Course # Cutting Edge Cornea

Transcription

1 Course # 061 Cutting Edge Cornea

2 44 year old female with sudden onset right eye pain. Has happened 3 times previouslyevery time first thing in the morning Cutting Edge Cornea Terri Kim, M.D. Chairman, Corneal Department Duke University School of Medicine Anatomy EBMD Most common corneal dystrophy RCE and decreased vision Microcysts trapped epithelial cells May occur after trauma fingernail, tree branch, beer bottle Cornea EBMD 43 diopters of refractive power Lubrication, BCL, Muro 500 microns centrally ASP with excimer laser PTK Transparent avascular Dua s layer and its role 1

3 Treatment 61 year old male noticing gradual decrease in Corneal Transplant vision of last few years. Vision is worse in the PKP vs DSAEK mornings and slowly improves throughout the DSAEK advantages day. Had a mother that went blind Speed of recovery: 90 days vs. ~ 1 yr No induced astigmatism BCVA 20/50 OU No wound leaks or wound rupture Pachy 625 OU Refractive predictability and stability Fewer rejections Fuch s Dystrophy DSAEK Most common endothelial dystrophy Autosomal dominant Tiny excrescences of thickened descemet s Stromal edema, MCE, Bullae, SE fibrosis Treatment DSAEK Indications Muro, Lower IOP, Hair Dryer Fuchs Dystrophy Posterior Polymorphous Dystrophy Pseudophakic/Aphakic Bullous Keratopathy CHED Prior Rejection 2

4 DSAEK Complications Decreased Best Corrected Visual Acuity Pachy OD 460, OS 490 Graft Dislocation eye rubbing No apical scarring Technically challenging 1) donor preparation 2) insertion technique Exam DSAEK Future Technology DMEK Descemet s Membrane Endothelial Keratoplasty Treatment Glasses/contact lens Corneal Transplant Collagen Cross Linking Collagen Cross Linking 16 year old male with progressive decrease in Goals vision right eye > left eye. Patient Selection Procedure PMHx Seasonal Allergies Complications Results MRx OD x /20 3

5 CXL Goals CXL Procedure Strengthen and stabilize cornea Vitamin B2 (Riboflavin) Prevent progression of disease UV light 370nm wavelength Eliminate need for cornea transplantation Bandage Contact Lens Improve vision (+/ ) CXL Patient Selection Collagen Cross Linking Keratometry 60 Diopters Progression of disease (k s, Va, Ct) No scarring Pachymetry > 400 microns Not FDA Approved: Off Label CXL Candidates CXL Complications Keratoconus Infection Pellucid Marginal Degeneration Epithelial healing difficulty Post LASIK Ectasia 4

6 CXL Results Contact Lens Overwear Stabilization of progression > 90% D/C contact lens wear Improvement in Va > 65% Preservative Free Artificial Tears, Punctal Plugs Consider Restasis, Steroids CXL Future considerations Follow up 2 weeks later Infectious keratitis SPK resolved Lasik for KCN, Post Lasik ectasia Patient feels much better MRx OD 3.50 sphere 20/25 OS 4.00 sphere 20/20 Next step? Treatment 21 year old college female complaining of red Switch to daily wear CL s eyes. Wears CL s. Admits to sleeping in them. Reduce contact lens wear time Feels vision constantly fluctuates. Pt already with visually significant corneal 4.00 sphere OU ulcer Strongly consider refractive surgery 5

7 Lasik and PRK Custom wavefront guided treatment 42 year old male landscaper complaining of Corrects both lower order and higher order decreased vision and FBS of right eye. States aberrations eye remains red most of the day. Has been Reduction of glare and halo compared to non custom going on for several months. Lasik Microkeratome or Femtosecond laser for flap creation PRK Epithelium removal, Mitomycin C MRx OD x /20 OS plano sphere 20/20 Excimer laser treatment Pterygium PRK OD A non cancerous growth of conjunctival tissue Lasik OS over the cornea Cause is unknown, but likely secondary to uv light exposure May have iron deposition at leading edge (Stocker Line) Lasik and Omni Pterygium excision indications Goal is to offer a competitive alternative to Excessive irritation current Lasik referrals Difficulty with contact lens wear Initially perform procedure at separate location Visually significant Why send to Omni Corneal and Refractive trained ophthalmologist Performed multiple procedures under Dr. Theodore Perl Goal Better than 20/20 6

8 Pterygium excision Granular Dystrophy 3 techniques Autosomal dominant corneal stromal Bare sclera (60%) dystrophy Amniotic membrane (10%) FBS, Glare, Decreased Va, Recurrent Erosions Conjunctival autograft (5%) Crumb like opacities sparing peripheral cornea Mitomycin C cuts recurrence rate in half Later in life > increase in size, coalesce and Recurrence rate increased in recurrent invade deeper stroma pterygia Specimen for pathology Pterygium excision Treatment 1 st choice conj autograft, MMC, Tisseel fibrin BCL, lubrication for erosions sealant Improve vision > PTK 2 nd choice amniotic membrane, MMC, Tisseel Remove anterior stromal deposits microns Pts with glaucoma, conj scarring, multiple pterygia Deposits will recur > can retreat as needed Need sufficient pachy PKP Limbal Stem Cell Deficiency:INTRODUCTION 18 year old female with gradually decreasing Stem cells Undifferentiated proliferating vision in both eyes over last several years. cells Present in all self renewing tissues Occasionally has episodes of extreme pain in 0.5% 10% of total cell population both eyes. No patters to the pain. Will Properties: Long lived, long cell cycle time spontaneously resolve over several hours. have increased potential for error free proliferation with poor differentiation Va OD 20/60 capability to divide in asymmetric manner OS 20/100 7

9 HISTORICAL BACKGROUND CLINICAL MANIFESTATIONS & SYMPTOMS: 1971 Davanger and Evensen found the limbus Tearing Blepharospasm Photophobia of cornea is the root of corneal epithelium decreased vision recurrent episodes of pain proliferation and migration 1983 Schofield et (epithelial breakdown) history of chronic al proposed niche hypothesis inflammation with redness Schermer et al found the limbus of cornea was deficient in the expression of K3 RELEVANT ANATOMY SIGNS: The corneal epithelium nonkeratinised, The presence of a conjunctival phenotype on stratified squamous epithelial cells. the cornea (conjunctival overgrowth, Thickness ~50 μm Limbus CORNEAstratified, nonkeratinised squamous conjunctivalization) is central to the diagnosis of LSCD dull and irregular reflex of the corneal epithelium which varies in thickness and epithelium Gradual transition CONJUNCTIVAstratified, nonkeratinised columnar epithelium transparency an ingrowth of thickened fibrovascular pannus, chronic keratitis, scarring with mucin secreting goblet cells and calcification. Persistent epithelial defectsstippled fluorescein staining melting and architecture of the limbus palisade (of Vogt) arrangement. perforation of the cornea can occur AVAILABLE TREATMENT OPTIONS RELEVANT PHYSIOLOGY CONSERVATIVE OPTIONS: The corneal epithelium undergoes a constant In Acute phase: Immunosuppresion Topical process of cell renewal and regeneration steroids Cyclosporine use of intensive nonpreserved lubrication bandage contact lenses regenerates approximately every 7 days proliferative reserve in the form of autologous serum eye drops. Only the latter multipotent stem cells is supported by evidence in the literature Hypothesis stem cells flourish only in limbal Conservative treatment usually provides area vascularity temporary remission but the condition tends to deteriorate over time. 8

10 SURGICAL OPTIONS: PARTIAL LIMBAL STEM CELL DEFICIENCY In the acute phase following injury Fibrin adhesives for LASIK flap repeated debridement of migrating complications conjunctival epithelium (sequential sector Fibrin adhesives for IOL fixation conjunctival epitheliectomy (SSCE) can Fibrin adhesives for ocular surface reduce or prevent conjunctival ingrowth. The procedures use of an amniotic membrane graft has also been reported to be successful New adhesives SURGICAL OPTIONS TOTAL LIMBAL STEM CELL DEFICIENCY Other Topics To restore a corneal phenotype ocular surface reconstruction (OSR) is required Corneal/scleral melts Indicated in bilateral blinding ocular surface diseases Pharmacology update such as Stevens Johnson syndrome (SJS), ocular cicatricial pemphigoid (OCP), and severe chemical/ thermal burns. Intacs Clinically, the process involves a sequential three step approach.i. Correct any dry eye disease and lid abnormality Ocular Surface Disease that is contributing to ocular surface failure correction of meibomian gland dysfunction Corneal exposure Trichiasis SMILE technique entropion Punctal occlusion Repair of symblepharon frequent application of preservative free artificial tears or autologous serum Clinical and Research Perspectives on Adhesives for Anterior Segment Use Cyanoacrylate adhesives for corneal wounds Cyanoacrylate adhesives for cataract wounds Fibrin adhesives for pterygium surgery Dr. Hannush 9