Cataract Surgery and LASIK Update 2013Random Case Studies

Jeffrey Martin, M.D. FACS

Managing Partner

North Shore Eye Care

Assistant Clinical Professor of Ophthalmology at SUNY Stony Brook

The lenses are non-glare…perfect for those moments you’re frozen in

headlights…

CASE STUDY

• 23 year old male

• One day post PRK

• Presents with 20/40 vision

• Moderate discomfort

• Contact lens in place

CASE STUDY

• What do we do first?

1. Scream, “Why me? Why me?”

2. Remove the contact lens and culture

3. Increase antibiotic to q2 hours and stop steroid

4. Increase steroid to q2 hours and leave antibiotic at standard dose

CASE STUDY

• We increased steroid to q2 hours.• Patient improved over 2 to 4 days.

CASE STUDY

• 32 year old hospital worker • Presents 5 days post LASIK with pain,

redness, and photophobia • Vision of 20/40 • Pt on Durezol and Zymaxid

CASE STUDY #2

CASE STUDY #2

• What do we do?

1. Scream, “Oh no, not again!”

2. Lift flap, culture and keep on Zymaxid

3. Lift flap, culture and switch to tobramycin 3 %

4. Lift flap, culture and start fortified antibiotics

CASE STUDY #2

• What is the significance about place of employment?

1. No significance

2. Less worried, hospital workers are really clean

3. More worried, hospital workers are filthy

4. More worried, resistant bugs

CASE STUDY #2

• Symptoms– Red eye– Moderate to severe pain– Photophobia– Decreased vision– Discharge

BACTERIAL KERATITIS

• Signs– Focal white opacity

• Infiltrate if in corneal

stroma

• Ulcer with epithelial

defect

– Mucopurulent discharge

– Stromal edema

– Anterior chamber reaction

• Hypopyon possible

– Conjunctival injection

diffuse

– Corneal thinning

– Upper eyelid edema

– Posterior synechiae

BACTERIAL KERATITIS

• Which is true about Fungal Keratitis?

1. Should be treated aggressively with steroids

2. Is commonly bilateral

3. Often has satellite lesions

4. Has been linked to Dr. Mauro’s eye exams

DIFFERENTIAL OF BACTERIAL KERATITIS

• Differential– Fungal

• Infiltrates have feathery borders with satellite lesions• Traumatic injury from vegetative matter• Contact lens wear is a risk factor• Fusarium and aspergillus most common• Candida in diseased eyes

– Dry eye, herpes simplex or zoster, exposure keratopathy

BACTERIAL KERATITIS

FUNGAL KERATITIS

DIFF. OF BACTERIAL KERATITIS

• Which is false about Acanthamoeba Keratitis?

1. It can be misdiagnosed as HSV keratitis

2. A ring infiltrate is seen early

3. It is typically painful

BACTERIAL KERATITIS• Differential

– Acanthamoeba• Extremely painful

– Out of proportion to physical findings– Circumcorneal injection and photophobia– Minimal discharge– Cells and flare– Epithelial pseudodendrites early

• Contact lens wearer with poor hygiene, swimming with contact lenses• In late stages (3 to 8 weeks), infiltrate becomes ring shaped• Can be misdiagnosed as HSV

ACANTHAMOEBA

DIFF BACTERIAL KERATITIS• Which is true about HSV Keratitis

1. Is often bilateral

2. Presents with decreased corneal sensitivity

3. More common in promiscuous people (like Dr. Mauro)

4. I am only picking on John because he is not lecturing today, therefore no pay back.

BACTERIAL KERATITIS

• Differential– HSV Keratitis

• Eyelid vesicles• Epithelial dendrites• Reduced corneal sensation• History of recurrent unilateral episodes

– Recurrence due to fever, stress, trauma, UV light

• Bacterial superinfections possible

HERPES SIMPLEX KERATITIS

HERPES SIMPLEX

• Neurotrophic ulcer– Sterile ulcer with

smooth borders– May be associated

with stromal melting and perforation

HERPES SIMPLEX

• Stromal disease– Disciform keratitis

• Disc shaped stromal edema with intact epithelium

• Mild iritis• Keratitc precipitates• Increased IOP

HERPES SIMPLEX

• Stromal disease– Necrotizing interstitial keratitis

• Uncommon• Multiple or diffuse whitish corneal stromal infiltrates • With or without epithelial defect• Stromal inflammation, thinning, and

neovascularization• Iritis, hypopyon and glaucoma may be present

NECROTIZING IK

HERPES SIMPLEX

• Uveitis

– As a result of stromal involvement

– Less common• Anterior chamber reaction and granulomatous KP

without corneal disease

• High IOP

DIFF BACTERIAL KERATITIS• Which is true about Atypical Mycobacteria

Keratitis?

1. Typically aggressive course

2. Years ago, seen in a high percentage of LASIK infections

3. Resolve quickly with treatment

BACTERIAL KERATITIS

• Differential– Atypical mycobacteria

• Follows ocular injuries with vegetative matter or surgery

• Represented high percentage of LASIK infections

• Indolent course

• Need prolonged treatment– Every hour for one week then gradual tapering

– Fluoroquinolones, amikacin, clarithromycin or tobramycin

ATYPICAL MYCOBACTERIA KERATITIS

BACTERIAL KERATITIS

• Which is not one of the most common bugs?

1. Staph

2. Strep

3. Pseudomonas

4. Moraxella

5. Atypical mycobacteria

BACTERIAL KERATITIS

• Etiology– Most common

• Staph– Well defined gray-

white stromal infiltrate– May enlarge to form

dense stromal abscess

BACTERIAL KERATITIS

• Etiology– Most common

• Strep– Purulent

» Severe anterior chamber reaction and hypopyon common

– Crystalline» Patients on chronic topical steroids

BACTERIAL KERATITIS• Strep keratitis• Strep Crystalline keratitis

BACTERIAL KERATITIS

• Etiology– Most common

• Pseudomonas– Rapidly progressive

supprative and necrotic– Hypopyon and discharge– Soft contact lens use

BACTERIAL KERATITIS

• Etiology – Most common

• Moraxella– Preexisting ocular surface disease– Immunocompromised– Indolent infiltrates in the inferior cornea– Full thickness– May perforate

BACTERIAL KERATITIS

• Treatment– Low risk

• Small nonstaining peripheral• Broad spectrum topical antibiotics every hour or

two– Fluoroquinolone

• Contact lens wearer– Add tobramycin or ciprofloxacin ointment

BACTERIAL KERATITIS

• Treatment

– Borderline risk• Medium size 1 to 1.5 mm peripheral infiltrate

• Smaller infiltrate with epitheilial defect

• Anterior chamber reaction

• Discharge

• Fluoroquinolone q1h around the clock– Loading dose q5 min times 5

– Then q 30 min for a few doses

BACTERIAL KERATITIS• Treatment

– Vision threatening• Larger than 1 to 2 mm

• Visual axis

• Unresponsive to treatment

• Corneal scrapings for smears and culture

• Fortified Abx– Fortified tobra or gent

– Fortified vanco or cephaloporins

– Alternating q1 hour… they get a drop every 30 minutes

» Load with q 5 min times 5

BACTERIAL KERATITIS

• Treatment– Sometimes topical steroids are used

• Sensitivities are known• Infection under control• Severe inflammation persists• Keratitis may worsen

– Fungus– Atypical mycobacteria– pseudomonas

STAPH HYPERSENSITIVITY

• Symptoms– Mild pain– Mild photophobia– Localized red eye– Chronic blepharitis

• Eyelid crusting• History of chalazia or styes• Foreign body sensation

STAPH HYPERSENSITIVITY

Blepharitis

STAPH HYPERSENSITIVITY• Signs

– Singular or multiple unilateral or bilateral peripheral corneal stromal

infiltrates

– Clear space between infiltrates and limbus

– Variable staining with fluorescein

– No anterior chamber reaction

– Sectoral conjunctival injection

– Others• Blepharitis, inferior spk, peripheral scarring, corneal neovascularization

• Treatment– Antibiotic and steroid

• Recurrent episodes– Oral doxy or tetracycline– Restasis– Blepharitis treatment

STAPH HYPERSENSITIVITY

STAPH HYPERSENSITIVITY• Differential

– Infectious corneal infiltrate• Round

• Painful

• Anterior chamber reaction

– Other causes or peripheral corneal thinning or ulceration• Connective tissue disease

• Terrien marginal degeneration

• Mooren ulcer

• Dellen

• Peripheral Corneal Thinning– Connective Tissue Disease

• Peripheral corneal thinning/ulcers may be associated with infiltrates

• Unilateral or bilateral

• May involve the entire peripheral cornea

• Perforation can occur

• Can be first sign of disease

RHEUMATOID PERIPHERAL CORNEAL THINNING

RHEUMATOID PERIPHERAL CORNEAL THINNING

• What is true about Connective Tissue Disease Cornea Thinning?

1. Nothing can be done

2. Treatment is often coordinated with a Rheumatologist

3. Standard corneal transplants are very successful

RHEUMATOID PERIPHERAL CORNEAL THINNING

• Treatment

– Management usually coordinated with a rheumatologist

– Antibiotic ointment

– Cycloplegia

– Oral doxycycline for metalloproteinase inhibition

– Systemic steroids

– Immuosuppressives

– Punctal occlusion for dry eye

– Have patients wear glasses for protection

– Avoid topical steroids… increase risk of perforation

• Peripheral corneal thinning– Terrien marginal degeneration

• Often asymptomatic usually bilateral

• Slowly progressive thinning

• Typically superior more often in males

• AC quiet, conjunctiva white

• Yellow lipid line with corneal pannus over involved area

• Against the rule astigmatism can occur

• Epithelium remains intact

• Perforation possible with minor trauma

• Which is false about Terrien Marginal Degeneration?

1. Rarely is there significant morbidity

2. Steroids are useful for excessive thinning

3. Against the rule astigmatism is common

TERRIEN MARGINAL DEGENERATION

TERRIEN

• Peripheral Corneal Thinning– Mooren ulcer

• Unilateral or bilateral• ? Autoimmune• Painful corneal thinning and ulceration with inflammation• Starts focally nasal or temporal• No limbal sparring• Epithelial defect, stromal thinning, leading edge• Perforation can occur• Associated with Hepatitis C

MOOREN ULCER

MOOREN ULCER

• Which is true about Moorens Ulcer?

1. Treatment is rarely necessary

2. Is a diagnosis of exclusion

3. Oral immunosuppressives not necessary

MOOREN ULCER

• Treatment– Rule out underlying systemic disease

– Topical corticosteriods

– Topical cyclosporine

– Oral steroids

– Oral immunosuppressives

– Corneal glue

– Lamellar keratoplasty

• Peripheral Corneal Thinning– Furrow Degeneration

• Painless

• Adjacent to area of arcus

• Elderly

• Noninflammatory without neovascularization

• Perforation is rare

• Does not require treatment

FURROW DEGENERATION

• Peripheral corneal thinning– Dellen

• Painless oval corneal thinning• From corneal drying and stromal dehydration• Epithelium intact• Adjacent to abnormal conjunctiva or corneal

elevation

DELLEN

DELLEN

• Audience participation question

1. Stop with the corneal thinning already

2. I find corneal thinning so interesting, please continue

3. Mauro, please intervene

CATARACT SURGERY @ NSEC

• Technique– Topical anesthesia with IV sedation

– Anticoagulants ok

– No injections around eye

– Small incision, no sutures

– No eye patch necessary

• Start medications right away

– Co-management encouraged

CATARACT SURGERY• What about laser cataract surgery?

– Strong future– Incisions

• Penetrating and nonpenetrating• Capsulorrhexis• Lens division

– Still improvement to be had at each stage– Looking at 3 platforms

CATARACT SURGERY

• Meds– Three days prior

• Antibiotic and NSAID

– After Surgery• Antibiotic, NSAID and Steroid• Antibiotic stops after 2 weeks• NSAID, Steroid for 4 weeks… sometimes 6

CATARACT SURGERY• Intraocular lens implants

– Choice depends on preexisting astigmatism– Monofocal– Toric– Multifocal– Accommodating

• Technique important– Control astigmatism– Hit target

• Iol master• Modern IOL formulas

– Dry eye

LASIK @ NSEC• iLASIK

– Bladeless and custom– Nearsightedness, farsightedness and astigmatism

• State of the art LASIK center in Smithtown– Humidity and temperature controlled– Excellent staff

• Run by RN

• Co-management encouraged• Lifetime Commitment• More cases qualify for LASIK because flaps can be 100 micron

PRK• Better in some cases

– Thin corneas– Irregular corneas– High prescriptions– Dry eyes– Contact sports

• Higher corrections due to mitomycin c• Longer recovery• More dicomfort

LASER VISION CORRECTION MEDS

• LASIK

– Antibiotic and steroid for 10 days

• PRK/LASEK

– Antibiotic until contact lens out (5 days)

– Steroid for 1 to 2 months

THANK YOU