Eyeworld

EW CORNEA 40 February 2019 by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer patient," he said. "If you are going to handle epithelial downgrowth, be prepared for multiple, difficult surgeries in cases of sheet-like, cystic epithelial downgrowth." Case study Dr. Nuijts presented the case of a 40-year-old female patient who received an Artisan phakic IOL (Ophtec, Groningen, the Nether- lands) in 2006. The simple surgery would turn into a 12-year, ongoing case. Two years later, the patient underwent excision of an iris cyst in her left eye together with part of the corneal stroma of the eye. After Handling epithelial downgrowth can involve numerous surgeries that span many years E pithelial downgrowth is the aggressive migration and proliferation of epithe- lial cells within the eye, associated with penetrating eye injuries or anterior segment surgery. The wild growth of these cells can greatly impair vision, cause pain, and induce high intraocular pressures leading to bouts of acute glaucoma. The growth of cells over the intraocular structures is often sheet-like, causing inflammation and tissue damage. Epithelial ingrowth is difficult to remove and frequently recurs. Rudy Nuijts, MD, professor of corneal transplantation and refractive surgery, Maastricht UMC+, University Eye Clinic, Maas- tricht, the Netherlands, described a case of epithelial downgrowth in a patient who required treatments for well over 12 years. He presented the case at the 22nd ESCRS Winter Meeting. "We performed nine surgeries over a 12-year time period in this another 2 years, recurrent iris pro- lapsing led to surgery with amnion membrane transplantation treat- ment. At this point (2010), due to persistent leakage, the patient was referred to Dr. Nuijts. Dr. Nuijts observed corneal pigmentation, synechiae, and an el- evated phakic lens. His examination further revealed right-sided uncor- rected distance visual acuity (UDVA) of 1.5 logMAR, left-sided UDVA of 1.0 logMAR, right-sided corrected distance visual acuity (CDVA) of +1.25, and left-sided CDVA of –1.75 x 67°:1.2. The patient's endothelial cell density (ECD) was 2217 cells/ mm 2 (right eye) and 1438 cells/ mm 2 (left eye). Lamellar keratoplasty was un- dertaken to reconstruct the cornea (October 2010), involving trephi- nation 3.0 mm behind the thinned cornea at 12 o'clock and the im- plantation of a mushroom-shaped graft. He dissected the anterior syn- echiae in preparation of the lamellar keratoplasty using a Moria (Antony, France) microkeratome with its 200 µm head and diameter of 3.0 mm. The postoperative visual outcomes were UDVA 0.6 logMAR and CDVA +0.5 logMAR. The left-sided ECD was 1309 cells/mm 2 . Managing a new development Sheet-like epithelial downgrowth from 12 o'clock toward both the nasal and temporal sides was noted about 1.5 years later (April 2012). At this time, the patient's CDVA was –0.25: –0.75 x 40°: 1.0– and ECD was 1175 cells/ mm 2 . To manage Long-term management of epithelial downgrowth after phakic IOL implantation Case presentation of sheet-like epithelial downgrowth from 12 o'clock nasally and temporally Another device that has un- dergone clinical trials is made by Morcher (Stuttgart Germany). Ophtec and Morcher were the first companies to develop artificial iris devices. "I became interested in Morcher devices years ago for select patients who had specific iris needs. This company makes a variety of devices that accommodate different needs. Individual surgeons around the country were petitioning the FDA to get single-use compassionate device exemptions, and the FDA was giving them the OK. Then the FDA told Morcher that they would not approve them anymore and that Morcher needed to do a clinical trial. Morcher declined to start a clinical trial because they thought it would be too expensive. I asked Morcher if I could run a clinical trial through my practice, and they agreed. Over the last few years we have published several papers regarding our experiences with Morcher implants, 1,2,3,4,5 and we are hoping to go to the FDA in 2019 for a guidance meeting to get the FDA's perspective on what else we need to do to get this out on the market commercially. My hope is that this will happen in the next 3–5 years," he said. EW References 1. Olson MD, et al. Interim results of a com- passionate-use clinical trial of Morcher iris diaphragm implantation: report 1. J Cataract Refract Surg. 2008;34:1674–80. 2. Date RC, et al. Outcomes of a modified cap- sule tension ring with a single black occluder paddle for eyes with congenital and acquired iris defects: report 2. J Cataract Refract Surg. 2015;41:1934–44. 3. Miller KM, et al. Outcomes of implanta- tion of modified capsule tension rings with multiple black occluder paddles for eyes with congenital and acquired iris defects: report 3. J Cataract Refract Surg. 2016;42:870–8. 4. Lin SR, Miller KM. Lessons learned from implantation of Morcher 50D and 96S artificial iris diaphragms. Case Rep Ophthalmol. 2017;8:527–534. 5. Miller KM, et al. Safety and efficacy of black iris diaphragm intraocular lens implantation in eyes with large iris defects: report 4. J Cataract Refract Surg. 2018;44: 686–700. Editors' note: Dr. Miller has no finan- cial interests related to his comments. Contact information Miller: miller@jsei.ucla.edu Update continued from page 36 Presentation spotlight

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