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Grand Rounds

Grand Rounds. Brett Mueller, D.O., Ph.D. April 20, 2018. Patient Presentation. CC Gradual decrease in vision OD HPI 65 year-old white male, who is a taxi driver that complains of gradual decrease in vision with trouble with glares and halos especially when driving at night. History ( Hx ).

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Grand Rounds

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  1. Grand Rounds Brett Mueller, D.O., Ph.D. April 20, 2018

  2. Patient Presentation CC Gradual decrease in vision OD HPI 65 year-old white male, who is a taxi driver that complains of gradual decrease in vision with trouble with glares and halos especially when driving at night.

  3. History (Hx) Past Medical Hx: none Past Surgical Hx: none Meds: none Allergies: NKDA Social Hx: none

  4. External Exam

  5. Anterior Segment Exam

  6. Posterior Segment Exam

  7. Topography OD Outside Facility: Noted 5.0 diopters of irregular astigmatism with the step axis being located at 155 degrees in 2012

  8. Topography OS Outside Facility: Noted 0.75 diopters of irregular astigmatism with the step axis being at 180 in 2012

  9. Lens Star 900

  10. Lens Star 900

  11. AcrySofToric IOLs

  12. Assessment 65 year-old white male with a visually significant cataract with stable pellucid marginal degeneration OD Proceed with cataract surgery of the right eye. But what lens do we put in? Plan

  13. Background Research • Patients with stable keratoconus tolerate placement of a toric IOL very well • 1 year final uncorrected visual acuity was 20/40 or better for 75% of the patients

  14. Background Research Video Journal of Cataract and Refractive Surgery, 2015 “Toric IOL for Keratoconus” By: Robert H. Osher, MD • Describes that Torics are good in keratoconus patients if • Stable • Multiple Devices with similar biometry • IOL master and Lenstar are not good at giving accurate biometric data, better to get manual Ks and a manual axial length • Really, no formula or piece of data is good at predicting final visual acuity so need to make the patient aware of this

  15. Surgical Plan Glasses 5.00 Diopters of Astigmatism at 155 Lenstar 6.60 Diopters of Astigmatism at 156 Topography 4.75 Diopters of Astigmatism at 154

  16. Surgical Plan • Can we place a toric lens? • Stable • 3 devices with a similar axis and astigmatism measurements ranging from 4.75 – 6.60 diopters • The patient states he wants us to do it • YES!!!!

  17. Lens Star 900

  18. Post Operative Results

  19. Pellucid Marginal Degeneration • Rare cornea ectatic disorder that presents in early adulthood (ages 20-40) with inferior cornea thinning. • No associated inflammation • Central cornea is of normal thickness

  20. Pellucid Marginal Degeneration • Incidence: Unknown • Prevalence: Unknown • Etiology: Unknown

  21. Pellucid Marginal Degeneration • Could be that keratoconus, keratoglobus and PMD are phenotypic variations of the same disease • 10% of PMD cases are associated with keratoconus and 13% are associated with keratoglobus

  22. Risk Factors • Onset or progression of PMD can be associated with: • Eye rubbing • Inflammation • Atopy • Hard Contact Lens Wear • Oxidative Stress

  23. General Pathology • Focal disruption of Bowman’s membrane with stromal thinning and normal epithelium, endothelium and Descemet’s membrane.

  24. Pathophysiology • Exact pathophysiology of PMD is unknown, but thought to be secondary to collagen abnormalities • The thin, weakened cornea is hypothesized to protrude as a result of intraocular pressure

  25. Diagnosis • Clinical diagnosis in a patient who is asymptomatic except for progressive visual deterioration with a crab-claw appearance on topography. • Can rarely present with acute corneal hydrops

  26. Treatment • Spectacles, contacts or with a penetrating keratoplasty • PK or a DALK is usually done when a patient becomes intolerant to contact lens • Intrastromal rings • Collagen crosslinking

  27. Prognosis • 88.2% of patients were managed nonsurgically • 36.4% treated with spectacles • 51.8% treated with contact lenses • 11.8% treated with a PK, and all patients had a clear graft at 9 year follow-up Tzelikis PF, Cohen EJ, Rapuano CJ, Hammersmith KM, Laibson PR. Management of pellucid marginal corneal degeneration. Cornea. 2005 Jul;24(5):555-60. PubMed PMID: 15968160.

  28. Summary • PMD is a rare ectatic disease that normally presents with worsening visual acuity • Majority of patients are treated medically • In patients that require cataract surgery, toric IOLs can be considered in patients with stable corneal ectactic disease

  29. Thank-you • Dr. Soltau • Dr. Cassol • Dr. Vaghei • Dr. Gambrell • Dr. Osher

  30. 2nd Annual Surgical Olympics

  31. References 1. BSCS, Refractive Surgery 2015-2016 • Jaimes M, Xacur-García F, Alvarez-Melloni D, Graue-Hernández EO, Ramirez-Luquín T, Navas A. Refractive lens exchange with toric intraocular lenses in keratoconus. J Refract Surg. 2011;27:658–664.[PubMed] • Nanavaty MA, Lake DB, Daya SM. Outcomes of pseudophakictoric intraocular lens implantation in Keratoconic eyes with cataract. J Refract Surg. 2012;28:884–889. [PubMed] • Visser N, Gast ST, Bauer NJ, Nuijts RM. Cataract surgery with toric intraocular lens implantation in keratoconus: a case report. Cornea. 2011;30:720–723. [PubMed] • Tzelikis PF, Cohen EJ, Rapuano CJ, Hammersmith KM, Laibson PR. Management of pellucid marginal corneal degeneration. Cornea. 2005 Jul;24(5):555-60. PubMed PMID: 15968160. • BSCS, Cornea and External Disease 2015-2016

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