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Grand Rounds “Triple Procedure Via Open-Sky Approach”

Kevin Lowder, MD – PGY3 10/26/2018. Grand Rounds “Triple Procedure Via Open-Sky Approach”. Patient Presentation. CC Severe vision loss OS HPI

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Grand Rounds “Triple Procedure Via Open-Sky Approach”

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

  2. Patient Presentation CC Severe vision loss OS HPI • 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.

  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

  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

  5. Physical Exam

  6. Physical Exam

  7. Physical Exam

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

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

  10. 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

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

  12. 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?

  13. Conclusions

  14. References

  15. Special Thanks Dr. Asghari

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