EyeWorld India September 2018 Issue

EWAP FEATURE 19 Challenging cases in corneal surgery by Ellen Stodola EyeWorld Senior Staff Writer and Digital Editor AT A GLANCE • A stepwise approach to severe ocular surface disease and associated limbal stem cell deficiency may be helpful, beginning with optimizing severe dry eye. • To treat pseudophakic bullous keratopathy, Dr. Agarwal advocates using the combination of a glued IOL, a single-pass four- throw pupilloplasty, and pre-Descemet’s endothelial keratoplasty (PDEK). Surgeons discuss two issues they see often in cornea surgery and what treatment strategy they employ S ometimes surgeons face particularly chal- lenging cases where specific technology or techniques need to be utilized. Amar Agarwal, MD , Chennai, India, and Clara Chan, MD , Toronto, Canada, discussed how they tackle some of the challeng- ing cornea cases they’ve faced. Severe ocular surface disease and associated limbal stem cell deficiency Dr. Chan finds the most challeng- ing issues that she encounters are patients with severe ocular surface disease and associated limbal stem cell deficiency. She noted that pa- tients with Stevens–Johnson syn- drome, graft-versus-host disease, and ocular cicatricial pemphigoid are particularly difficult. “These are patients that cannot be cured with a simple DMEK,” she said. Dr. Chan said what makes these cases particularly challeng- ing is that “there is no magic bul- let cure.” The medical therapies to optimize the ocular surface and the patients' severe dry eye are often not covered by insurance, and often the patients are lower income or on long-term disability and thus unable to afford many of the treatments, including scleral contact lenses. “Surgical options like a stem cell transplant or a keratoprosthesis for these patients are high risk, and the prognosis is often very guarded even in the best cases,” she said. “Even on maximal treatment, patients are still symptomatic with varying degrees of dry eye, decreased vi- sion, and eye pain.” Dr. Chan said that there's also a high proportion of monocular patients with these ocular diagnoses, so there's addi- tional pressure on the physician. Dr. Chan has several steps for managing these cases, and she pointed out that rehabilitation can take months to years. She advocated a step-wise approach. First, she stressed the importance of optimization of the patients’ severe dry eye. Next, she said to do oculoplastics repair of any eyelid deformities, lagophthalmos, or lash trauma issues. After that, physicians should do glaucoma management via a tube shunt or cyclophotocoagulation since glaucoma drops are toxic to the al- ready compromised and inflamed ocular surface. The last step would be surgical intervention to reha- bilitate their corneal blindness. “In a young patient with no general health issues, a stem cell transplant with systemic immu- nosuppression would be my first choice, [but] in an older patient with multiple medical co-morbid- ities, a Boston type 1 keratopros- thesis would be my first choice,” Dr. Chan said. Pseudophakic bullous keratopathy managed with the triple procedure of glued IOL, single-pass four-throw pupilloplasty, and PDEK. A is preop, B 45 days postop. Source: Amar Agarwal, MD continued on page 20 September 2018