EyeWorld India September 2018 Issue

20 EWAP FEATURE September 2018 Views from Asia-Paci c Jodhbir S. MEHTA, MD Head of Cornea and External Disease Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 jodhbir.s.mehta@snec.com.sg I n this article, two experienced corneal surgeons, Dr. Agarwal and Dr. Chan, share their tips in dealing with challenging corneal surgical cases. End-stage ocular surface disease, as Dr. Chan discusses, is still a difficult management proposal for any corneal surgeon. The main reason is that the ocular surface not only consists of the cornea, but the conjunctiva, the eye lids, and tear film. Hence the “corneal surgery” only makes up for a small component in the surgical rehabilitation of the patient. As is mentioned, I think it requires a multidisciplinary team approach, with glaucoma, oculoplastics, and retina colleagues to achieve the best outcomes. Sometimes no surgery, i.e. scleral contact lens, is the best approach. In addition to points mentioned in the article, patient education, regular assessment of the ocular surface through regular (3M) cultures are important factors that will affect outcomes. Patients with end-stage ocular disease, e.g. SJS or OCP, often have abnormal ocular flora and we routinely culture the ocular surface in these patients. It has been shown that these bugs may be the instigating agents for long-term inflammation or cause acute on chronic exacerbation. In patients with partial limbal stem cell dysfunction we have found DALK alone without stem cell reconstruction to be useful; however, in more advanced cases, this must be combined with stem cell procedures either autologous, e.g. conjunctival/oral mucosa or allogenic (with systemic immunosuppression). I am hesitant to offer a KPro unless we can have good patient compliance to follow-up. Long-term infection risk and contact lens wear are issues, especially in humid climates. For bullous keratopathy, endothelial keratoplasty has revolutionized the way we perform this surgery, whether it is DSAEK (and its variations—ultra-thin, nanothin, femto), PDEK, and DMEK. There are several papers in the literature showing good 1-year outcomes following EK surgery in patients with ACIOL. We also reported the same in 2014 but we also looked at 3-year data. When one looks at the 3-year data, there is a distinct difference in the longer-term outcomes, with the ACIOL cases doing worse at 3 years with only 50% graft survival. Hence since 2013, we have been removing all the ACIOLs in patients coming for EK surgery and either performing scleral externalization using a similar technique to the glued IOL (as in Dr. Agarwal’s case), or iris fixation. As in the case, we will often combine this with an EK procedure, either DSAEK or DMEK. The visualization of the graft can be difficult in such cases due to chronic stromal edema and often it can be difficult to perform the surgery, the use of dyes can help aid visualization of your EK graft and in these scenarios we will use membrane blue instead of vision blue for staining. Of course, if available, intraoperative OCT can also be useful. The pupilloplasty technique is a good tip to maintain air/gas in the anterior chamber. In cases with severe scarring we will generally perform a DSAEK instead of DMEK and if there is still visually significant stromal scarring will perform a DALK at a later date, normally between 6M and 12M postop. We have recently published a series of patients who underwent this surgery with 90% graft survival at 4 years. Editors’ note: Dr. Mehta declared no relevant nancial interests. Johan HUTAURUK, MD Director, Jakarta Eye Center JEC@Kedoya, 8th Floor, Jl Terusan Arjuna Utara No. 1, Kedoya, West Jakarta, Indonesia 11520 Tel. no. +62-21-2922-1000 Fax no. +62-21-2569-6060 johan.hutauruk@jec.co.id S evere ocular surface disorders are almost always related to limbal stem cell deficiency such as Stevens–Johnson Syndrome (SJS). My first step for severe conditions is to release the symblepharon. Without being first corrected, such symblepharon is a major obstacle, if not a contraindication, for the ensuing corneal transplantation and ocular surface reconstruction. “ My first step for severe conditions is to release the symblepharon. Without being first corrected, such symblepharon is a major obstacle, if not a contrain- dication, for the ensuing corneal transplantation and ocular surface reconstruction. ” - Johan Hutauruk, MD The next step is the management of limbal stem cell deficiency, and my preferred method is the Cincinnati procedure as described by Edward Holland. This technique is a combination of keratolimbal allograft (KLAL) with the living-related conjunctival limbal allograft (LR-CLAL). I also use amniotic membrane transplantation to reduce inflammation and promote re-epithelialization. These procedures require adequate immunosuppression to achieve good outcomes. I use Boston Keratoprosthesis type 1 only for older patients with simultaneous glaucoma procedure, such as a tube shunt, at the time of K-pro implantation. Bullous Keratopathy In my opinion, even for severe bullous keratopathy with stromal involvement and corneal scarring, it is better to perform posterior lamellar keratoplasty because of the higher risk of graft failure in penetrating keratoplasty. DSAEK is my first choice for this kind of problem and with poor visualization during surgery, it is easier to handle compared to DMEK, with less endothelial cell damage. I always use sulfur hexafluoride (SF6) as a tamponading agent in challenging cases without the need of using an air bubble with high intraocular pressure for the patient’s comfort. I just leave the SF6 with moderate IOP with inferior iridotomy to help prevent angle closure and the patient lies supine in the recovery room for about an hour. Editors’ note: Dr. Hutauruk declared no relevant nancial interests. Challenging...refractive surgery – from page 19