Eyeworld

DEC 2018

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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73 December 2018 EW MEETING REPORTER tend to be thicker and are easier to unscroll. Dr. Terry then described two variations in DMEK tissue injec- tion: endothelium-out and endo- thelium-in. The endothelium-out technique (natural scrolling confor- mation of the tissue) is a tapping method of opening the tissue. Meanwhile, endothelium-in (tissue folded over viscoelastic) is a pull- through method with an anterior chamber maintainer. For surgeons looking to take the first steps in learning the DMEK procedure, Dr. Terry recommend- ed attending didactic and wet lab courses, viewing videos online on DMEK, and understanding the variations in DMEK techniques and unique challenges of each. He added that the most important step is to "be the first assistant at the micro- scope with an experienced DMEK surgeon." This will help a surgeon learn the nuances of the surgery before doing his or her first case. Dr. Terry also offered advice on how to make your first DMEK and operating with refraction in mind are all important. Finally, he highlighted postop- erative considerations. These include patient education, close monitoring of IOP, simplification of medical management, patient prep, and knowing when "enough is enough." Mark Terry, MD, Portland, Oregon, discussed the challenge of transitioning to DMEK. DMEK today is easier and faster with standardization of techniques, he said, noting that eye banks now take several steps to help eliminate some complications prior to surgery. Tissue is now prestripped, eliminat- ing the risk of the surgeon destroy- ing tissue at the time of surgery. Tissue is prestamped, which helps eliminate the risk that it would be inserted upside down, and it is preloaded. DMEK requires a different skill set than DSAEK. The DMEK scroll always spontaneously rolls up with endothelium on the outside of the scroll, so touching the tissue directly kills endothelium, Dr. Terry said, adding that donors over 60 years old The "gold standard" is confocal microscopy, Dr. Tu said, which is an alternative to corneal biopsy and offers real-time imaging. He noted that bacterial keratitis is not easily imageable because the bacteria are so small. Corneal morphology can be imaged, and atypical infectious keratitis will be the greatest utility for confocal microscopy. Editors' note: Dr. Tu has no financial interests related to his presentation. Topics in keratoplasty A section of the Cornea Subspecialty Day program highlighted a variety of keratoplasty topics. Mark Man- nis, MD, Sacramento, California, presented "Perfecting Penetrating Keratoplasty: Lessons Learned Over Time." Though there has been a shift to endothelial keratoplasty (EK), Dr. Mannis said that surgeons still need to know how to do pene- trating keratoplasty (PK). He noted that PK "still dominates outside North America." Dr. Mannis highlighted several instances when PK is still necessary, particularly in pan-layered corneal disease and therapeutic keratoplasty (infection, trauma, or in regions of the world with significantly ad- vanced disease). Signature skills for PK include patient selection, open sky man- agement in the OR, suturing skills, refractive management, immuno- modulation, and glaucoma manage- ment. Dr. Mannis said surgeons should take certain preoperative consid- erations, especially making sure to optimize the ocular surface. Choice of anesthetic and knowing your eye bank are also important factors preoperatively. Intraoperatively, Dr. Mannis said establishing a team approach, having a speculum of choice, being prepared for the worst complication, added that 111 eyes (73%) had inter- face fluid but no air injection. Dr. Lass said significant factors associated with graft dislocation include operative complications, do- nor history of diabetes, and a donor cornea with thicker precut thickness. He also discussed the impact of graft dislocation with graft failure in the CPTS. Eyes with graft dislocation had an eight times increased risk for failure through 3 years compared with eyes without graft dislocation. There was a 66% success at 3 years with dislocation vs. 96% without graft dislocation. Editors' note: Dr. Lass has no financial interests related to his presentation. Anterior segment imaging During a session at Cornea Subspe- cialty Day, Elmer Tu, MD, Chicago, discussed diagnostic imaging in infectious keratitis. Bacterial keratitis is generally discrete "colony" lesions and there's usually inflammation. Meanwhile, clinical signs of fungal keratitis may include min- imal necrosis, minimal inflamma- tion, a growth pattern that includes branching filaments (punctate "on end" opacities and additive to the corneal contour), satellite lesions, and a feathery, irregular margin. Dr. Tu said to watch out for the sudden onset of or worsening of hypopyon because that could indicate fungal keratitis, as could penetration of fungal elements into the anterior chamber. Any pigmentation strongly suggests a fungal etiology, Dr. Tu said. Dr. Tu highlighted culture meth- ods before moving on to discuss how optical coherence tomography (OCT) may help identify infectious keratitis. He noted that OCT has a limited ability to identify organisms but may be useful in special cases, like CMV endotheliitis or retrocor- neal plaque assessment. View videos from the AAO Annual Meeting: EWrePlay.org Kevin Miller, MD, discusses late IOL dislocation. continued on page 74

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