Eyeworld

I OCUR SURFACE CONSIDERATIONS FOR SURGERY N FOCUS 36 | EYEWORLD | JUNE/JULY 2020 Contact Dhaliwal: dhaliwaldk@upmc.edu Lee: wblee@icloud.com Rapuano: cjrapuano@willseye.org contact lens or temporary tarsorrhaphy to suture the eyelids partially closed (laterally, so you can get a look in through nasal opening and patients can get medicine in). If dryness is an issue, you can also use punctal plugs, he said. to start drops first and use plugs secondarily in cases without blepharitis, allowing inflammatory cells on the ocular surface to get better clear- ance via the puncta before surgery. If glaucoma drop toxicity is present, he tries to get drops switched to preservative-free solutions prior to EK. Dr. Dhaliwal stressed the importance of optimizing the surface. Often during EK, as you're getting the graft to unfold, you can get corneal epithelial defects. It's therefore import- ant to optimize the ocular surface ahead of time to optimize healing postoperatively. Dr. Dhaliwal said that optimizing the surface can include working on the lids and looking for Demodex or blepharitis. She likes to use tea tree oil wipes, which are available over the counter. Dr. Dhaliwal also recommended a beaded mask, which is a way of getting the meibomian glands to clear. She'll have patients use an arti- ficial tear spray, which she said is well adopted by those who find it easier to use than getting a drop in the eye. Dr. Dhaliwal uses anti-inflammatories to control dry eye and inflammation ahead of time, particularly topical cyclosporine or lifitegrast. But she added that it depends on the patient. Dr. Rapuano said ocular surface disease, dry eye, and blepharitis may be less of a concern with EK than PK because you're not disturbing the front layers of the cornea. He said you still want to maximize the health of the surface of the cornea, but PK will disturb it more than EK. With PK, you want to make sure the sur- face is as healthy as possible. The transplant's epithelial layer might be unhealthy or gone completely, which could result in a large or total corneal epithelial defect over the trans- plant. If you have a bad surface and still have to do PK, Dr. Rapuano said to maximize the surface health as best as possible. He also said to ask the eye bank for tissue that has an intact epithelium. During surgery, he added that suturing or gluing amniotic membrane over the surface of the cornea can help, as can using a bandage continued from page 35 A Salzmann's nodule in the setting of Fuchs corneal endothelial dystrophy; the surgical plan will be to do a lamellar keratectomy at the time of the EK procedure Patient with MRSA corneal ulcer from infected bullae in the setting of severe corneal edema and Fuchs corneal endothelial dystrophy; the residual scar measured 65% of the cornea centrally so the decision to do an EK was changed to a PK given corneal disease in all layers of the cornea Source (all): W. Barry Lee, MD

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