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41 EW CORNEA February 2019 months post-DSAEK, the patient's CDVA was 20/40, the left-sided IOP was slightly elevated at 22 mm Hg, the DSAEK graft was clear, and pa- chymetry was 664 micrometers. The patient received fluorometholone 2 dd for the graft and dorzolamide/ timolol 2 dd. Despite the repeated efforts in- volved to keep the epithelial down- growth in check, Dr. Nuijts thinks that medical treatment with 5 FU is preferable to surgery. "Do not rush too quickly into block excision," Dr. Nuijts said. "Our patient had wor- ries about a block excision and that is why we decided to follow this strategy. 5 FU and MMC are not cy- totoxic at the right concentrations and can be effective in stopping epithelial downgrowth." EW Reference 1. Nuyts RM, et al. The effects of 5-fluoroura- cil and mitomycin C on the corneal endotheli- um. Curr Eye Res. 1992;11:565–70. Editors' note: Dr. Nuijts has financial interests with Johnson & Johnson Vision (Santa Ana, California), Alcon, Asico (Westmont, Illinois), Bausch + Lomb (Bridgewater, New Jersey), Carl Zeiss Meditec (Jena, Germany), Chiesi (Cary, North Carolina), HumanOptics (Erlangen, Germany), Ophtec, Ocu- lentis (Berlin, Germany), and Thea (Clermont-Ferrand, France). Contact information Nuijts: rudy.nuijts@mumc.nl this new development, Dr. Nuijts decided on a combined procedure of 5 fluorouracil (FU) and a full thick- ness perforating graft, at this site, based on a study that he was previ- ously involved in that corroborated the lack of endothelial cell toxicity with the use of the antimetabolite 5 FU at concentrations of 50 mg/ ml. 1 He injected 0.1 cc 5 FU 10 mg/ ml intracamerally for 5 min and performed penetrating keratoplasty at the site of the earlier lamellar keratoplasty. "Epithelial downgrowth may initially retract after intracameral injection of 5 FU or mitomycin C," Dr. Nuijts said. "It is not toxic to the endothelium when given up to 5 minutes, for even as much as 50 mg/ml concentrations. It may show a delayed effect of up to 3–4 months." Nine months after the com- bined procedure, the patient's vision was decreased to CDVA 0.6 logMAR. Dr. Nuijts observed a membrane that had proliferated on the an- terior surface of the tilted Artisan lens and crept along its edge that began lifting the IOL. There was minimal enclavation temporally due to traction of the membrane. Dr. Nuijts excised the membrane and repositioned the Artisan lens (March 2013). A follow-up 3 months later revealed an increasing membrane formation on the IOL, UDVA of 0.6 logMAR, and ECD of 712 cells/mm 2 . Dr. Nuijts opted for a second intra- cameral injection of 0.1 ml 10 mg/ ml 5 FU for 5 minutes under visco protection. He explained, "Epitheli- al downgrowth recurred in this case, and the patient preferred not to perform an extensive block excision but to use medical antimetabolite treatment." Approximately 6 months later, the patient experienced an acute bout of glaucoma with decreased vision and pain that required an emergency visit. The patient's CDVA was 0.05 logMAR and her IOP was 64 mm Hg. She presented with a shallow anterior chamber with the pIOL touching the endothelium and synechia formation. The pIOL was explanted the next day. Eight months following the pIOL explan- tation (June 2014), the patient's CDVA (with contact lens) was 0.9 logMAR and the ECD was 438 cells/ mm 2 . The endothelial membrane appeared to retract, and there was increasing ovalization of the pupil and evidence of a subcapsular poste- rior cataract. Dr. Nuijts removed the mature cataract via phaco, dissected the synechiae, and implanted an AcrySof IQ SN60WF (Alcon, Fort Worth, Texas). After cataract surgery In July 2015, 7 months after the cataract surgery, CDVA for plano was –1.75 x 155°, giving the patient a vision of 20/16. The ECD was 696 cells/mm 2 and the cornea was clear, with some ectropion uveae. A few months later, the patient developed cyst formation with cystic epithelial downgrowth. Dr. Nuijts injected 5 FU into the cyst (1ml 25 mg/ml) in the patient's left eye, mixed with trypan blue under simultaneous drainage and visco protection of the anterior chamber. He used two syringes that he injected into the cyst, one for the drainage and the other for the injection of the 5 FU. The cyst persisted between 10 and 3 o'clock. The left sided CDVA was 20/25 with plano –1.5 x 150°. It was treated by an intracyst injection of 0.002 mg/ml mitomycin C with trypan blue under visco protection 1 year later (March 2016). "Mitomy- cin C attacks cells that are in their rest phase as well, so it was seen to be effective in studies. We used the same double injection technique as above," Dr. Nuijts explained. Within 2 months of the mi- tomycin C injection, he noted the cyst starting to close and continu- ing to do so over a time period of roughly 6 months. One year after the mitomycin C treatment, there was recurrence of the cyst. CDVA decreased to 0.16 logMAR, and the patient's IOP was 15 mm Hg. The corneal pachymetry was 663 µm and corneal edema was evident. At this point, Dr. Nuijts excised the cyst in combination with a DSAEK procedure. He noted extensive pos- terior capsular opacification (PCO) roughly 6 months later that he treated with YAG capsulotomy. At 9 Cystic epithelial downgrowth treated by intracyst injection of mitomycin C with trypan blue under visco protection Source (all): Rudy Nuijts, MD

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