Eyeworld

127 October 2015 EW MEETING REPORTER specialist, don't start the patient on antibiotics; let the referral physician do that. By administering antibiot- ics yourself, you'll ensure that the specialist will have to wait before he or she can culture the infiltrate and find the appropriate treatment for the patient. Editors' note: Drs. Al-Mohtaseb and Hamill have no financial interests related to their comments. If you've empirically treated a low-risk ulcer and the patient didn't improve, move that ulcer to the high-risk group and culture it, Dr. Al-Mohtaseb said. If the infection is not improving or worsening after antibiotic treatment, reculture and rethink your management—the patient could have a resistant organ- ism, a co-infection or a new infec- tion, or could be noncompliant with the medication. In addition, never empirically treat fungal keratitis, she rejection rate than DSEK grafts and allow for faster visual rehabilitation. Patients who have had a DSEK in one eye and a DMEK in the other eye routinely prefer the DMEK eye, Dr. Hamill said. In addition, not being able to directly manipulate the DMEK graft can be an advan- tage; some studies have shown that DMEK procedures preserve more endothelial cells than DSEKs, which could be due to less manipulation of the graft. What is the verdict on DSEK versus DMEK? Dr. Hamill believes that although the DMEK procedure is more difficult with a steeper learn- ing curve, visual results are promis- ing and this could be the procedure of choice in the future. Editors' note: Dr. Hamill has no finan- cial interests related to his comments. Managing infectious keratitis While there is a consensus among cornea specialists and non-cornea specialists for how to treat small, peripheral corneal ulcers caused by infectious keratitis, there is a differ- ence in how cornea specialists and comprehensive ophthalmologists manage large, central, deep ulcers. Zaina Al-Mohtaseb, MD, Houston, helped to close that gap by present- ing attendees with a guide for diag- nosing and treating this potentially blinding disease. While most comprehensive ophthalmologists treat microbi- al keratitis empirically, in some situations it is best to culture the infiltrate before proceeding with an- tibiotic treatment. Dr. Al-Mohtaseb stratifies ulcers into a low-risk ulcer group that don't need to be cul- tured and a high-risk group that do. Low-risk ulcers, with small infiltrates that are peripheral and not sight threatening, can be treated empir- ically, but high-risk ulcers, such as those with large infiltrates, limbal or scleral involvement, trauma, or atyp- ical presentation, must be cultured before starting treatment. About 80% of low-risk ulcers will resolve with empiric therapy, and in these cases, it can cause more problems to culture the infiltrate than it solves, Dr. Al-Mohtaseb said. said—always culture these organisms first. Penetrating keratoplasty (PK) is always an option if the infection can't be cleared with antibiotics, but remember to counsel patients that the point of the PK procedure is to preserve the globe—not to preserve vision, Dr. Al-Mohtaseb said. Dr. Hamill added a useful pearl to Dr. Al-Mohtaseb's treatment advice—if you're going to refer an infectious keratitis patient to a continued on page 128

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