1. Grand Rounds “Triple Procedure Via Open-Sky Approach”
Kevin Lowder, MD – PGY3
10/26/2018

2. Patient Presentation CC HPI Severe vision loss OS
49 yo WF with hx of PK OS secondary to fungal corneal ulcer for which patient was not compliant with drop regimen, now presenting with subsequent graft failure over several months as she has not been using steroids as prescribed.
Fungus = Cladosporium

3. History (Hx) Past Ocular Hx: PK OS (9 months prior)
Ocular Meds: pred forte QID OS, Muro 5% ung QHS OS, Ofloxacin QID OS
Past Medical Hx: COPD, Depression, Bipolar Disease, ADHD, Anxiety.
Fam Hx: Non-contributory
Meds: psychiatric & COPD meds
Meds: Dulera 100/5 Metered Dose Inhaler, 120 ACTUAT. LORTAB. buspirone hydrochloride 10 MG (buspirone 9.1 MG) Oral Tablet. Combivent (albuterol 0.09 MG/ACTUAT / ipratropium bromide MG/ACTUAT) Metered Dose Inhaler, 200 ACTUAT. LAMICTAL. 3

4. History (continued) Allergies: NKDA
Social Hx: Current smoker, occasional EtOH, history of poor compliance with medications, poor follow up (lives 4 hours away and has difficulty with rides)
RoS: Noncontributory 4

5. Physical Exam OD OS VA 20/20-2 PH HM sc (PHNI) Pupils
4mm. Round. Brisk.
No rAPD
1mm, fixed. No RAPD, by reverse.
IOP
8 mmHg
11 mmHg
EOM
full
CVF
unable

6. Physical Exam PLE or SLE OD OS External/Lids WNL Conj/Sclera
Conj injection
Cornea
no epi defect. Bullous keratopathy,
extensive Descemet’s folds. 3+ Edema. Few
buried sutures. few end of minimally exposed
suture at 2oc and 6oc. Significant neovascularization
Ant Chamber
Normal depth
Iris
Pupillary membrane with synechiae to lens.
Lens
Clear
Mature cataract
Vitreous
No view

8. Physical Exam Fundus OD OS Optic Nerve WNL NO VIEW Macula “ ” Vessels
“ ”
Vessels
Periphery

9. Assessment: 49 yo WF with: Corneal graft rejection OS
Mature cataract OS

10. Plan Triple Procedure via “open-sky” approach Penetrating Keratoplasty
Intracapsular cataract removal (en-bloc)
IOL Implantation (in the bag)

11. Surgery Overview Create new PK “button” inside the old button
Release the synechiae to the lens
Capsulorrhexis
Hydrodissection
En-bloc removal of cataract
Gentle I&A
Careful insertion of intracapsular IOL
No loading required
Complete PK
trephine

13. Discussion Risks/Difficulties of traditional method:
Suprachoroidal hemorrhage
Vitreous prolapse
Endophthalmitis
Difficult capsulorhexis
Incomplete I/A of cortex
Uncertain IOL placement
Posterior capsule rupture

14. Discussion Proposed Changes to Technique:
Start with Deep Anterior Lamellar Keratoplasty
(80%) thickness
Via scleral tunnel:
Manual small-incision cataract extraction
IOL placement
***Of note, this procedure is recommended for initial
transplant; this case is unique in that the patient had
already undergone PK previously***
Dr. Asghari, what are your thoughts on this modified
Approach in an initial corneal transplant?

15. Conclusions

16. References

17. Special Thanks
Dr. Asghari