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Reporting from the XXXIII Congress of the ESCRS, September 5–9, Barcelona EW MEETING REPORTER 142 function, the conjunctiva moves on top of the cornea and leads to visual impairment, Dr. Kruse said. "It is very important to diagnose this problem properly because there are other diseases that look like limbal stem cell disease but are not," he said. LSCD is mainly defined by goblet cells on the ocular surface. Delayed staining with fluorescein will also help identify this issue. When dealing with cataract patients who have LSCD, it's important to note the extent of the disease—a lot of patients have only partial LSCD and you can maneuver around the problem, Dr. Kruse said. IOL calcula- tions may be hard, but the surgical approach is straightforward, he add- ed. Small incision surgery for anirid- ia may be an option in these cases because this can save the surface. In most patients with partial stem cell disease, the clinician can make an attempt to enhance the surface qual- ity by a simple method of sequential sectoral conjunctival epitheliectomy (SSCE), he said. This involves the removal of the focal fibrovascular pannus by using a crescent blade. By scraping away the tissue, surgeons can significantly enhance the ocular surface quality in some of these patients and do a straightforward cataract surgery, he said. in these cases seems to be connected to a breach of the blood-aqueous barrier. Dr. Price described one study that found that eyes with a glaucoma shunt had elevated levels of plasma proteins in the aqueous humor. When these proteins are inflammatory, oxidative, or apop- totic, they can easily damage the corneal endothelium. With this in mind, it's important to set realistic expectations for glaucoma surgery patients who are undergoing EK, Dr. Price said. "Glaucoma surgery is im- portant—we can't replace your optic nerve," she said. "Your transplant may fail sooner, but we can easily replace your transplant." Ocular surgery and limbal stem cell dysfunction (LSCD) Limbal stem cell deficiency can be a serious problem, but it can prove ex- ceptionally challenging for patients who also require cataract surgery. Friedrich Kruse, MD, Erlangen, Ger- many, discussed how to define and diagnose LSCD, diseases associated with LSCD, and how to perform cataract surgery in these patients. Limbal stem cell dysfunction is an ocular surface disease caused by a decrease in the population and/ or function of the corneal epithelial stem/progenitor cells that leads to the inability to sustain normal ho- meostasis of the corneal epithelium. If stem cells function, there is good surface epithelium, but if they don't Dr. Labbé showed that in addition to the toxic effects of preservatives, glaucoma medications increase expression of inflammatory markers on the ocular surface, and inflamma- tion has been shown to increase the risk of bleb failure, he said. Physicians can restore the ocular surface damaged by glaucoma drugs in several ways, said Jose Torras, MD, Barcelona. Avoid medications and preservatives when possible, Dr. Torras said, and avoid punctal plugs because they can increase the concentration of inflammatory cyto- kines on the ocular surface. Recom- mend artificial tears, omega-3 fatty acids and tetracylines, he added, and use autologous serum drops where available. One of the most important things to do is stop inflammation, Dr. Torras said, but avoid steroids because of the high rate of respond- ers—instead, use cyclosporine A drops. PK and EK go head to head Cornea surgeons have rapidly adopted endothelial keratoplasty (EK) procedures over the last several years, and in many areas of the world, they now perform more EK procedures than penetrating ker- atoplasty (PK) procedures. In the "Posterior lamellar keratoplasty" symposium, Marianne Price, PhD, Indianapolis, described how EK and PK procedures compare in terms of graft survival, endothelial cell loss, and graft rejection. In the early postop period, EK grafts tend to fail because of the steep learning curve associated with the procedure, but failure rates decline as surgeons gain more experience, Dr. Price ex- plained. Secondary grafts—whether PK or EK—usually do well, as long as the graft is replaced within 1 month. The take-home message here is that if the graft fails, don't wait—just replace it, Dr. Price said. The major risk factor for long- term graft survival, however, is prior glaucoma surgery. The problem, Dr. Price said, is that pseudophakic corneal edema—one of the main indications for EK—is increasingly associated with prior glaucoma sur- gery. The mechanism for graft failure October 2015 View videos from Sunday at ESCRS 2015: EWrePlay.org Sri Ganesh, MD, describes employing SMILE lenticules as donor tissue for treatment of hyperopia and keratoconus. continued on page 144

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