Eyeworld

EW FEATURE 91 we will leave the lens in place and just do the DSAEK. If the anterior chamber IOL was recently placed and followed quickly by persistent edema, it usually means it is unsta- ble and needs to be replaced. Of course, stability of the lens is always mechanically verified at the time of surgery." Another co-morbidity combina- tion that's not discussed often is cataracts in the presence of anterior basement membrane corneal dystro- phy, Dr. Lane said. "In these patients, the irregular surface means you'll get an error in your IOL calculations," he said. "You need to perform a sequential proce- dure, corneal scraping and letting the cornea heal smoothly, then the measurements and cataract surgery. Scraping first will ensure you're get- ting a pure, pristine surface for accu- rate IOL measurements." Future trends As diagnostics improve and treat- ment options for concomitant dis- eases are expanded, more surgeons are likely to incorporate surgical treatments earlier in the course of a disease. For instance, Dr. Terry noted the improved optics and large de- crease in recovery time has moved him to perform DSEK earlier in the disease and in younger patients, compared to full-thickness trans- plants. "For PK, the average age and vi- sion of someone undergoing surgery in my practice 20 years ago when they had Fuchs' was 78 years old and 20/100 vision. With DSAEK, it is now similar to simple cataract sur- gery cases at 65 years old with 20/60 vision," he said. EW Editors' note: Dr. Donnenfeld has financial interests with Alcon (Fort Worth, Texas) and Glaukos. The other physicians interviewed have no finan- cial interests related to their comments. Contact information Devgan: 800-337-1969, devgan@gmail.com Donnenfeld: 516-766-2519, eddoph@aol.com Lane: 651-275-3000, sslane@associatedeyecare.com Terry: 503-413-6223, MTerry@DeversEye.org Yoo: 305-326-6322, syoo@med.miami.edu Innovation. Selection. Value. Durability WinFame U.S.A Inc Tele: (626) 442-8238 Fax: (626)442-8239 e-mail: sales@winfameusa.com www.winfameusa.com ASCRS / ASOA San Diego Booth 423 Leadership in: FDA Approved Scanners Titanium Instruments NM-Crystalloid (Black Diamond ) Blade Sapphire Surgical knives Exhibition Contact: 626-255-9866 The same eye, post-DSAEK and post-phaco Source: Sonia H. Yoo, M.D. also recommended staggered sur- gery, waiting until the worst eye has vision equal to the better eye before operating on the better eye. "If there is more cataract than endothelial disease, I'll operate se- quentially, but if there's more corneal disease than cataract, I'll op- erate concurrently. The reasoning is that after endothelial keratoplasty, I don't want to have to go back into the eye later and potentially trauma- tize the graft. I don't want to risk damaging the graft," he said. Because diagnostic tools have been unable to help clinicians deter- mine what percentage of the visual disability is from corneal disease ver- sus cataract, coupled with retinal disease pathologies in some patients, "it's very difficult to determine what's at the heart of the visual problem," Dr. Yoo said. "To some de- gree, we're relying upon our own acumen to make the correct diagno- sis. There's a need for better diagnos- tics to sort it out." Having a complete patient his- tory can help, she said, adding she personally has a lower threshold for putting in an implant than when the patient does not have concur- rent corneal disease. Corneal trans- plant patients will require long-term steroid use, which hastens the pro- gression of cataract, so removing even early cataracts makes sense, Dr. Yoo said. "You know you're going to lose endothelial cells, and that usually sways me toward removing the cataract at the time of corneal trans- plant," she said. "The opposite is a trickier algorithm. When you've got visually significant cataract and corneal guttata without edema, it's more difficult to think about taking out the cataract alone." If a patient has a lower cell count (under 1,000 mm 2 ) and a pachymetry level higher than 680 microns, "I lean toward a combined procedure," she said. When pachymetry is between 640 and 680 microns, "I counsel them about their risk of corneal decom- pensation being higher than the av- erage person, but I'm more willing to perform cataract surgery alone." She added that surgical tech- niques can alter outcomes as well— soft shell techniques help preserve more cells, and newer phaco tech- nology that reduces the amount of energy and time also helps preserve more cells. Dr. Terry said he looks at the patient's age—if the patient has a minimal cataract but significant Fuchs' and is younger than 50 years old, "leave the lens in place and consider just performing DSAEK," he said. "Under the age of 50 the pa- tient still has some accommodation left in the lens, and the data shows that these younger lenses are less likely to develop cataract changes post-op." Dr Terry was quick to add that "phakic DSAEK surgery is more difficult to perform and the 50-year mark is not set in stone, but is a gen- eral threshold." Eyes with corneal edema and an anterior chamber IOL in place can present the greatest surgical dilemma. "Replacing the anterior chamber IOL with a sewn-in poste- rior chamber IOL allows the DSAEK surgery to be much easier, but can be a very extended surgery," Dr. Terry said. "On the other hand, leav- ing the anterior chamber IOL in place can make DSAEK very difficult due to the crowded chamber and the unicameral eye," he said. "We decide what course to take based on the sta- bility of the AC IOL. If the IOL has been in place for many years and the edema only occurred recently, March 2011 COMBINED SURGERY

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