CASE REPORT Traumatic Keratoplasty Rupture Resulting From Continuous Positive Airway Pressure Mask Miltiadis Fiorentzis, MD, Berthold Seitz, MD, and Arne Viestenz, MD We report an unusual case of traumatic wound Purpose: To report a rare case of traumatic wound dehiscence dehiscence due to a dislocation of a continuous positive caused by the use of a continuous positive airway pressure (CPAP) airway pressure (CPAP) mask during sleep after PKP. To the mask in a patient with chronic obstructive pulmonary disease best of our knowledge, this is the first report of this unusual (COPD) after penetrating keratoplasty (PKP). graft separation cause. Methods: Observational case report. CASE REPORT Case report: A 55-year-old man who was treated with uncompli- cated PKP due to pellucid marginal corneal degeneration in the right A 55-year-old man underwent an excimer laser-assisted PKP eye 9 months earlier presented to the emergency department after because of pellucid marginal corneal degeneration in the right eye. The postoperative course was uncomplicated (Fig. 1A). His medical a globe rupture caused by dislocation of his CPAP mask during history revealed chronic obstructive pulmonary disease (COPD), sleep. The best-corrected visual acuity (BCVA) was light perception treated with a CPAP mask. Three months after surgery and under in the right eye. The corneal graft was dehisced from 12 over 3 to 6 treatment with topical steroids 3 times a day, the BCVA was 20/32, o’clock (180 degrees) with interruption of the double running the corneal astigmatism approximately 1.8 diopters, and the central corneal sutures and nasal iris as well as vitreous incarceration. The corneal thickness 541 mm with in loco double running sutures graft was resutured in place with 33 interrupted 10-0 monofilament according to Hoffmann.3 nylon sutures. The BCVA improved to 20/100 three months after Nine months after uncomplicated PKP, the patient presented globe reconstruction. to our emergency department complaining about visual loss in the right eye after dislocation of his CPAP mask during sleep. The Conclusions: This case underlines the necessity of education for patient was not wearing protective glasses at the time of trauma. The patients undergoing keratoplasty regarding the use of protective BCVA of the right eye was light perception; the graft was dehisced eyewear, to avoid predictable or accidental ocular injuries and graft from 12 over 3 to 6 o’clock (180 degrees) with broken running dehiscence or its subsequent consequences. CPAP masks should be sutures (Fig. 1A, interrupted semicircle) and nasal iris as well as fitted (eyeball sparing) to the margins of the orbit after PKP. vitreous incarceration (Fig. 1A, arrow). The Seidel test was positive with complete ocular hypotension. Key Words: CPAP mask, penetrating keratoplasty, wound dehis- The loose ends of the double running sutures were readapted cence, corneal graft separation, globe rupture to fix the cornea in one half of the circumference (Fig. 1C, star). In the open part of the eyeball, the preformed teeth and notches of (Cornea 2015;34:717–719) excimer laser keratoplasty (key/key hole) were used to create a better coaptation of corneal tissue with 2 positioning sutures (Fig. 1B, C; arrows).4 After that, multiple single sutures in the area of the ound dehiscence is an uncommon complication after remnants of the double running suture were positioned (Fig. 1D, penetrating keratoplasty (PKP). The potential causes of arrows). Then, the graft was resutured in place with 33 interrupted W fi the wound separation include, for example, trauma, suture- 10-0 mono lament nylon sutures. The double running suture remnants were removed (Fig. 1F). The iris was replaced, and related complications, infectious keratitis, or spontaneous 1 anterior vitrectomy (Fig. 1E) was performed. The lens was slightly dehiscence, for example, after suture removal. Factors such subluxated in the nasal direction without any cataract formation. as inappropriate wound apposition, avascularity of the On the first postoperative day, the uncorrected visual acuity was interface, prolonged treatment with topical steroids, elevated counting fingers at 2 m and the graft was watertight. Three months after intraocular pressure, or suture complications may have an the emergency surgery, the corneal graft was clear and centered with effect on the further development of corneal wound healing.1,2 well-positioned single sutures (Fig. 1B). The BCVA in the right eye was 20/100. The lens remained slightly subluxated but clear. Received for publication January 22, 2015; revision received February 17, 2015; accepted February 24, 2015. Published online ahead of print April DISCUSSION 16, 2015. From the Department of Ophthalmology, Saarland University Medical Center CPAP is considered as the standard treatment for sleep UKS, Homburg/Saar, Germany. apnea–hypopnea syndrome worldwide.5 CPAP primarily im- The authors have no funding or conflicts of interest to disclose. proves oxygenation by increasing functional residual capacity Reprints: Miltiadis Fiorentzis, MD, Department of Ophthalmology, Saarland University Medical Center UKS, 100 Kirrberger St, 66424 Homburg/ and may also increase lung compliance and decrease the work Saar, Germany (e-mail: miltiadis.fi[email protected]). of breathing. Published ocular complications associated with Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. the use of face masks include keratoconjunctivitis sicca, Cornea Volume 34, Number 6, June 2015 www.corneajrnl.com | 717 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Fiorentzis et al Cornea Volume 34, Number 6, June 2015 FIGURE 1. Corneal graft dehiscence over 180 degrees (A, interrupted semicircle) with loosening of corneal sutures and iris incarceration (A, arrow). Teeth and notches (key/key hole) fixation (B and C, arrows) and readaptation of the loose ends of the double running sutures (C, stars). Multiple single sutures in the area of the remnants of double running suture (D, arrows). E, Anterior vit- rectomy. F, Finalization of corneal graft resuturing with single stitches and removal of the double running suture. corneal abrasion, choroidal effusion, and increased ocular experience an accidental or deliberate physical attack, whereas pressure.6 Physicians should be alerted that patients with the elderly are more likely to have fallen.1 The visual prognosis keratoconus have a higher prevalence of obstructive sleep is reported to depend on the degree of intraocular tissue loss and apnea and therefore are prone to need a CPAP mask.7 the concomitant posterior segment damage at the time of With the growing number of PKP operations, the trauma.1 Ocular complications related to wound dehiscence are incidence of traumatic wound dehiscence is bound to intraocular lens expulsion or dislocation, expulsive hemorrhage, increase.1,2 After PKP, the surgical wound may never achieve endophthalmitis, vitreous incarceration, epithelial downgrowth, the tensile strength of the primary corneal tissue, exposing the glaucoma, or retinal detachment after wound disruption.1,2,9 eye to an increased susceptibility to even minor trauma.1,2 The A greater majority of graft dehiscence is reported in the incidence of traumatic dehiscence after PKP has been reported superior quadrant.2 The rupture is possibly caused in these cases to be 1.3% to 5.8%.2,8 Therisktobeharmedbyagloberupture from a contrecoup type of force. Tseng et al2 reported that the due to a blunt trauma is 27 times higher in eyes after intraocular direction and the nature of the trauma are the ultimate surgery.9 It has been reported that a higher wound strength can determinants of the location of the injury and that the temporal be achieved after femtosecond laser-assisted keratoplasty, but it inferior quadrant was most commonly involved. Renucci et al1 did not prevent the wound dehiscence in our case.10 suggested that there is no particular quadrant specificity for graft The time interval between PKP and globe rupture may dehiscence. It would be reasonable to suppose that the inferior range widely, occurring as early as a few days or as late as .30 temporal quadrant with the lack of protection by the eyebrow or years postoperatively. Younger patients are more likely to the nose would be most vulnerable. In our case, the direction of 718 | www.corneajrnl.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Cornea Volume 34, Number 6, June 2015 Traumatic Keratoplasty Rupture the trauma was applied through the CPAP mask from the nose 2. Tseng SH, Lin SC, Chen FK. Traumatic wound dehiscence after to the nasal inferior site of the graft. penetrating keratoplasty: clinical features and outcome in 21 cases. – Cornea. 1999;18:553–558. After trauma, the host graft junction remains suscepti- 3. Hoffmann F. Suture technique for perforating keratoplasty. Klin Monbl ble to wound separation, putting graft survival at risk in the Augenheilkd. 1976;169:584–590. long term after PKP. Therefore, a sustained period of 4. Seitz B, Langenbucher A, Kus MM, et al. Nonmechanical corneal postoperative care should be provided after the surgery. A trephination with the excimer laser improves outcome after penetrating satisfactory visual outcome is rare but can be achieved if the keratoplasty. Ophthalmology. 1999;106:1156–1164. 5. Ballester E, Badia JR, Hernández L, et al. Evidence of the effectiveness posterior segment stays intact and no further complications of continuous positive airway pressure in the treatment of sleep occur. Ophthalmologists should be aware of even unusual apnea/hypopnea syndrome. Am J Respir Crit Care Med. 1999;159: possible causes of wound dehiscence in their patients and of 495–501. the potential wound complications at all times in the post- 6. Zandieh S, Katz ES. Retrograde lacrimal duct airflow during operative course. Patients should become more acquainted nasal positive pressure ventilation. J Clin Sleep Med. 2010;6: 603–604. with the consequences of possible trauma of the eye.