Grand Rounds “Triple Procedure Via Open-Sky Approach”

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Presentation transcript:

Grand Rounds “Triple Procedure Via Open-Sky Approach” Kevin Lowder, MD – PGY3 10/26/2018

Patient Presentation CC HPI Severe vision loss OS 49 yo WF with hx of PK OS secondary to fungal corneal ulcer for which patient was not compliant with drop regimen, now presenting with subsequent graft failure over several months as she has not been using steroids as prescribed. Fungus = Cladosporium

History (Hx) Past Ocular Hx: PK OS (9 months prior) Ocular Meds: pred forte QID OS, Muro 5% ung QHS OS, Ofloxacin QID OS Past Medical Hx: COPD, Depression, Bipolar Disease, ADHD, Anxiety. Fam Hx: Non-contributory Meds: psychiatric & COPD meds Meds: Dulera 100/5 Metered Dose Inhaler, 120 ACTUAT. LORTAB. buspirone hydrochloride 10 MG (buspirone 9.1 MG) Oral Tablet. Combivent (albuterol 0.09 MG/ACTUAT / ipratropium bromide 0.018 MG/ACTUAT) Metered Dose Inhaler, 200 ACTUAT. LAMICTAL. 3

History (continued) Allergies: NKDA Social Hx: Current smoker, occasional EtOH, history of poor compliance with medications, poor follow up (lives 4 hours away and has difficulty with rides) RoS: Noncontributory 4

Physical Exam OD OS VA 20/20-2 PH HM sc (PHNI) Pupils 4mm. Round. Brisk. No rAPD 1mm, fixed. No RAPD, by reverse. IOP 8 mmHg 11 mmHg EOM full CVF unable

Physical Exam PLE or SLE OD OS External/Lids WNL Conj/Sclera Conj injection Cornea no epi defect. Bullous keratopathy, extensive Descemet’s folds. 3+ Edema. Few buried sutures. few end of minimally exposed suture at 2oc and 6oc. Significant neovascularization Ant Chamber Normal depth Iris Pupillary membrane with synechiae to lens. Lens Clear Mature cataract Vitreous No view

Physical Exam Fundus OD OS Optic Nerve WNL NO VIEW Macula “ ” Vessels “ ” Vessels Periphery

Assessment: 49 yo WF with: Corneal graft rejection OS Mature cataract OS

Plan Triple Procedure via “open-sky” approach Penetrating Keratoplasty Intracapsular cataract removal (en-bloc) IOL Implantation (in the bag)

Surgery Overview Create new PK “button” inside the old button Release the synechiae to the lens Capsulorrhexis Hydrodissection En-bloc removal of cataract Gentle I&A Careful insertion of intracapsular IOL No loading required Complete PK trephine

Discussion Risks/Difficulties of traditional method: Suprachoroidal hemorrhage Vitreous prolapse Endophthalmitis Difficult capsulorhexis Incomplete I/A of cortex Uncertain IOL placement Posterior capsule rupture

Discussion Proposed Changes to Technique: Start with Deep Anterior Lamellar Keratoplasty (80%) thickness Via scleral tunnel: Manual small-incision cataract extraction IOL placement ***Of note, this procedure is recommended for initial transplant; this case is unique in that the patient had already undergone PK previously*** Dr. Asghari, what are your thoughts on this modified Approach in an initial corneal transplant?

Conclusions

References

Special Thanks Dr. Asghari