EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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57 EW RESIDENTS August 2014 "Studies have shown that the health of a corneal graft may be adversely affected by the placement of a glau- coma drainage device 1 ; however, this particular eye had refractory disease as a result of multiple surgeries. Glaucoma surgery was inevitable." I asked Dr. Law how the peripheral anterior synechiae (PAS) might affect the case. He stated, "The extent of PAS can increase after each addition- al surgery." Interestingly, he pointed out that outflow can also be adverse- ly affected after additional surgeries Discussion The case was presented to some of the local experts. Dr. Law commented: "Glaucoma is a common outcome in eyes that have had multiple interventions." Given the patient's elevated intraoc- ular pressure, Dr. Law recommended glaucoma surgery. "We have exten- sive experience in placing drainage devices in similar eyes following penetrating keratoplasty or after the implantation of intraocular devices such as the Ophtec 311 [Ophtec USA, Boca Raton, Fla.] and kerato- prostheses." Regarding the pres- ence of the corneal graft he stated, patient and was asked to share some of my perspectives. Case presentation A 67-year-old man of Middle Eastern descent with a history of peripheral corneal degeneration of unknown etiology underwent penetrating keratoplasty of the left eye (OS) in 1975 and right eye (OD) in 1977. He underwent repeat penetrating keratoplasty OS in 1998 for graft failure and uncomplicated bilateral cataract extraction with intraocular lens (IOL) implantation in 2002. In 2005, he presented to Stein Eye with a Paecilomyces fungal keratitis complicated by perforation requiring an emergent therapeutic penetrating keratoplasty. He then developed a fungal endophthalmi- tis, ciliary body detachment and hypotony, and underwent pars plana vitrectomy, IOL explanta- tion, and ciliary body repair OS. He had persistent corneal surface disease OS including marked surface irregularity and recurrent epithelial defects secondary to limbal stem cell deficiency. Two years later, he was referred to Dr. Miller's clinic. He was sur- gically aphakic and functionally aniridic OS at that time (Figure 1). He reported significant photopho- bia, glare sensitivity, dissatisfaction with his cosmetic appearance, and poor visual acuity. He was on max- imal medical therapy with elevated intraocular pressure. His uncorrected distance visual acuity (UDVA) was 20/50-1 OD and counting fingers at 1 foot OS with no improvement on pinhole testing. His corrected distance visual acuity (CDVA) with spectacles was 20/50-2 OU with manifest refractions of –1.00 +4.00 x 015 OD and +9.50 sphere OS. Slit lamp biomicroscopy OD showed peripheral corneal thinning with opacification, a clear corneal graft, and a posterior chamber IOL. Biomicroscopy OS revealed periph- eral corneal thinning, a clear corneal graft with temporal guttata, periph- eral anterior synechiae from 9 to 11 o'clock, an irregular 11 mm pupil, and aphakia. His optic nerve OS revealed mild pallor with a 0.6 cup to disk ratio. His posterior segments were within normal limits bilaterally. Introduction from Kevin M. Miller, MD This month we present an inter- esting but unfortunate gentleman who was seen by multiple specialists at UCLA's Stein Eye Institute. He is a complex patient who presented emergently to our tertiary care facil- ity for evaluation following multiple surgeries. The patient required a multispecialty surgical approach to address his visual rehabilitation. He was recently evaluated by Nathaniel Roybal, MD, PhD, one of the current third-year residents, while rotating through the cornea service. Nathaniel chose this case due to its novelty and interesting discussion. Nathaniel is headed to the University of Iowa for a vitreoretinal fellowship when he graduates. Our discussant panel includes Simon K. Law, MD, PharmD, from the glaucoma division at Stein Eye, and Sophie X. Deng, MD, PhD, from the cornea division at Stein Eye. I also provided care for this Artificial anterior segment by Nathaniel Roybal, MD, PhD Nathaniel Roybal, MD, PhD, third-year resident Kevin Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Eye Institute, Los Angeles continued on page 58 Academic grand rounds Figure 1: Appearance of the patient at the time of initial presentation to Dr. Miller. The left eye was aphakic and aniridic. Figure 2: Appearance of the patient following Ophtec 311, Ahmed tube shunt, and Boston type 1 keratoprosthesis implantation Source (all): Jules Stein Eye Institute