Eyeworld

Cornea Society News – published quarterly by the Cornea Society 4 Case-based presentations on decision- making in corneal transplantation A symposium at the ASCRS•ASOA Symposium & Congress spon- sored by the Cornea Society focused on decision-making in corneal transplantation, with case-based presentations. The session was mod- erated by Anthony Aldave, MD, and Marian Macsai, MD. Francis Price, MD, Indianapolis, discussed managing corneal edema with moderate Fuchs' dystrophy in a 50-year- old. When making decisions, you have to consider patient symptoms, potential surgery, and objective findings on the exam, Dr. Price said. The treatment choices have evolved over the years as to when to graft with Fuchs' dystrophy. What you do depends on your options, Dr. Price said. Options will depend on the experience of the surgeon and the individual situation of the patient. For each option, Dr. Price said it's important to look at how reliable the visual recovery is and what the risks and complications are. He said to choose the least invasive option, which for him is Descemet's membrane endothelial keratoplasty (DMEK), which is only Descemet's and endothelial cells. It offers the best visual recovery and least risk of rejection. "But we still have unpredictable refractive changes," Dr. Price said. DMEK is becoming more like cata- ract surgery, Dr. Price said. Some patients are 20/20 or 20/40 by day 5, and DMEK accelerates cataract formation a little more than Descemet's stripping endo- thelial keratoplasty (DSEK) or penetrat- ing keratoplasty (PK). Dr. Price spoke about decision-mak- ing for cataract with corneal problems. Make sure the AC depth is deep enough for later phaco, he said, and if not, re- move the lens during DMEK. "In summary, it's all about deci- sions," he said, adding that the number one factor is patient symptoms. Audrey Talley Rostov, MD, Seattle, presented a case of a 68-year-old woman with a history of Fuchs' dystrophy and cataract. She said to consider a number of factors, including what the BCVA is, if there is morning blur, how the patient's activities in daily life are affected, the grade of the cataract and the grade of the guttata, the pachymetry, and the endothelial cell density (ECD). Dr. Talley Rostov's patient had a BCVA of 20/50, glare with headlights when driving at night but no morning blur, ECD of 870, and pachymetry of 589. When considering treatment op- tions, Dr. Talley Rostov said you need to decide when to do a combined proce- dure. With epithelial edema, a combined procedure would be indicated. It would also be indicated for stromal edema with morning blur, pachymetry gener- ally greater than 620 microns (which depends on the baseline), and ECD of less than 800. Rajesh Fogla, MD, Hyderabad, India, described corneal ectasia in an atopic patient with prior hydrops. His case involved a 14-year-old male with a history of vernal conjunctivitis for the past 5 years. The patient had a history of eye rubbing and presented with a sudden decrease in vision in the right eye for the past week. Dr. Fogla noticed diffuse corneal edema involving the inferior half of the ectatic cornea and acute hydrops. To treat the patient, he used an inferior peripheral iridectomy and C3F8 (13%) gas injected into the AC. There was good resolution of the edema 1 month later. Dr. Fogla said that hydrops can be managed using non-expansile gas injection into the anterior chamber. If the scar does not involve the visual axis, consider deep anterior lamellar keratoplasty (DALK) surgery. Preoper- ative evaluation and surgical planning are essential, Dr. Fogla added, and intraoperative microperforation can be managed effectively. Postoperatively, Dr. Fogla said to manage the ocular surface judiciously. The final section of the symposium looked at management of corneal opaci- fication and graft failure, and presenta- tions focused on corneal scarring in a younger patient with reduced endotheli- al cell density, visually significant recur- rent corneal stromal dystrophy follow- ing PTK, Descemet's stripping automated endothelial keratoplasty (DSAEK) failure, and PK failure. CN Editors' note: Dr. Price has financial inter- ests with Haag-Streit (Koniz, Switzerland). Dr. Talley Rostov has financial interests with Allergan (Dublin, Ireland), Bausch + Lomb (Bridgewater, New Jersey), Ocular Therapeutix (Bedford, Massachusetts), and Shire (Lexington, Massachusetts). Dr. Fogla has no financial interests related to his comments. Dr. Talley Rostov presents a case she handled of Fuchs' dystrophy and cataract.

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