Post on 09-Feb-2017
BY:NOOR MUNIRAH BINTI AWANG ABU BAKAR
OPTOMETRIST (MOC NO. O-0869)
Pseudophakic Bullous Keratopathy
History:
58/C/F came to HSB Hospital on 1st April 2016
This is her 8th visit to HSB. To review: Post op x 2/52 LE DSAEK for LE pseudophakic bullous
keratopathy Post op x 1/52 LE rebubbling for partial graft detachment
Complaint of LE painless blurring of vision remains after surgery.
Ocular History: Next slide Medical History: Underlying hypertension, on
medication
Ocular History:
Ocular History: BE pseudophakia (ACIOL) done in 2001 at PH Hospital
March 2015: LE pain with redness, photophobia and tearing. Patient went to clinic.
May 2015: She was referred to HS Hospital for LE epithelial bullae and ben following up there.
Sept 2015: Referred to HSB for expert opinion since the LE epithelial bullae is recurring.On hypertonic saline QID LE and ATPF 2H LE.
March 2016 at HSB: LE DSAEK under GA for LE phakic IOL with secondary bullous keratopathy
March 2016 at HSB: Post LE DASEK x10 days- Op for LE rebubbling for partial graft detachment
Series of Ophthalmology Visit at Hospital Sg Buloh
No Visit date
Reason Findings Diagnosis & Management
1 17/9/2015 Referred from Seremban Hospital to HSB
Complaint of: LE pain associated
with tearing even with bandage contact lens (BCL).
-RE findings were unremarkable-LE findings:•VA: 6/36•RX: -1.75 (6/12)•Corneal sensation: Reduced•Cornea: Conj injected, Corneal bullae 3.5mm (V) x 4mm (H) nasally paracentral
Dx: LE pseudophakic bullous keratopathy
Mx: •BCL for 2/52•TCA 2/52 (5/10/2015)•Prescribe CMC QID LE & ATPF 2 hourly LE
2 5/10/2015 Complaint of: LE pain associated
with tearing even with bandage contact lens (BCL).
-RE findings were unremarkable-LE findings (same as previous):•VA: 6/36•RX: -1.75 (6/12)•Corneal sensation: Reduced•Cornea: Conj injected, Corneal bullae 3.5mm (V) x 4mm (H) nasally paracentral
Dx: LE pseudophakic bullous keratopathy
Mx: •BCL for 2/52•Plan for LE DSAEK •TCA 3/52 (29/10/15) for LE DSAEK decision
3 29/10/2015
For LE DSAEK decision
Complaint of: LE pain , cannot
tolerate
-RE findings were unremarkable-LE findings (same as previous):•VA: 6/36•RX: -1.75 (6/12)•Corneal sensation: Reduced•Cornea: Conj injected, Corneal bullae 3.5mm (V) x 4mm (H) nasally paracentral
Dx: LE pseudophakic bullous keratopathy
Mx: •Agree to proceed with LE DSAEK on 16/3/2016.•TCA 4/12 (1/3/2016) for PC
4 1/3/2016 Pre-clerking for LE DSAEK
Mx: •LE DSAEK on 16/3/2016.
Series of Ophthalmology Visit at Hospital Sg Buloh
No Visit date
Reason Assessment & Findings Diagnosis & Management
5 16/3/2016 LE DSAEK under GA for LE phakic IOL with secondary bullous keratopathy
Few hours after surgey: c/o some LE pain & nauseaAssessment:LE conj injected, AC bubble full, Siedel’s negative, air released leaving 50% air fill
Imp: LE post DSAEK stable
Mx:• Maxidex 2 hourly,CMC
QID, Paracetamol QID• Advice pt to lie flat on 1
pillow except when eating/toilet
6 22/3/2016 •Post op 1 week LE DSAEK for LE pseudophakic bullous keratopathyComplaint of:
LE pain since 4 days ago & has coughing past few days
Assessment:•LV: 6/36 (ph: NI)•LE Anterior: Conj injected, Inferior half detachment seen between the graft, Corneal sensation reduced, Lens stable, Siedel’s negative
Imp: LE post DSAEKManagement:•Admitted for air injection into AC under LA.•Cont. Maxidex & CMC
7 25/3/2016 •Op for LE rebubbling for partial graft detachment
Assessment (2 hours post op):•90% air fill•Graft attached
Management:•Maxidex & CMC LE•BCL•Discharge on 26/3/2016 (post op 1 day)
8 1/4/2016 Today’s visit
Pseudophakic bullous keratopathy
Taken 1 day before LE DSAEK
Corneal bullae
Post-op LE DSAEK
•Post-op LE DSAEK•Taken 0n 24th March, before graft rebubbling•Inferior half detachment seen between the graft
Assessment
Assessment Examination RE LE
VA (aided) 6/9 6/36 (ph:6/36)
RAPD test No RAPD No RAPD
IOP 14 16
Anterior segment
•Cornea: Clear•Conj: White•AC: D&Q
•ACIOL stable
•BCL in situ•Subconjunctival hemorrhage inferiorly
•Cornea central epithelial defect measuring 4.4 (V) x 5.2 (H)
•Superior air bubble present 1/4th of AC•Graft attached
•Inferotemporally noted slight inadherent but stable•AC well formed
Posterior segment
•OD pink•CD 0.3
•Flat retina & macula normal
•OD pink•CD 0.3
•Flat retina & macula normal
Patient’s left eye:LE Cornea central epithelial defect measuring 4.4 (V) x
5.2 (H)
Management
Imp:Post LE DSAEK 2 weeks for LE pseudophakic bullous keratopathy: stablePost op 1 week LE rebubbling for partial graft detachment: stable
Management:Reduce Maxidex 4 hourly LEContinue CMC QID LE Artificial tears preservative free(ATPF) QID/PRNBCL LE x 2 weeksTCA 2/52
Management
Rationale of management given: Maxidex
Contain dexamethasone(corticosteroids) that are used for reducing inflammation.
Reducing eye inflammation following eye surgery. Preventing rejection of grafts in the eye
CMC An antibiotic-To treat bacterial infection
Artificial tears preservative free(ATPF) For dryness and irritation & to treat epithelial defect
BCL To shield the cornea and epithelium from the eyelid Temporary relief of corneal pain and discomfort (Corneal graft and
epithelial defect)
Summary of visit:
Discussion
Case analysis: Patient initially had LE pseudophakic bullous keratopathy and
undergone LE DSAEK followed by LE post DSAEK complication: partial graft detachment.
The VA is still not improved post op during last visit as there was the presence was cornea central epithelial defect measuring 4.4 (V) x 5.2 (H)
Thus, discussion part will cover on: Pseudophakic bullous keratopathy (definition, ACIOL-induced,
pathophysiology, management) Penetrating keratoplasty VS DSAEK Complication of DSAEK: Graft detachment Optometric management
Discussion
The VA is still not improved post op during last visit as there was the presence was cornea central epithelial defect measuring 4.4 (V) x 5.2 (H).
In this case, epithelial defect was treated with: Lubrication. The first step involves support of the ocular surface with
aggressive lubrication using preservative-free artificial tears or lubricating ointment every one to two hours.
Bandage contact lens (BCL). Soft therapeutic contact lenses serve to protect the corneal surface from mechanical trauma from the eyelids. (Katzman & Jeng,2014)
Discussion (Bullous keratopathy)
Refers to corneal swelling due to insufficiency of the corneal endothelial pump resulting formation of subepithelial bullae. (Heegaard & Grossniklaus, 2014)
Failure of the corneal endothelium to maintain the normally dehydrated state of the cornea
(Endothelial cells function as pumps & maintaining corneal clarity).
Failure due to: Fuchs corneal endothelial dystrophy (Bilateral, Genetic, Progressive) Corneal endothelial trauma (surgery): Cataract surgery
Cause eye discomfort, decreased vision, glare, photophobia, reduce contrast
Discussion (Pseudophakic bullous keratopathy)
Any type of intraocular surgery, especially cataract surgery, may damage endothelial cells and accelerate the decline in endothelial cell count.
Pseudophakic bullous keratopathy (PBK) is a post-operative condition that can occur as a complication of cataract extraction surgery and intraocular lens placement.insult to the endothelium and long-term cell damage
May be manifest in the immediate post-operative period or symptoms may not present for many years.
Some studies have shown that endothelial cell loss may continue to progress for many years after the operation.
Discussion (Pseudophakic bullous keratopathy)
Possible mechanism for endothelial cell loss:
ACIOL was the cause of pseudophakic BK in this
case
Discussion (Pseudophakic bullous keratopathy)
Particular attention has also been directed at the relationship between intraocular lens type and the severity of endothelial cell loss.
Many studies report that anterior chamber intraocular lenses are associated with a greater degree of endothelial cell loss than posterior chamber intraocular lenses.
ACIOL
“Intermittent touch" (between IOL and cornea)
Chronic irritation with low-grade inflammation caused by the IOL haptics or footplates
Disrupt the normal flow of aqueous in the anterior chamber•Affects the nutrient flow
Endothelial damage PSK
Discussion (Pathophysiology)
Discussion (Management)
1. Hypertonic agents, such as sodium chloride 2% and 5% solution and ointment.
• Creates a hypertonic tear film, thereby drawing water out of the cornea
2. Bandage contact lens • Useful as an adjunct to medical treatment for the temporary relief of
corneal pain and discomfort.• To shield the cornea and epithelium from the eyelid.
3. Corneal transplantation • Indicated when vision is decreased significantly by corneal edema or
when pain becomes intractable.• In this case, LE DSAEK procedure was performed.
Discussion (DSAEK)
Discussion (Corneal transplant: PK VS DSAEK)
PK DSAEKIn Penetrating keratoplasty (PK) a circular
button-shaped, full-thickness section of tissue is removed from the diseased or
injured cornea using a trephine or a femtosecond laser
Descemet's stripping automated endothelial keratoplasty (DSAEK) is the gold standard
for the surgical treatment of corneal endothelial diseases.
Indications:•Corneal ectasia
•Infectious or non-infectious corneal ulcerations or perforations
•Combined stromal and epithelial disease (Peters )
•Stromal scarring
Showing excellent results & treatment of choice over PK
•Fuchs' endothelial dystrophy•Pseudophakic bullous keratopathy
•endothelial failure after PK•Iridocorneal endothelial syndrome
The principle of DSAEK: Full-thickness corneal transplant
procedure; Interrupted and/or running sutures are placed in radial fashion at equal
tension to minimize post-operative astigmatism
The principle of DSAEK: Replaces only the diseased endothelium with a graft consisting of a thin layer of posterior stroma, Descemet's membrane
and endothelium
Gimeno et al., 2010)
Discussion (Corneal transplant: Why DSAEK?)
DSAEK PKSuture-related problems can be
eliminatedSuture-related complications
Minimal change in refractive error
Anisometropia
Faster and better visual rehabilitation & recovery
Long duration of visual rehabilitation
Reduces the risk of sight threatening complications that
may occur with the PK intraoperatively
Risk of intraoperative expulsive hemorrhage
Eye becomes much stronger and more resistant to injury
Long-term risk of corneal allograft rejection or wound rupture with minor trauma
Gimeno et al., 2010)
Discussion (DSAEK)
Procedure
•Inserts a full air bubble through a side port to push the donor disc up against the host posterior stroma
•Once the graft is adherent, the air bubble is left in place for 10 minutes
Prior to leaving the operating room, bubble will be removed 20 to 25 percent
Risk of graft detachment because the donor tissue is held in place with an air bubble instead of sutures
Discussion (Complication)
The DSEK offers an effective and efficient alternative to traditional PKP.
Complications of DSAEK (Suh et al. 2008):
In this case
•Susceptible to detachment because the donor tissue is held in place with an air bubble instead of sutures•Due to: lack of tight, full air bubble or rubbing eye•May happen post op 1 day, 2 days, or even 1 week•Solution: Rebubbling or repositioning the graft
Discussion (Optometric management)
Bullous keratopathy Early detection, vision can be preserved, with complete history
taking to rule out the etiology Detect any graft dislocation or failure and refer to
ophthalmologist.
A comprehensive eye exam by an optometrist using • Slit lamp, specular microscope or confocal microscope: To
examine the cornea to look for subtle changes in the appearance of cells in the endothelium that are characteristic of the disease.
• Pachymetry : To detect increased corneal thickness that might indicate corneal swelling from the disease.
• Visual acuity testing : Reveal decreased vision due to corneal swelling.
Management with Bandage Contact lens: Bandage contact lenses to reduce discomfort
Discussion (Optometric management)
Consult on do’s and dont’s post-DSAEK procedure: Explain to patient the eye will be red, sore and watery for
a week or two. Vision can be quite hazy whilst the cornea is still
oedematous, but should clear as the graft starts to function.
Keep the eyes looking vertically upwards to help hold the graft in place whilst it sticks.
Avoid rubbing the in the first few weeks to prevent dislocating the graft.
Steroid drops are used to settle the inflammation and reduce the risk of rejection In some patients there may be a problem with a rise of IOP (glaucoma)
associated with the steroid eye drop treatment, and this may require additional medical or surgical treatment.
References
Gimeno FL, Lang, M, Mehta JS, Tan DT. Descemet's Stripping Automated Endothelial Keratoplasty: Past, Present and Future. Expert Rev Ophthalmol. 2010;5(3):303-311.
Suh LH, Yoo SH, Deobhakta A, Donaldson KE, Alfonso EC, Culbertson WW, O'Brien TP. Complications of Descemet's stripping with automated endothelial keratoplasty: survey of 118 eyes at One Institute. Ophthalmology. 2008 Sep;115(9):1517-24. doi: 10.1016/j.ophtha.2008.01.024. Epub 2008 Apr 18.
Katzman LR, Jeng BH. Management strategies for persistent epithelial defects of the cornea. doi:10.1016/j.sjopt.2014.06.011
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