitis as the most frequent indication for sclerokeratoplasty \u003csup\u003e2,18\u003c/sup\u003e. After unspecified keratitis, fungal keratitis was the most common cause of keratitis with a filamentous fungi predominance, results that are similar to other studies of being the most common pathogens in the developing world. Fungal keratitis treatment is challenging, the limited antifungal therapy availability, high costs and poor ocular penetration, resistance to antifungal medication, and tendency to recur, therapeutic penetrating keratoplasties (PKP) are often needed. Some authors have described the use of corneoscleral transplantation as a useful option for better control of the infection particularly when it has reached adjacent and internal ocular structures\u003csup\u003e2,14\u0026ndash;16,19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePanda et al described the use of sclerokeratoplasty in infectious keratitis resistant to treatment and impending perforation and performed a comparison between SKP and PKP. In this study from a total of 20 eyes, 10 eyes per group reported better anatomical and visual outcomes with SKP\u003csup\u003e4\u003c/sup\u003e. Similarly, Jonas and associates reported the outcomes of tectonic sclerokeratoplasty and tectonic penetrating keratoplasty for the treatment of impending or perforated corneas. Unlike our results, the main reason for corneal ulceration in their study was rheumatoid arthritis. In their case series, SKP and keratoplasty showed similar anatomical and visual outcomes, suggesting SPK as an acceptable alternative in patients with severe peripheral corneal disorders\u003csup\u003e1\u003c/sup\u003e. In the autoimmune scenario such as rheumatoid arthritis, Wegener granulomatosis, pemphigoid, and systemic lupus erythematosus the inflammation is due to a local imbalance of a specific collagenase, and its tissue inhibitor\u003csup\u003e6\u003c/sup\u003e. Pharmacological systemic treatment is imperative as an initial management to be able to control underlying disease and it attributes to surgical success.\u003c/p\u003e \u003cp\u003eEven though this technique is often used as a therapeutic approach, some reports suggest that satisfactory visual results can be achieved and maintained after SKP\u003csup\u003e4,14\u003c/sup\u003e. We did not observe a significant difference between initial and final CDVA, however in agreement with the available literature, performing SKP even under emergency conditions can result in preventing the loss of the globe and visual prognosis can be preserved, as can be seen in the functional preservation and globe preservation survival analysis.\u003c/p\u003e \u003cp\u003eIn the presence of severely damaged and inflamed eyes, the use of large grafts is mandatory to preserve the integrity of the eye. Therefore, anatomical disturbance of the anterior segment and iridocorneal angle is expected. The build-up of inflammatory elements in the trabeculum and secondary edema of the meshwork have also been described in association with severe infectious keratitis, which in addition to the need for intensified and prolonged use of topical steroids to control severe inflammation and prevent graft rejection, making ocular hypertension and glaucoma a common scenario in these cases\u003csup\u003e20\u0026ndash;22\u003c/sup\u003e. Chronic inflammation is also likely to develop anterior synechiae, membrane overgrowth in the anterior chamber or scar formation leading to angle closure. Panda et al\u003csup\u003e17\u003c/sup\u003e, compared therapeutic sclerokeratoplasty versus therapeutic penetrating keratoplasty (PK) in refractory corneal ulcers, and despite larger grafts being related to greater IOP complications, the incidence of IOP elevation was significantly higher in the PK group. When performing sclerokeratoplasty, peripheral lamellar dissection is advised to preserve the angle structures to avoid intraocular pressure-related complications. Besides anterior chamber angle preservation, the use of through-and-through support mattress sutures in SKP has been described for preventing secondary angle closure glaucoma and achieving long-term IOP stability within normal ranges\u003csup\u003e22\u003c/sup\u003e. Liesenborghs et al\u003csup\u003e23\u003c/sup\u003e, analysed the risk factors for ocular hypertension development after keratoplasty, finding a definite association between pre-existing glaucoma, high preoperative IOP and triple procedure surgery. None of the eyes in our study had combined surgery and no data of preexisting glaucoma was reported. However, we found that a quarter of the patients presented with intraocular hypertension after a corneoscleral graft. Several factors can lead to glaucoma after penetrating keratoplasty, some of them can be attributed to the strong anterior chamber inflammatory response, angle, and trabecular meshwork distortion, peripheral anterior synechiae formation and prolonged use of systemic and topical steroids\u003csup\u003e24\u0026ndash;26\u003c/sup\u003e. In accordance with our results, a moderate association between regrafting and post-penetrating keratoplasty glaucoma has been described by Wu et al\u003csup\u003e27\u003c/sup\u003e. Ocular hypertension was a complication present in 50% of the patients with autoimmune diseases in contrast with other authors, where they found that a high incidence of secondary ocular hypertension was associated in eyes with moderate to severe infectious keratitis\u003csup\u003e26\u003c/sup\u003e however, severe intraocular inflammation seems to be the main risk factor. Following other authors\u003csup\u003e16\u003c/sup\u003e, no additional surgical treatment was needed to control intraocular pressure, it was successfully managed and controlled with topical medication. The technique, preserving the angle structures, with the possibility of a subtotal cyclodialysis, a partial ciliary body disinsertion, or the likelihood that the transplanted tissue including the trabecular meshwork may be functional can perhaps explain our results.\u003c/p\u003e \u003cp\u003eJust over a quarter of the patients in this study presented with wound healing impairment in the manner of persistent epithelial defects as compared with Hirst et al, reporting an incidence of 52% in their series, all of them requiring a partial tarsorrhaphy to manage epithelialization \u003csup\u003e16\u003c/sup\u003e. The persistence of the corneal defect could be explained due to an alteration or loss of the patient\u0026acute;s limbal stem cells, or because of rejection of the donor graft stem cells, but most likely in consequence of a large corneoscleral graft, total corneal denervation befalls. The loss of the sensory innervation of the cornea decreases the number of corneal stem cells, lessens metabolic and mitotic rates in the corneal epithelium and reduces acetylcholine and choline acetyltransferase concentrations, resulting in the development of persistent epitheliopathy\u003csup\u003e16\u003c/sup\u003e. The nature and chronicity of the epithelial breakdown can induce progressive stromal thinning and subsequent corneal perforation. It appears that performing a partial tarsorrhaphy prophylactically or after epithelium malfunction seems to be a beneficial tool to prevent further and devastating complications, some authors report an 80\u0026ndash;100% success rate for re-epithelization in non-healing epithelium after tarsorrhaphy\u003csup\u003e16,28\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the present work, in similarity with other studies\u003csup\u003e1,14\u003c/sup\u003e) successful anatomical restoration was achieved within 85% of the eyes treated.\u003c/p\u003e \u003cp\u003eLimitations of the present study are those related to its retrospective nature, a relatively small sample size, and the lack of a control group. However, sclerokeratoplasty is a rare procedure even in the busiest corneal clinics. The aetiology behind the procedure varies widely and so does the surgical technique and preoperative and postoperative medical regime. Therefore, conducting a prospective clinical trial to compare both procedures (PKP and SCK) may result increasingly difficult for most clinical settings. It is worth mentioning that a more profound analysis regarding the responsible infectious organism and its relation to visual prognosis and complications was not possible mainly because of culture-negative scrapes as these patients are almost invariably treated with an intense antibiotic regime before presenting to our clinic. Despite the limitations, this study remains one of the largest in size to this day and offers insight into the main indications and prognosis of patients requiring SCK.\u003c/p\u003e \u003cp\u003eIn conclusion, sclerokeratoplasty is a challenging and technically demanding procedure followed by defiant complications, sometimes the only achievable treatment option in complex situations such as perforated corneal ulcers, impeding perforation or refractory infections. However, as shown in this study, it is likely this procedure salvages the eye and even preserves vision.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eThe study was approved by the Ethics and Research Committees of our institution, Institute of Ophthalmology \u0026ldquo;Conde de Valenciana\u0026rdquo; (CONBIOETICA \u0026minus;\u0026thinsp;09-CEI-023-20160830), following the tenets of the Declaration of Helsinki, all patients were informed about the risks and benefits of the surgical management and provided written informed consent.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD.L.G. and E.O.G.H. conceptualized and designed the work, monitored data collection and drafted and revised the paper. D.J.C and A.J.C designed the statistical design plan, analysed, interpreted the data collected, and analysed the paper. L.P.A. and N.M. conceptualized the work and monitored data collection. J.E.V.G., A.N. and E.O.G.H. revised the work and gave final approval for publication.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJonas, J. B., Rank, R. M. \u0026amp; Budde, W. M. Tectonic sclerokeratoplasty and tectonic penetrating keratoplasty as treatment for perforated or predescemetal corneal ulcers. American Journal of Ophthalmology 132, 14\u0026ndash;18 (2001). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/s0002-9394(01)00874-1\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/s0002-9394(01)00874-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrysik, K., Wroblewska-Czajka, E., Lyssek-Boron, A., Wylegala, E. A. \u0026amp; Dobrowolski, D. Total Penetrating Keratoplasty: Indications, Therapeutic Approach, and Long-Term Follow-Up. Journal of Ophthalmology 2018, 1\u0026ndash;6 (2018). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1155/2018/9580292\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1155/2018/9580292\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor, D. M. \u0026amp; Stern, A. L. Reconstructive Keratoplasty in the Management of Conditions Leading to Corneal Destruction. Ophthalmology 87, 892\u0026ndash;904 (1980). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/s0161-6420(80)35151-8\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/s0161-6420(80)35151-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanda, A., Sharma, N., Angra, S. K. \u0026amp; Singh, R. Therapeutic sclerokeratoplasty versus therapeutic penetrating keratoplasty in refractory corneal ulcers. Aust N Z J Ophthalmol 27, 15\u0026ndash;19 (1999). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1046/j.1440-1606.1999.00141.x\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1046/j.1440-1606.1999.00141.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBouazza, M. \u003cem\u003eet al.\u003c/em\u003e [Non-traumatic corneal perforations: Therapeutic modalities]. J Fr Ophtalmol 38, 395\u0026ndash;402 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/j.jfo.2014.11.012\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/j.jfo.2014.11.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJhanji, V. \u003cem\u003eet al.\u003c/em\u003e Management of corneal perforation. Surv Ophthalmol 56, 522\u0026ndash;538 (2011). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/j.survophthal.2011.06.003\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/j.survophthal.2011.06.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokogawa, H., Kobayashi, A., Yamazaki, N., Masaki, T. \u0026amp; Sugiyama, K. Surgical therapies for corneal perforations: 10 years of cases in a tertiary referral hospital. Clin Ophthalmol 8, 2165\u0026ndash;2170 (2014). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.2147/OPTH.S71102\u003c/span\u003e\u003cspan address=\"https://doi.org:10.2147/OPTH.S71102\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCellini, M., Fresina, M., Strobbe, E., Gizzi, C. \u0026amp; Campos, E. C. Corneoscleral graft in Mooren's ulcer: a case report. Cases Journal 2, 180 (2009). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1186/1757-1626-2-180\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1186/1757-1626-2-180\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHernandez-Camarena, J. C. \u003cem\u003eet al.\u003c/em\u003e Trends in Microbiological and Antibiotic Sensitivity Patterns in Infectious Keratitis: 10-Year Experience in Mexico City. Cornea 34, 778\u0026ndash;785 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1097/ICO.0000000000000428\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1097/ICO.0000000000000428\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurke, J. W. Total Keratoplasty. Trans Am Ophthalmol Soc 18, 440\u0026ndash;447 (1920).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarraquer, J. Total Penetrating Keratoplasty. \u003cem\u003eProceedings of the Royal Society of Medicine\u003c/em\u003e 54, 1116\u0026ndash;1118 (1961). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1177/003591576105401220\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1177/003591576105401220\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGirard, L. Penetrating Sclerokeratoplasty. Cornea 1, 45\u0026ndash;52 (1982).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTicho, U. \u0026amp; Ben-Sira, I. Total keratoplasty. Arch Ophthalmol 90, 104\u0026ndash;106 (1973). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1001/archopht.1973.01000050106006\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1001/archopht.1973.01000050106006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonaldson, K. E., Dubovy, S. R. \u0026amp; Forster, R. K. Corneoscleral block excision grafts: indications, techniques, and outcomes. Cornea 30, 1277\u0026ndash;1285 (2011). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1097/ICO.0b013e3182114124\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1097/ICO.0b013e3182114124\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGao, H. \u003cem\u003eet al.\u003c/em\u003e Conjunctival Flap Covering Combined with Antiviral and Steroid Therapy for Severe Herpes Simplex Virus Necrotizing Stromal Keratitis. The Scientific World Journal 2015, 1\u0026ndash;6 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1155/2015/565964\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1155/2015/565964\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHirst, L. W. \u0026amp; Lee, G. A. Corneoscleral transplantation for end stage corneal disease. Br J Ophthalmol 82, 1276\u0026ndash;1279 (1998). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1136/bjo.82.11.1276\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1136/bjo.82.11.1276\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanda, A. Lamellolamellar sclerokeratoplasty. Where do we stand today? Eye (Lond) 13 (Pt 2), 221\u0026ndash;225 (1999). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1038/eye.1999.55\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1038/eye.1999.55\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurk, R. O. W. \u0026amp; Joussen, A. M. Corneoscleroplasty with maintenance of the angle in two cases of extensive corneoscleral disease. Eye 14, 196\u0026ndash;200 (2000). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1038/eye.2000.53\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1038/eye.2000.53\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarbany, M., Gris, O. \u0026amp; Guell, J. L. Therapeutic sectorial full-thickness sclero-keratoplasty for recurrent fungal keratitis. Arch Soc Esp Oftalmol 90, 385\u0026ndash;388 (2015). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/j.oftal.2014.04.024\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/j.oftal.2014.04.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBodh, S. A., Kumar, V., Raina, U. K., Ghosh, B. \u0026amp; Thakar, M. Inflammatory glaucoma. Oman J Ophthalmol 4, 3\u0026ndash;9 (2011). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.4103/0974-620X.77655\u003c/span\u003e\u003cspan address=\"https://doi.org:10.4103/0974-620X.77655\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCastroviejo, R. Total penetrating keratoplasty; a preliminary report. Am J Ophthalmol 34, 1697\u0026ndash;1706 (1951). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/0002-9394(51)90035-9\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/0002-9394(51)90035-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCobo, M., Ortiz, J. R. \u0026amp; Safran, S. G. Sclerokeratoplasty with maintenance of the angle. Am J Ophthalmol 113, 533\u0026ndash;537 (1992). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1016/s0002-9394(14)74725-7\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1016/s0002-9394(14)74725-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiesenborghs, I. \u003cem\u003eet al.\u003c/em\u003e Risk Factors for the Development of Ocular Hypertension After Keratoplasty: A Systematic Review. Cornea 39, 394\u0026ndash;402 (2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1097/ICO.0000000000002209\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1097/ICO.0000000000002209\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhulke, S., Kaushik, S., Kaur, S. \u0026amp; Pandav, S. S. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma Pract 11, 67\u0026ndash;72 (2017). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.5005/jp-journals-l0028-1226\u003c/span\u003e\u003cspan address=\"https://doi.org:10.5005/jp-journals-l0028-1226\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoozbahani, M., Hammersmith, K. M., Nagra, P. K., Ma, J. F. \u0026amp; Rapuano, C. J. \"Therapeutic Penetrating Keratoplasty: A Retrospective Review\". Eye Contact Lens 44 Suppl 2, S433-S441 (2018). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1097/ICL.0000000000000522\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1097/ICL.0000000000000522\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakiyalak, D. \u0026amp; Chattagoon, Y. Incidence of and risk factors for secondary ocular hypertension in moderate to severe infectious ulcerative keratitis. Clinical Ophthalmology Volume 12, 2121\u0026ndash;2128 (2018). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.2147/opth.s169280\u003c/span\u003e\u003cspan address=\"https://doi.org:10.2147/opth.s169280\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu, S. \u0026amp; Xu, J. Incidence and risk factors for post-penetrating keratoplasty glaucoma: A systematic review and meta-analysis. PLOS ONE 12, e0176261 (2017). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1371/journal.pone.0176261\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1371/journal.pone.0176261\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosar, C. B. \u003cem\u003eet al.\u003c/em\u003e Tarsorrhaphy: clinical experience from a cornea practice. Cornea 20, 787\u0026ndash;791 (2001). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org:10.1097/00003226-200111000-00002\u003c/span\u003e\u003cspan address=\"https://doi.org:10.1097/00003226-200111000-00002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\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":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sclerokeratoplasty, Ocular Surface Disease, Ocular Perforation, Corneal Transplantation","lastPublishedDoi":"10.21203/rs.3.rs-4573181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4573181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSclerocorneal grafts are procedures considered in cases with extensive corneal and scleral tissue destruction. The study aims to describe sclerokeratoplasty outcomes in severely diseased eyes. We performed a retrospective review of clinical records. Demographic characteristics, medical history, surgical indications, aetiology of perforation, visual outcomes, complications associated with the surgical procedure, and ocular integrity at the end of the follow-up were obtained. Wilcoxon-signed rank tests and Mann-Whitney tests were used to compare complications between groups and outcomes at final follow-up. Survival analysis was performed to analyse vision preservation and global integrity and presented in Kaplan-Meier curves. 40 eyes from 40 patients with a mean age of 48.83\u0026thinsp;\u0026plusmn;\u0026thinsp;18.85 years and a mean follow-up of 21.13\u0026thinsp;\u0026plusmn;\u0026thinsp;33.92 months were included in the study. Median corrected visual acuity before and after the procedure remained at 2.8 logMAR. Twenty-seven eyes presented complications. The most common complications were a persistent epithelial defect in 11, hypertension in 10, and perforation in 8 eyes. More than half of the eyes (67.5%) presented with either one or more of all complications after corneoscleral graft. No significant differences were found regarding age, gender, or DM history. Concerning perforation, a significant difference was found between infectious and non-infectious only in the presentation of ocular hypertension (p\u0026thinsp;=\u0026thinsp;0.048). Vision was preserved in 72.5% of the eyes, with a median survival probability of 4.12 years. Preservation of the ocular integrity was achieved in 85% of the eyes, with a median survival probability of 12 years. Sclerokeratoplasty despite being challenging and technically demanding followed by defiant complications, in some situations such as infectious keratitis and autoimmune diseases, is likely a procedure that salvages the eye and preserves vision.\u003c/p\u003e","manuscriptTitle":"Outcomes of Sclerokeratoplasty in Severe Ocular Surface Disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:35:07","doi":"10.21203/rs.3.rs-4573181/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-01T10:36:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T12:04:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-04T11:28:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-30T09:38:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313059110210114000164772866799712860662","date":"2024-06-25T17:08:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105738629652688989682512847239623072437","date":"2024-06-25T12:37:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66553484021467469631469571924341079035","date":"2024-06-25T00:00:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-24T20:10:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T20:08:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-24T12:00:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-24T05:19:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-06-13T03:07:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af034517-a94e-428e-bd7d-606469099c18","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34581256,"name":"Health sciences/Diseases/Eye diseases/Corneal diseases"},{"id":34581257,"name":"Health sciences/Diseases/Eye diseases/Conjunctival diseases"}],"tags":[],"updatedAt":"2024-10-21T16:06:41+00:00","versionOfRecord":{"articleIdentity":"rs-4573181","link":"https://doi.org/10.1038/s41598-024-76033-5","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-10-16 15:57:21","publishedOnDateReadable":"October 16th, 2024"},"versionCreatedAt":"2024-07-18 20:35:07","video":"","vorDoi":"10.1038/s41598-024-76033-5","vorDoiUrl":"https://doi.org/10.1038/s41598-024-76033-5","workflowStages":[]},"version":"v1","identity":"rs-4573181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4573181","identity":"rs-4573181","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}