The EBAI CME 2013 - 21st and 22nd of September 2013, Golden Valley Resort, Ghodbunder Road, Thane West, Mumbai.

1. Dr Vandana Jain
MS,DNB,MNAMS,FLVPEI, FICO,MBA
Fellow L.V. Prasad Eye Institute
FICO( Massachusetts Eye & Ear Infirmary)
MBA( Stanford Business School)
Cornea, Cataract and Refractive Surgeon
Managing Director, Advanced Eye Hospital & Institute

2. Age
Visual
Acuity
Previous
history/Durati
on
Findings Serology Surgery Followup
Visual
Acuity
Outcome Complications
6220/400
Pterygium
excision/ 9
months
Necrotizing
scleritis with
cataract
Negative
SPG with
AMG
18 months HMCF
Stable
ocular
surface
Cataract
progression

3. Age
Visual
Acuity
Previous
history/Duration
Findings Serology Surgery Followup
22 20/400
Cataract surgery and
transcleral
cyclophotocoagulati
on/ 4 years
Aphakic glaucoma with
ciliary staphyloma with
uveal exposure with
corneal edema
Negative
SPG with conj.
Flap
36 months

4. Age
Visual
Acuity
Previous
history/Duration
Findings Serology Surgery
Follow
up
Visual
Acuity
Outco
me
48 20/20
Pterygium
excision twice/7
months
Necrotizing scleritis
with uveal
exposure
Negative SPG with AMG
13
months
20/20 Stable

6. Age VA
Previous
history/Duration
Findings Organism
Medical
therapy
surgery
Visual
Acuity
Outcome
Complicat
ions
76 20/400
Pterygium
excision with
MMC/ 3 years
Scleral abscess,
AC reaction
GPC/ Staph
epidermidis
Systemic
Steroids/
Topical
gatifloxacin
Scleral
debride
ment/
Scleral
patch
graft
FCCF Resolved Cataract

8. Our Study
 A total of 13 eyes underwent scleral patch grafting for scleral
defects of varying etiologies
 Necrotizing scleritis following pterygium surgery (40%) was the
most common cause
 Tectonic success was achieved in 10 eyes (76.9%)
 Scleral grafting with overlying conjunctival or amniotic
membrane graft is an effective and simple measure to
preserve globe integrity both structurally and functionally
Eye (2007) 21, 930–935

9. Oculoplasty colleagues

10. Br J Ophthalmol. 2006 July; 90(7): 924–925
•42 year old lorry driver
•Traumatic corneal
perforation >1.5 mm
•Glue BCL failed

11. •77-year-old white female with retinal
detachment
•Planned for scleral buckling procedure
•Converted into a scleral graft
procedure, as extreme scleral thinning
was found intraoperatively.
•An alcohol-preserved donor sclera graft
was used
Indian J Ophthalmol. 2011 May-Jun; 59(3): 235–238

12. Ophthalmology 2012;119:2631–2636

13. Advantages of Scleral Implants
 Readily available
 Can be easily preserved for months
 Strong, flexible and easy to handle
 Natural curvature allowing it to neatly blend with host sclera
 Avascular ,well tolerated with little inflammatory reaction

14. Scleral Grafts
 Human sclera grafts are
widely used in ophthalmic
surgery
 Processing of sclera grafts
in an eye bank is easy to
handle compared to the
complexity of cornea
transplants

15. Preparing the Graft
 Demand for sclera grafts can be covered without a lot of
trouble
 For the preparation of sclera grafts
 All other tissues removed from donor bulb including retina,
choroid, cornea, corpus vitreum and lens
 The sclera graft can be stored dry or in ethanol until
transplantation
 HIV infection, syphilis, hepatitis C, hepatitis A, tuberculosis,
HTLV-1 and -2 infection, active leprosy, active typhoid,
smallpox and active malaria are also contraindication

16. Contraindications for Sclera preservation
 Active viral Hepatitis
 Acquired immunodeficiency syndrome (AIDS) or HIV
 Active viral encephalitis or encephalitis of unknown origin
 Creutzfeldt-Jakob disease
 Rabies
 Instrinsic eye disease
 Retinoblastom
 Malignant tumors of the anterior ocular segment

17. Unlike Cornea Preservation!
 Laser photo ablation surgery
 Corneas from patients with anterior segment surgery and
poor cornea
 Donor age or death to enucleation time is not important

18. Sclera Preservation
 Glycerine Preservation (Dehydration)
 Tissue may be stored at room temperature up to 3 months
 Surgical utilization requires hydration-
 15 to 30 minutes immersion in BSS with antibiotics
 Absolute Ethanol
 Ethanol conc above 70%
 Room temperature,
 Maintain up to 5-day full validity
 Before utilization the tissue washed in BSS containing antibiotics

19. Sclera Preservation
 Freezing
 At -20 degrees for 3 mnths
 Thawing at room temperature after which kept refrigerated
at 2 - 6ºC for utilization
 Should never undergo refreezing and its storage time
limit, once unfrozen, should never exceed 24 hours

20. Sclera Preservation
 Freeze Dried
 Rapid freezing followed by dehydration of the material
under high pressure.
 Superior method for sclera preservation as compared to
95% ethanol.
 Provides an easy method to manipulate tissue,
 Longer shelf life,

21. Indications of Scleral Transplant
 Ocular implantation after enucleation
 Synthetic eye implant is wrapped in sclera.
 Muscles are then attached to the sclera, which allows artificial
eye to move with companion eye
 Lid retraction
 Sclera is used to reconstruct eyelid
 Glaucoma surgery –
 Ahmed valve is inserted into the eye to reduce intraocular
pressure. The valve is covered with a piece of sclera to allow
movement of the eyelids across the implant.

22. Indications of Scleral Transplant
 Scleral thinning
 Well-reported complication following pterygium excision,
retinal detachment repair, systemic vasculitis, high myopia
or trauma
 Reinforcement of thin or perforated sclera is necessary,
especially when choroid is exposed to prevent prolapse of
ocular contents and secondary infection

23. •Scleral thinning with exposure of
residual tumor beneath conj
•Choroidal Melanoma
Large, hand-crafted scleral graft beneath
the conjunctiva
Ophthalmology 2012;119:2631–2636

24. 9 months later showing evidence of absorption and thinning
of the graft with uveal pigment at the edge
Ophthalmology 2012;119:2631–2636

25. Need to be careful about!
 Need to keep a close watch on epithelialisation and
vascularisation
 Risk of graft necrosis, graft dehiscence and
endophthalmitis
 Scleral graft should be well covered with vascular
conjunctival layer

26. To Conclude
 Preparation in the eye bank and storage are less stringent
compared to cornea preservation
 Scleral grafts are well accepted and have multiple
indications
 Need to pay attention to the epithelialisation and
vascularisation

27. THANK YOU
THANK YOU