Pseudophakic Bullous Keratopathy case

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


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


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.


Possible mechanism for endothelial cell loss:

ACIOL was the cause of pseudophakic BK in this

case


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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Pseudophakic Bullous Keratopathy case

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