CAKE and PIE magazines’ Daily Congress News on the Anterior and Posterior Segments
Surgical Options for Corneal Ectasia Problems by Brooke Herron
C
orneal ectasia — where the thinning of the cornea causes it to change shape — is a group of progressive eye disorders, under which several sight-debilitating conditions fall (e.g. keratoconus). Treatment options can range from the conservative contact lens or to more invasive alternatives, like corneal transplantation (or keratoplasty). Therefore, during the last day of the 37th World Ophthalmology Congress (WOC2020 Virtual®), ophthalmologists from Africa and the Middle East discussed the various surgical options to treat corneal ectasia during the session titled Surgical Management in Corneal Ectasia and Other Corneal Problems.
Femtosecond AK for high astigmatism post-keratoplasty “We know that keratoplasty is a common procedure for treating many corneal problems — but one of the main problems with keratoplasty is postoperative astigmatism,” said Dr. Tamer Gamaly of the Magrabi Eye Hospitals and Centers in Abu Dhabi, United Arab Emirates. “Plus, the functional visual acuity of the patient can take up to one year, usually after removing all the sutures from the graft,” he added.
that further adjustment and refinement will help in treating more patients.
Femtosecond endothelial keratoplasty Endothelial cell loss can result in increased corneal edema and decreased visual acuity. According to Dr. Saeed Algehedan of Global Eye Care in The Kingdom of Saudi Arabia, penetrating keratoplasty has long been the goldstandard of treatment in these cases. However, it’s not without drawbacks: visual recovery is slow (6-24 months), and 50% of patients require a contact lens or refractive surgery to achieve useful vision. It’s also associated with postoperative astigmatism, suture-related complications, graft failure, infectious keratitis, among others. “Now femtosecond endothelial keratoplasty (FEK) is providing us with an excellent alternative,” shared Dr. Algehedan. FEK has several benefits: it is performed under topical anesthesia; it’s suture-less; visual recovery is faster; it has less-induced astigmatism; and there are fewer intra- and postoperative complications. “This procedure has been done and is expanding worldwide,” he continued. In addition to the positive outcomes in
his own patient cases, he then shared results from recent studies which also reported excellent results. “FEK is a new surgical technique for endothelial transplantation that has a high success rate, a short learning curve, fewer complications, lower rate of rebubbling need, proper graft centration and faster recovery,” explained Dr. Algehedan.
Endothelial keratoplasty in glaucoma patients The coexistence of corneal endothelial disease and glaucoma is not uncommon: Elevated intraocular pressure (IOP) is associated with endothelial cell loss. And on the other hand, keratoplasty can lead to glaucoma, especially with the long-term use of steroids or from surgical complications, began Dr. Fouad El Sayyad of Sayyad Eye Center in Giza, Egypt. Over keratoplasty, procedures like DSAEK (Descemet stripping automated endothelial keratoplasty) and DMEK (Descemet membrane endothelial keratoplasty) have several advantages in glaucoma cases. Studies have shown that endothelial keratoplasty can be performed with great outcomes in pre-existing glaucoma patients, said Dr. El Sayyad. However, Dr. El Sayyad also conceded that there are challenges: “History of glaucoma surgery can cause increased graft dislocation.” Studies have reported graft dislocations in up to 26% of DMEK cases and up to 36% in DSAEK. Therefore, these patients should be monitored closely, he concluded.
Dr. Gamaly then presented a patient case where the patient’s astigmatism gradually worsened at each follow-up — from -2D, eventually to -9D at month 3 — after removing the sutures. However, he noted that the patient’s BCVA was still 20/28. After considering the various treatment options, Dr. Gamaly chose femtosecond astigmatic keratoplasty (AK). Following the procedure, he reported the astigmatism dropped to -1D, while the BCVA remained at 20/28. He concluded that femtosecond AK can reduce astigmatism in cases of highastigmatism post-keratoplasty, noting
Progressive steepening: Okay for roads, bad for corneas.
5
