DALK IN DANGEROUS INFECTIONS

Transcription

1 32 INTERNATIONAL CONGRESS of the HELLENIC SOCIETY OF INTRAOCULAR IMPLANT AND REFRACTIVE SURGERY CORNEA ROUND TABLE: STROMAL REPAIR DALK IN DANGEROUS INFECTIONS, MD Clinica Degli Occhi Sarnicola, Grosseto No financial interest to disclose.

2 PRECOCIOUS DALK in CORNEAL INFECTIONS POORLY RESPONSIVE TO MEDICAL TREATMENT -Enrica Sarnicola, Unisersity of Siena -Caterina Sarnicola, University of Ferrara -, Grosseto, Ambulatorio di Chirurgia Oculare Santa Lucia No financial disclosure

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4 DALK NEW INDICATION -660 consecutive DALK procedures: 489 cases of keratoconus (74%) including extreme ectasia 158 cases of corneal infections (24%) 13 cases other (2%) other corneal opacities, dystrophies, penetrating trauma etc, ASCRS, Boston 2014 E. Sarnicola, WCC, San Diego, 2015

5 DALK NEW INDICATION -660 consecutive DALK procedures: 489 cases of keratoconus (74%) including extreme ectasia 158 cases of corneal infections (24%) 13 cases other (2%) other corneal opacities, dystrophies, penetrating trauma etc, ASCRS, Boston 2014 E. Sarnicola, WCC, San Diego, 2015

6 158 (24%) DALK IN CORNEAL INFECTION 131 (83%) cases of post-infective stromal scar 98 HSV infection 20 Bacterial keratitis 9 Acanthamoeba keratitis 4 Fungal keratitis 27 (17%) cases of active infection, ASCRS, Boston 2014 E. Sarnicola, WCC, San Diego, fungal keratitis 6 Acanthamoeba keratitis

7 158 (24%) DALK IN CORNEAL INFECTION 131 (83%) cases of post-infective stromal scar 98 HSV infection 20 Bacterial keratitis 9 Acanthamoeba keratitis 4 Fungal keratitis 27 (17%) cases of active infection, ASCRS, Boston 2014 E. Sarnicola, WCC, San Diego, fungal keratitis 6 Acanthamoeba keratitis

8 11 eyes Acanthamoeba 23 eyes Fungi

9 - EARLY DALK in infectious keratitis poorly responsive to medical treatment Significant ulcer (>150μ but <300μ) in optical zone : (Presumed scar penalizing VA) Dangerousness of infection (Fungal and Acanthamoeba keratitis) Absence of prompt medical therapy response (NO reduction, or at least stabilization, of size lesion and/ or symptoms, after 1 week of targeted therapy) Patient s compliance

10 SURGICAL TECHNIQUE - Large (as much as possible: mm) 400 μ trephination - Debulking of the corneal lesion (as deep as possible) - Disinfection of the recipient bed - Instruments and surgical gloves change - Cannula big-bubble or layer by layer DALK - Same size for donor and recipient - Interrupted sutures - Histological and microbiological examination of the removed, tissueascrs, Boston 2014

11 ANTIAMOEBIC PROTOCOL Drugs: Antiseptic: Chlorhexidine Gluconate Inhibitor of DNA synthesis: Propamidine Isethionate Protein synthesis inhibitor: Neomycin Sulfate Preoperative : 3 drugs First 48 h : every hour, day and night Third day : every hour, daylight Regression of infection signs : QID Postoperative : 3 drugs QID for 1 st month 1 drug only (Propamidine Isothionate) QUID for 2 nd month

12 ANTIFUNGAL PROTOCOL Antifungal Drugs: Systemic/Oral Topical: 8 Candida Amphotericin 0,15% Voriconazole 200mg (twice/day) Voriconazole 1% 9 Fusarium Voriconazole 1% Voriconazole 200mg (twice/day) 5 Aspergillus Voriconazole 1% Voriconazole 200mg (twice/day) 1 Curvularia Amphotericin 0,15% Voriconazole 200mg (twice/day) Voriconazole 1%

13 SURGICAL TIMING in FUNGAL INFECTION 1 Fusarium 3 days of therapy 2 Fusarium 6 days of therapy 6 Fusarium 7 Candida 7-14 days of therapy 4 Aspergillus 1 Aspergillus 1 Candida 20 days of therapy 1 Curvularia SURGICAL TIMING in ACANTHAMOEBA INFECTION days from onset of symptoms days of targeted therapy

14 OUTCOMES 21 ddalk 13 pddalk (1 small Descemet rupture in Acanthamoeba) No recurrence of the infection BSCVA: range 6-10/10 avarage 8/10 No complication: No secondary cataract No secondary glaucoma Etc

15 - HISTOLOGICAL EXAMINATION: Peripheric margin FREE OF INFECTION (1,5 mm at least) Deep margin: ALL CASES FREE of infection 32 CASES NOT FREE of infection 2 CASES (ddalk in Acanthamoeba)

16 PK in ACANTHAMOEBA Male, 61 yrs. Corneal trauma with foreing body Delay in diagnosis. Treated as bacterial keratitis Biopsy confirmed the acantamoeba keratitis Treated medically with topical PHMB, chlorhexidine and topical steroids Progression of disease; melting. PK

17 After 5 days postop: endophthalmitis required vitrectomy and silicon oil

18 -1 month later : Fungal keratitis (Fusarium). 2 nd PK Then..rejections, retinal detachment, secondary glaucoma, limbal deficiency, perforation Enucleation

19 Acanthamoeba keratits 15 years old girl Soft conctat lens wear Late diagnosis (1 month) previously treated as bacterial keratitis Lab diagnosis : Acanthamoeba keratitis Local therapy every 2 hours: Chlorhexidine Gluconate, Propamidine Isethionate and Neomycin Sulfate ULCER PROGRESSION, STROMAL NEOVASCULARIZATION ecc

20 EARLY DALK IN ACANTHAMOEBA KERATITIS Cannula Big-bubble DALK Ø 9 mm No perforation 1 week post-op

21 EARLY DALK IN ACANTHAMOEBA KERATITIS Gradual re-epithelisation (with tapering of topical antiamebals) Stromal haze gradually cleared

22 EARLY DALK IN ACANTHAMOEBA KERATITIS Follow-up 1 anno: BCVA = 20/30, No recurrence

23 EARLY DALK IN ACANTHAMOEBA KERATITIS 1 week post-op

24 EARLY DALK IN ACTIVE FUSARIUM INFECTION 3 months post-op

25 CONCLUSION Because DALK is a safe procedure: Long term graft survival : 99% after 10 years in literature Low rate of rejection, and easy treatable Very low risk of secondary complication: glaucoma, secondary cataract, secondary limbal deficiency and graft vascularization.

26 in acanthamoeba or fungal infection, a precocious DALK should be considered: significant ulcer in optical zone poorly responsive to medical treatment You need a DALK surgeon with a low PK conversion rate

27 INTERACTIVE CLINICAL CASES WET LABS LIVE PATIENTS EVALUATION

28 S.I.C.S.S.O. PARTY!!!WET LABs SICSSO 2014 in PAESTUM

29 EARLY DALK IN ACTIVE FUSARIUM INFECTION

30 Female 27 years old CL wearer History of swimming wearing CL Theraphy: PHMB e Chlorhexidine e Levofloxacin

31 DESCEMETOCELE DALK

32 MICORBIOLOGY RESISTENT TO LEVO