Eyeworld

EW FEATURE 61 To provide residual myopia of approximately –0.50 to –0.75 D, Dr. Goins generally aims for the IOLMaster (Carl Zeiss Meditec, Jena, Germany) to provide a residual myopia of –1.5 to –2.0 D. "A hyperopic shift of approxi- mately +1 to +1.5 D can be expected after EK, however, the duration of corneal edema may affect the calculation," Dr. Goins said. "With an increase in corneal edema, there may be a concomitant increase in curvature preoperatively, which disappears following EK." Another key point is to stage potential EK patients early in the process and measure keratometry before chronic edema affects the anterior keratometry. Lens use varies Among the areas of triple procedures where unknowns remain is how to consistently obtain successful results with various types of lenses. Dr. Goins noted that toric or multifocal lenses might be used successfully, especially if keratometry is done before chronic edema changes corneal shape. However, "once bullous corneal changes ensue, the accuracy of surgery falls off," Dr. Goins said. Dr. Goins recommended treat- ing such patients with phaco fi rst, followed by DMEK. Dr. Terry, who has presented at several clinical meetings on the dan- gers of implanting a toric or a mul- tifocal IOL in patients with Fuchs' dystrophy, said toric lenses may be appropriate in a patient who has "just a trace of guttae and is unlikely to ever need a transplant." "A multifocal IOL is not a good idea in any Fuchs' eye because the presence of guttae degrades the quality of the image and causes light scatter, both of which make multi- focal IOLs less benefi cial and even disappointing for the patient," Dr. Terry said. Although some toric lens DMEK patients have obtained excellent results, others had dramatic shifts over more than 60 degrees in the axis of the astigmatism postopera- tively, once the mild stromal edema resolved from the DMEK. Such eyes required a lens rotation weeks after the triple procedure. Calcium deposit focus Although most surgeons interviewed for this article reported relying on hydrophobic acrylic lenses, Dr. Price said his lens of choice in recent years has been a hydrophilic lens (Lenstec, St. Petersburg, Fla.). However, he may switch due to reports of calci- um deposits, which have occurred in "one among hundreds" of his cases with the lens. "We don't know why they happen," Dr. Price said. "Whatever is causing it is pretty rare in our experience." Surgical pearls Surgical pearls in triple procedures suggested by Dr. Goins include the frequent use of an endocapsular tension ring to ensure IOL stability and centration. Among DMEK sur- geries using a temporal clear corneal incision, Dr. Goins prefers that the haptics of the IOL be oriented with the incision horizontally and not vertically. Dr. Chan suggested a slightly smaller rhexis than usual that is well centered to ensure complete overlap so that the IOL is stable during the insertion of the donor corneal disc. Additionally, she said triple proce- dures benefi t from use of a cohesive viscoelastic to reform the bag so that it can be easily removed and per- forming the descemetorrhexis after IOL insertion but prior to removal of the viscoelastic. Dr. Terry noted that combined DMEK surgery can be more diffi cult than combined Descemet's stripping automated endothelial keratoplasty (DSAEK). For instance, a shallow- er anterior chamber is desired for DMEK, while the opposite is true for DSAEK. Additionally, there are times in combined DMEK surgery that the corneal endothelium comes in close proximity with the IOL due to the reduced anterior chamber depth, emphasizing the need f or a very small pupil during tissue unscrolling in DMEK surgery. "With time and experience, both EK procedures can be used in combination with phaco," Dr. Terry said. "Surgeons should be comfortable with unscrolling before attempting the combined DMEK procedure due to the increased risk of tissue damage." EW September 2014 Phaco and corneal comorbidities Monday, October 20 5:30 - 7:30 pm | Hyatt McCormick Place Join Ophthalmic Women Leaders (OWL) and Women in Ophthalmology (WIO) for an intriguing program, wine-tasting reception and much more. Sponsored by: Ophthalmic Women Leaders Member Meetings OWL Office, McCormick Place S400B Saturday, October 18 8 to 9 am Hot Topics for Young Professionals & Those New to Ophthalmology 10 to 11 am Hot Topics for Those Who Work in Practice Settings 2 to 3 pm Hot Topics for Business Owners & Entrepreneurs 4 to 5 pm Hot Topics for Those Who Work in Corporate Settings Sunday, October 19 7 to 8:30 am Executive Roundtable Visit www.owlsite.org for information and to register Developing Leaders. Advancing the Industry. Building Community. Join us in Chicago! Editors' note: Drs. Chan, Terry, Baig, and Goins have no fi nancial interests related to their comments. Dr. Price is an unpaid consultant for Lenstec. Contact information Price: fprice@pricevisiongroup.net Chan: clarachanmd@gmail.com Terry: MTerry@deverseye.org Baig: kbaig@toh.on.ca Goins: kenneth-goins@uiowa.edu

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