Download Chen Tenwek 2015 Bullous Keratopathy

Approach to the Management of
Bullous Keratopathy
Michael C. Chen, MD
May 15, 2015
HM
CF 1M
Pain
HM
HM
Pain
HM
HM
Pain
Infectious keratitis
Purpose
To give an overview of how to approach and manage
bullous keratopathy
Corneal Anatomy
Wilson SA et al. Management of corneal abrasions. Am Fam Physician 2004;70:124.
Endothelial Pump
Hatton MP et al. Corneal edema in ocular hypotony. Exp Eye Res 2004;78:549.
Corneal Anatomy
 Normal endothelial cell density at birth: > 3500 cells/mm2
Bourne WM et al. Specular microscopy of human corneal endothelium in vivo. Am J Ophth 1976;81:319-23.
Pigatto JAT et al. Morphological analysis of the corneal endothelium in eyes of dogs using specular microscopy. Pesq. Vet Bras 2008;28;427-30.
Endothelial Cell Loss
 Decreases with age
 Without surgery: 0.6% per year
Bourne WM et al. Specular microscopy of human corneal endothelium in vivo. Am J Ophth 1976;81:319-23.
Bourne WM et al. Central corneal endothelial cell changes over a ten-year period. IOVS 1997;38:779-82.
Endothelial Cell Loss
 Without surgery: 0.6% per year
 With cataract surgery: Initial loss + 2.5% per year
 With corneal transplant: Initial loss + 4.2% per year
Bourne WM et al Continued cell loss ten years after lens implantation. Ophthalmology 1994;101:1014-23
Ing JJ et al, Ten-year postoperative results of penetrating keratoplasty. Ophthalmology 1998;105:1855-65
Endothelial Loss: SICS
Study
ECD Loss
Timepoint
George et al.
4.21%
6 weeks
Mathew et al.
7.67%
6 weeks
Gogate et al.
15.3%
25.9% with PC rent
6 weeks
Ganekal et al.
16.49%
6 weeks
Jiang et al.
19.0%
1 month
Ganekal S et al. Comparison of morphological and functional endothelial cell changes after cataract surgery: phacoemulsification versus manual small-incision cataract
surgery. Mid E Afr J Ophth 2014;21:56-60.
George R et al. Comparison of Endothelial cell loss and surgically induced astigmatism following conventional extracapsular cataract surgery, manual small-incision surgery
and phacoemulsification
Gogate P et al. Comparison of endothelial cell loss after cataract surgery: phacoemulsification versus manual small-incision cataract surgery. JCRS 2010;36;247-253.
Jiang T et al. Cataract surgery in aged patients: phacoemulsification or small-incision extracapsular cataract surgery. Int J Ophth 2011;513-8.
Mathew PT et al. Endothelial cell loss and central corneal thickness in patients with and without diabetes after manual small incision cataract surgery. Cornea 2011;30:424-8.
Endothelial Cell Loss
 ECD threshold for corneal
decompensation: ?
 ~ 500 to 700 cells/mm2
Endothelial Cell Loss
 ECD threshold for corneal
decompensation: ?
 ~ 500 to 700 cells/mm2
Inadequate endothelium
Stromal edema
Subepithelial bullae
Pain and decreased vision
Treatment Options
Non-Surgical
Surgical
 Hypertonic saline
 Collagen Crosslinking
 Bandage contact lens
 Phototherapeutic keratectomy
 ? Honey
 Amniotic membrane
 Conjunctival Flap
 Corneal cautery
 Anterior stromal puncture
 Corneal transplantation
Treatment Approach
Step 1:
 Treat any underlying inflammation or increased IOP
 Avoid carbonic anhydrase inhibitors (i.e. dorzolamide,
brinzolamide, acetazolamide)
Things to Consider
Clinical factors:
 Severity of edema
 Location of edema (stromal or epithelial)
 Visual potential
 Functional status of the contralateral eye
Patient factors:
 Primary concern (pain or vision)
 Compliance and followup ability
 Finances
5% Hypertonic Saline
 Cornea osmotic pressure: 300 mOsm
 5% hypertonic saline: 1500 mOsm
 Frequency of treatment: 4-8x/day
Brubaker RF et al. Microcryoscopic determination of the osmolality of interstitial fluid in the living rabbit cornea. Invest Ophthal 1962;653-660
Stanley JA et al. In vivo determination of endothelial permeability to water. Invest Ophthal 1966;371-7.
 Early (stromal) vs. Late (stromal + epithelial) stages of
disease
 Visual acuity and pachymetry improved only in Early
group
 Effective in patients with central corneal thickness
<694 microns
 Not effective in patients with bullae
Knezovic et al, Therapeutic efficacy of 5% hypertonic solution in patients with bullous keratopathy, Coll Antropol 2006;30:405-8
Bandage Contact Lens
 Hydrophilic soft contact lens
 Addition of 5% hypertonic saline
may be helpful
 May increase neovascularization
 ? Duration of leaving the contact in
 ? Prophylactic antibiotics
Gasset AR et al. Bandage lenses in the treatment of bullous keratopathy. AJO 1971;72;376-80
Takahashi et al. Hydrophilic contact lenses in corneal disease. 3. Topical hypertonic saline therapy in bullous keratopathy. Arch Ophth 1971; 86: 133-7
http://www.issaquahvision.net/uploads/image/products/products_contactlenses_contact.jpg
Honey
 Used by Egyptians as early as
5000 years ago
 Hyperosmotic
 Anti-inflammatory
 Anti-oxidative
Mansour AM et al. Bullous keratopathy treated with honey. Acta Ophth Scand 2004;312-3.
http://www.nectarcafenj.com/files/honey-kills-bacteria1.jpg
 24 patient with bullous keratopathy
 1 drop of raw honey 3-4x/day
 All patient had clearing of bullae
 Mean VA improved from CF50cm
to CF2m
 ?Clostridium botulinum spores
Mansour AM et al. Bullous keratopathy treated with honey. Acta Ophth Scand 2004;312-3.
http://www.nectarcafenj.com/files/honey-kills-bacteria1.jpg
Collagen Cross-linking (CXL)
 Application of topical riboflavin-A and ultraviolet-A
light induces corneal stromal crosslinks and stiffens the
tissue
 Crosslinking compacts the anterior stromal collagen
fibers and decreases the hydration of the cornea
www.lasik-sa.co.za
Collagen Cross-linking (CXL)
Within 1 month:
 Improvement in visual acuity
 Improvement in symptoms
 Decrease in central corneal thickness
Regression observed over 3-6 months
 More effect on earlier stages of disease?
Arora R et al. Role of corneal collagen cross-linking in pseudophakic bullou skeratopathy: a clinicaopathological study. Ophthalmology 2013;120:2413-8.
Sharma N et al. Outcomes of corneal collagen crosslinking in pseudophakic bullous keratopathy. Cornea 2014; 33:243-6.
Phototherapeutic Keratectomy
 Excimer laser (193 nm) ablation
 Removes abnormal basement membrane/stroma
 Promotes stronger adhesion between epithelium and
stroma
Lowers the osmotic load of the stroma
Deeper treatments (100 microns)
effective in relieving pain
 Promotion of scarring
 Ablation of nerve plexus
Lin P et al. Combined phototherapeutic keratectomy and therapeutic contact lens for recurrent erosions in bullous keratopathy. BJO 2001;85:908-11.
Maini R et al. A comparison of different depth ablations in the treatment of painful bullous keratopathy with phototherapeutic keratectomy. BJO 2001;85:912-5.
Thomann U et al. Phototherapeutic keratectomy for bullous keratopathy. BJO 1995;79:335-8.
http://www.institutmacularetina.com/wp-content/uploads/PRK.jpg
Amniotic Membrane
 Use on eye first described in 1940, popularized in
1990s
 Harvested from innermost layer of human placenta
 Basement membrane is similar to that of conjunctiva
 Mechanisms:
 mechanical barrier
 scaffold for epithelial growth
Dua HS et al. The amniotic membrane in ophthalmology. Suv Ophth 2004;49:51-77.
Altiparmak UE et al. Prospective comparison of two suturing techniques of amniotic
membrane transplantation for symptomatic bullous keratopathy. AJO 2009;147:442-06.
 At 6 months, no difference in symptoms between
groups
 At least 80% of both groups had no pain
Chawla B et al. Comparative evaluation of phototherapeutic keratectomy and amniotic membrane
transplantation for management of symptomatic chronic bullous keratopathy. Cornea 2010:29:976-9..
Conjunctival Flap
 Popularized by Gundersen in
1958
 Superior conjunctiva mobilized
over cornea
 Alleviates pain by providing a
mechanical barrier
Gundersen T, Arch Ophth 1958;60:880-8.
Indiana University http://eyeatlas.glick.iu.edu/photo.php?id=43
Gundersen T, Arch Ophth 1958;60:880-8.
Conjunctival Flap
Disadvantages:
 Cosmesis
 Flap retraction (10-15%)
 Shortened fornix
 Loss of ability to perform future glaucoma surgery
 Potential loss of limbal stem cells for future corneal
transplant
Corneal Cautery
 Debride loose epithelium
 Apply ~450 spots with
electrocautery
DeVoe. Electrocautery of Bowman’s membrane. Arch Ophth 1966;76;768-71
Anterior Stromal Puncture
 First described in 1986 for recurrent erosion syndrome
 Promotes stronger adhesion between epithelium and
stroma
 Low cost and possible to perform at slit lamp
 Usually no progression of neovascularization
 Can be performed while waiting for a corneal transplant
McLean EN et al. Recurrent erosion: treatment by anterior stromal puncture. Ophthalmology 1986;93:784-8.
Cormier G et al. Anterior stromal punctures for bullous keratopathy. Arch Ophth 1996;114:654-8.
Gomes JAP et al. Anterior stromal puncture in the treatment of bullous keratopathy. Cornea 2001;570-2.
Sridhar MS et al. Anterior stromal puncture in bullous keratopathy. Cornea 2001;573-9.
Anterior Stromal Puncture
Anterior Stromal Puncture
Video
Preop
3 Weeks
Postop
At 6 months:
 Presence of
bullae
 Presence of
subepithelial
fibrosis
 Complete
absence of pain
ASP (n=18)
37.5%
AMT (n=20)
22.2%
100%
88.9%
75%
66.7%
Paris FdS. Amniotic membrane transplantation versus anterior stromal puncture in bullous keratopathy.: a comparative study. BJO 2013;97:980-4
Corneal Transplantation
Penetrating Keratoplasty
(full thickness)
Descemet’s Stripping
Endothelial Keratoplasty
(partial stroma/
DM/endothelium)
Descemet’s Membrane
Endothelial Keratoplasty
(DM/endothelium)
Tan et al. Corneal transplantation. Lancet 2010;379:1749-61
Penetrating Keratoplasty
Full thickness transplant
 Long rehabilitation time/
Many followup visits
 Irregular astigmatism
 Suture related complications
 Risk of dehiscence with
trauma
Tan et al. Corneal transplantation. Lancet 2010;379:1749-61
Corneal Transplant Prognosis:
By Diagnosis
10 year graft survival rate
 Keratoconus:
 Fuchs’ Dystrophy:
 Corneal scar (non-herpetic):
 Corneal scar (herpetic):
 Bullous keratopathy:
 Repeat corneal transplant:
89%
73%
70%
60%
42%
37%
Williams K et al. Risk factors for human corneal graft failure within the Australian corneal graft registry. Transplantation 2008; 86: 1720–24.
Endothelial Keratoplasty
Tan et al. Corneal transplantation. Lancet 2010;379:1749-61
Endothelial Keratoplasty
Video
Endothelial Keratoplasty
Video
Endothelial Keratoplasty
 Increasing popularity since 2005
 Preferred procedure for endothelial decompensation
Coster DJ et al. A comparison of lamellar and penetrating keratoplasty outcomes. Ophthalmology 2014;121:979-87.
Endothelial Keratoplasty
 Increasing popularity since 2005
 Preferred procedure for endothelial decompensation
Greenrod EB et al. Center and surgeon efect on outcomes of endothelial keratoplasty
versus penetrating keratoplasty in the United Kingdom. AJO 2014;158:957-66..
Endothelial Keratoplasty
 Predictable refractive error; less irregular astigmatism
 No suture related complications
 Less risk of dehiscence
 ? Less risk of rejection
 ? Steep learning curve and higher risk of graft failure
Take Home Points
 Management of bullous keratopathy is a challenge
 Respect the endothelium: prevention is key
 Consider clinical and patient factors in choosing treatment
Thank you!
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