Eyeworld

111 February 2017 EW MEETING REPORTER anterior chamber reaction, and re- tained lens fragments. "Meticulous cataract surgery with careful attention to protecting the cornea can prevent most serious corneal complications," she said. Intraoperative and postoperative complications of cataract surgery that affect the cornea vary in etiolo- gy and severity, and proper identi- fication preoperatively of a cornea "at risk" is crucial, as is a plan for preserving the endothelium. Once postoperative corneal edema is diagnosed, identification of the cause and a timely treatment plan must be initiated to prevent further loss of healthy endothelial cells, she concluded. Editors' note: Dr. Fynn-Thompson has no financial interests related to her comments. Case presentations A panel of surgeons looked at med- ical and surgical management of cor- nea and external disease by examin- ing a number of cases presentations. One case was a 75-year-old with worsening vision, particularly when reading or watching television. Upon examination of meibography, severe ocular surface problems were discovered. Preeya Gupta, MD, Durham, North Carolina, discussed how she would approach this patient. This is likely someone coming in for a cata- ract evaluation, who also has severe meibomian disease. There is good evidence in the literature that if you don't treat ocular surface disease, you'll have altered readings and measurements, she said. Dr. Gupta said that she would start by talking to the patient and explaining that instead of just a cataract, there is another disease process and that it's important to treat it before addressing the other. It resonates with patients when you tell them you want a better outcome for them, she added. Dr. Gupta has a low threshold for topical steroids to get ready for cataract surgery. An intense pulsed Corneal complications from cataract surgery Nicoletta Fynn-Thompson, MD, Boston, highlighted some possible corneal complications that can oc- cur from cataract surgery. Recent advances in cataract surgery have reduced incidence of corneal complications, she said. But there are still two areas that contin- ually remain a concern: protection of the corneal endothelium by minimizing endothelial cell loss and minimizing distortion of the anteri- or corneal surface. Identification of the cause and prompt management of cornea ede- ma can help preserve the endothe- lial function. It's important to note decompensation of the endothe- lium, detached Descemet's mem- brane, and retained lens fragments. A preoperative assessment is very important, Dr. Fynn-Thompson said. This includes an examination of the endothelium, taking a history of any previous trauma or eye sur- gery, obtaining specular microscopy, and obtaining pachymetry. Using specular microscopy and pachym- etry will give an idea of the status of endothelium, and then you can educate the patient ahead of time and let them know that they have an at-risk cornea. Dr. Fynn-Thompson also dis- cussed intraoperative management. She recommended using an OVD to protect the endothelium and said that she uses a "soft shell tech- nique." Keep the anterior chamber deep and perform phacoemulsifica- tion at the iris plane, not anterior to the iris. Dr. Fynn-Thompson also said to keep the anterior chamber formed and deep when performing phaco. Use a minimum amount of phaco power. Despite careful consideration, you could still see postoperative cor- neal edema. She then shared options for medical and surgical treatment if this does occur. EK, either DSAEK or DMEK, would be an option for sur- gical treatment. Dr. Fynn-Thompson spoke about options for dealing with a detached Descemet's membrane, postoperative edema with a mild the second eye 1 to 2 weeks after the first, and less expensive donor preparations. As more surgeons are adopting DMEK, there are also more inno- vations. Dr. Price spoke about the DMEK guarded trephine punch (Moria, Doylestown, Pennsylvania), which prevents a full thickness punch. He discussed the trifold donor technique, which was intro- duced by Massimo Busin, MD. This is a technique of folding the graft onto itself to maneuver it and then load it into the cartridge. Dr. Price spoke about a new blunt tipped hook and the use of a 2.5 scleral tunnel and AC maintainer with a side port. Intraoperative OCT is anoth- er valuable innovation for these procedures, he said, adding that this is a great teaching tool for those just starting to use DMEK as well as for those who have been doing it awhile. It allows the surgeon to see more clearly how the tissue is draped and can also help to verify orientation. Editors' note: Dr. Farid has financial interests with Abbott Medical Optics, Allergan, RPS (Sarasota, Florida), Shire, and TearScience (Morrisville, North Carolina). Dr. Price has finan- cial interests with Haag-Streit (Koniz, Switzerland). rejection is higher with DSAEK than with DMEK, and DMEK generally has a faster visual recovery (around 1–2 weeks compared to 3–4 months with DSAEK). A DSAEK graft is easier to manipulate and is reproducible, while DMEK is more challenging. DSAEK can use donor grafts of any age, while older donors work better in DMEK for ease of unfolding. She also touched on PDEK, where graft preparation is done by the surgeon, with increased endo- thelial loss and risk of tissue loss. This is also a smaller diameter graft. Dr. Farid has shifted most of her cases to DMEK, which she uses for all eyes with simple Fuchs' dystro- phy or mild to moderate endothelial failure/edema. She will use DSAEK in severe corneal stromal edema, when there is a drainage device in place, or when there is very poor iris anatomy. "Endothelial keratoplasty is now the most common technique for endothelial failure," she said. As surgical techniques and eye banking of donor tissues evolve, outcomes and safety will continue to improve, Dr. Farid concluded. In his presentation, Francis Price Jr., MD, Indianapolis, dis- cussed what's new in DMEK. He first discussed DMEK advantages, which include better visual recovery, more rapid visual recovery, lower risk of rejection, the ability to treat continued on page 112 View videos from Hawaiian Eye 2017: EWrePlay.org Sumit "Sam" Garg, MD, discusses trends in the treatment of ocular surface disease.

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