a 27-year - old malay male patient presented two weeks 
 after alkali splashed into his left eye while working . prior to 
 reporting to us , the patient consulted a general practitioner 
 who prescribed some topical eye drops ( details of the 
 treatment were not available ) and the eye condition worsened . 

anterior segment examination revealed a central corneal 
 ulcer ( 1  1 mm ) with stromal infiltration ( 4  6 mm ) , limbal 
 ischemia , normal anterior chamber depth and visual acuity 
 of counting fingers .
a gentle b - scan ruled out any posterior 
 segment abnormality . a clinical diagnosis of left corneal ulcer with limbal ischemia 
 secondary to alkali injury with secondary infection was made . 

culture from corneal scraping was negative . despite intensive 
 therapy with oral ( tab ciprobay 500 mg twice daily , bayer ) 
 and topical ciprofloxacin ( gutt ciloxan 0.3% hourly , alcon ) 
 ( no topical steroids used ) with other supportive therapy ( tab 
 vitamin c 1 g daily , pharmaniaga ) , further deterioration led 
 to formation of central corneal perforation with surrounding 
 stromal thinning and flat anterior chamber .
we performed a gunderson conjunctival flap under local 
 anesthesia ( la ) , which retracted and failed after one week . 

slit - lamp examination revealed a large central corneal perforation 
 ( 4  5 mm ) with surrounding stromal thinning involving two- 
 thirds of the cornea without any signs of infection . in order to maintain the shape of the eyeball and due to the 
 problem of non - availability of donor cornea
, we decided to use 
 processed bp xenograft ( lyolemb ) supplied by national tissue 
 bank , universiti sains malaysia after obtaining the consent of the 
 patient .
a 360 peritomy was done and the graft was sutured with 
 7 - 0 polyglycolic and polylactic acids ( vicryl ) to the perilimbal 
 area with conjunctival advancement .
topical ( gutt ciloxan 0.3% 
 hourly , alcon ) and oral ciprofloxacin ( tab ciprobay 500 mg 
 twice daily , bayer ) was prescribed in the postoperative period 
 [ figure 1 ] .
nine months follow - up 
 showed a well - taken graft without any exposure / dehiscence and 
 minimal inflammation [ figure 2 ] .
slit - lamp examination could 
 not reveal the details of the anterior chamber and beyond due to 
 conjunctival advancement and vision was noted as perception 
 of light with inadequate projection of rays .
conjunctival flap is unlikely to seal large corneal perforations 
 associated with corneal melting following chemical injury . 

efficacy of amt alone or with glue in treating small corneal 
 perforation has been well established but found unable to 
 promote corneal stability in patients with severe corneal 
 thinning and therefore , an additional urgent tectonic procedure 
 has to be undertaken.3 non - availability of donor cornea poses 
 a considerable problem in some countries .
processed bp is a tough lyophilised collagen sheet used 
 as a surgical armamentarium in wrapping orbital implants.4,5 it renders the material antigenically inert and adds to its 
 strength , pliability and longevity.5 it has been shown to be 
 well tolerated with minimal inflammation in animal studies.4 
 although theoretic concerns about prion disease can be raised , 
 no evidence of this problem has been reported from over 
 90,000 human implantations.6 devron reported no significant 
 ophthalmic reactions due to this xenograft in his cases of orbital 
 implants.7 at the national tissue bank , universiti sains malaysia , 
 the procured pericardium sheet was washed using chemical 
 agent ( sterile phosphate buffer at ph 7.4 ) and frozen to 40c . 

it was then freeze - dried and packaged in double - layer plastic 
 bag .
the processed bp was radio - sterilized at 2.5 mega rads 
 using gamma radiation and was then ready for use.8 we used 
 this locally processed bp in our case .
its use in complicated ocular surface 
 diseases such as large corneal perforation with corneal melting 
 can be promising .
its use needs to be further studied more 
 extensively as an alternative graft material in large corneal 
 perforations .
 to describe use of a locally processed bovine pericardium ( bp ) to 
 cover a large central corneal perforation following alkali injury 
 and discuss postoperative outcome.a 27-year - old malay male patient presented two weeks after 
 alkali splashed in his left eye while working . 
 a clinical diagnosis 
 of left central corneal ulcer with limbal ischemia following alkali 
 injury with secondary infection was made . 
 after failed medical 
 therapy , we performed a gunderson conjunctival flap under 
 local anesthesia that retracted after one week and resulted in 
 a large central corneal perforation with surrounding stromal 
 thinning . 
 the perforation was covered with a locally processed 
 bp xenograft ( lyolemb ) supplied by the national tissue bank , 
 university sains malaysia . 
 nine months follow - up showed a 
 well - taken graft without any exposure / dehiscence and minimal 
 inflammation.amniotic membrane transplantation when used as a patch graft 
 needs an urgent tectonic graft to promote corneal stability in 
 patients with severe corneal thinning . 
 the use of processed bp 
 can be a viable option in treating such cases . 
Case Report
Discussion