EyeWorld India September 2020 Issue

FEATURE 8 EWAP SEPTEMBER 2020 by Ellen Stodola Editorial Co-Director AT A GLANCE • Superficial keratectomy can help a surgeon address some ocular irregularities prior to keratoplasty. • Preservative-free tears, topical cyclosporine, or lifitegrast can help optimize the surface. Punctal plugs may be used as well. Surgeons also recommend tea tree oil wipes, beaded masks, and artificial tear spray. • OSD, dry eye, and blepharitis may be less of a concern with EK than PK because you’re not disturbing the front layers of the cornea. Contact information Dhaliwal: dhaliwaldk@upmc.edu Lee: wblee@icloud.com Rapuano: cjrapuano@willseye.org This article originally appeared in the June/July 2020 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. A nytime you’re going to do a corneal transplant, EK or PK, there are a few important considerations, according to Deepinder Dhaliwal, MD. One is you have to know whether the cornea is neurotrophic. Sometimes the cornea is scarred and hazy, Dr. Dhaliwal said, referencing a case where the patient had an epithelial defect that she initially thought was ruptured bullae. Dr. Dhaliwal performed an urgent transplant but had issues because the eye was inflamed from an ulcer. She tried to do a DMEK but couldn’t get the graft to unfold due to a severe fibrinous reaction in the anterior chamber intraoperatively, so she performed DSAEK at a later date. Dr. Dhaliwal stressed the importance of a quiet eye for DMEK. For this particular patient, Dr. Dhaliwal said she didn’t check corneal sensation ahead of time. Postoperatively, corneal sensation was reduced. This was when she realized the patient had Fuchs, neurotrophic keratitis, and a resolved infectious keratitis. The patient had been referred to her as “needing a transplant right away,” but Dr. Dhaliwal advised not operating on an actively inflamed eye if it can be avoided. Scarring, defects, and surface abnormalities When deciding between EK and PK, how much anterior corneal scarring there is matters, said Christopher Rapuano, MD. With EK, you’re replacing the back layers of the cornea. Chronic corneal swelling can cause some epithelial haze or anterior scarring, so a lot of patients who’ve had edema for a long time can have some scarring. “If it’s mild, we usually go ahead with an EK because while mild scarring might decrease vision somewhat, overall, you’re better off than with a PK,” Dr. Rapuano said. “Sometimes postoperatively when swelling goes away, that scarring may improve over 3–6 months.” Even if some of the scarring doesn’t go away, it may be treatable with excimer laser PTK. In dealing with severe/deep scarring plus corneal edema, Dr. Rapuano often goes straight to PK. For other surface problems like Salzmann’s nodules, epithelial basement membrane dystrophy (EBMD), or other surface irregularities, it doesn’t matter for PK because you’re cutting it all out, he said. But for Ocular considerations prior to keratoplasty Severe anterior blepharitis. Moderate epithelial basement dystrophy with subepithelial fibrosis.