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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 DSAE...
Ocular History:
Ocular History:
 BE pseudophakia (ACIOL) done in 2001 at PH Hospital
 March 2015: LE pain with redness,...
Series of Ophthalmology Visit at Hospital Sg Buloh
No Visit
date
Reason Findings Diagnosis &
Management
1 17/9/2015 Refer...
Series of Ophthalmology Visit at Hospital Sg Buloh
No Visit
date
Reason Assessment & Findings Diagnosis &
Management
5 16/...
Pseudophakic bullous keratopathy
Taken 1 day before LE DSAEKTaken 1 day before LE DSAEK
Corneal bullaeCorneal bullae
Post-op LE DSAEK
•Post-op LE DSAEK
•Taken 0n 24th
March, before graft rebubbling
•Inferior half detachment seen between th...
Assessment
Assessment
Examination RE LE
VA (aided) 6/9 6/36 (ph:6/36)
RAPD test No RAPD No RAPD
IOP 14 16
Anterior segmen...
Patient’s left eye:
LE Cornea central epithelial defect measuring 4.4 (V) x 5.2 (H)
Patient’s left eye:
LE Cornea central ...
Management
Imp:
Post LE DSAEK 2 weeks for LE pseudophakic bullous keratopathy:
stable
Post op 1 week LE rebubbling for ...
Management
Rationale of management given:
 Maxidex
 Contain dexamethasone(corticosteroids) that are used for reducing
i...
Summary of visit:
Discussion
Case analysis:
 Patient initially had LE pseudophakic bullous keratopathy and undergone
LE DSAEK followed by ...
Discussion
 The VA is still not improved post op during last visit as there was the
presence was cornea central epithelia...
Discussion (Bullous keratopathy)
 Refers to corneal swelling due to insufficiency of the corneal
endothelial pump resulti...
Discussion (Pseudophakic bullous keratopathy)
 Any type of intraocular surgery, especially cataract surgery, may damage
e...
Discussion (Pseudophakic bullous keratopathy)
Possible mechanism for endothelial cell loss:
ACIOL was the cause of
pseudop...
Discussion (Pseudophakic bullous keratopathy)
 Particular attention has also been directed at the relationship between in...
Discussion (Pathophysiology)
Discussion (Management)
1. Hypertonic agents, such as sodium chloride 2% and 5% solution
and ointment.
• Creates a hyperto...
Discussion (DSAEK)
Discussion (Corneal transplant: PK VS DSAEK)
PK DSAEK
In Penetrating keratoplasty (PK) a circular button-
shaped, full-thi...
Discussion (Corneal transplant: Why DSAEK?)
DSAEK PK
Suture-related problems can be
eliminated
Suture-related complication...
Discussion (DSAEK)
Procedure
•Inserts a full air bubble through a side port to push
the donor disc up against the host po...
Discussion (Complication)
The DSEK offers an effective and efficient alternative
to traditional PKP.
Complications of DS...
Discussion (Optometric management)
 Bullous keratopathy
 Early detection, vision can be preserved, with complete history...
Discussion (Optometric management)
 Consult on do’s and dont’s post-DSAEK procedure:
 Explain to patient the eye will be...
References
 Gimeno FL, Lang, M, Mehta JS, Tan DT. Descemet's Stripping Automated Endothelial
Keratoplasty: Past, Present ...
THANK YOU
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Pseudophakic Bullous Keratopathy case

Pseudophakic bullous keratopathy (PBK) is a post-operative condition that can occur as a complication of cataract extraction surgery and intraocular lens placement.

May be manifest in the immediate post-operative period or symptoms may not present for many years.

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Pseudophakic Bullous Keratopathy case

  1. 1. BY: NOOR MUNIRAH BINTI AWANG ABU BAKAR OPTOMETRIST (MOC NO. O-0869) Pseudophakic Bullous Keratopathy
  2. 2. 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
  3. 3. 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
  4. 4. 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.
  5. 5. 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 & nausea Assessment: 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 keratopathy Complaint 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 DSAEK Management: •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
  6. 6. Pseudophakic bullous keratopathy Taken 1 day before LE DSAEKTaken 1 day before LE DSAEK Corneal bullaeCorneal bullae
  7. 7. Post-op LE DSAEK •Post-op LE DSAEK •Taken 0n 24th March, before graft rebubbling •Inferior half detachment seen between the graft •Post-op LE DSAEK •Taken 0n 24th March, before graft rebubbling •Inferior half detachment seen between the graft
  8. 8. 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
  9. 9. Patient’s left eye: LE Cornea central epithelial defect measuring 4.4 (V) x 5.2 (H) Patient’s left eye: LE Cornea central epithelial defect measuring 4.4 (V) x 5.2 (H)
  10. 10. Management Imp: Post LE DSAEK 2 weeks for LE pseudophakic bullous keratopathy: stable Post op 1 week LE rebubbling for partial graft detachment: stable Management: Reduce Maxidex 4 hourly LE Continue CMC QID LE Artificial tears preservative free(ATPF) QID/PRN BCL LE x 2 weeks TCA 2/52
  11. 11. 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)
  12. 12. Summary of visit:
  13. 13. 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
  14. 14. 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)
  15. 15. 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
  16. 16. 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.
  17. 17. Discussion (Pseudophakic bullous keratopathy) Possible mechanism for endothelial cell loss: ACIOL was the cause of pseudophakic BK in this case ACIOL was the cause of pseudophakic BK in this case
  18. 18. 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
  19. 19. Discussion (Pathophysiology)
  20. 20. 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.
  21. 21. Discussion (DSAEK)
  22. 22. Discussion (Corneal transplant: PK VS DSAEK) PK DSAEK In 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)
  23. 23. Discussion (Corneal transplant: Why DSAEK?) DSAEK PK Suture-related problems can be eliminated Suture-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)
  24. 24. 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 Risk of graft detachment because the donor tissue is held in place with an air bubble instead of sutures
  25. 25. 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 •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
  26. 26. 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
  27. 27. 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.
  28. 28. 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
  29. 29. THANK YOU

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