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The authors have no financial interest in the subject matter of this poster

penetrating keratoplasty performed by surgeons in training Guilherme A N Rocha, MD Reinaldo F Silva, MD Mayana F Lopes, MD Nicolas C pereira, MD Luciene B Sousa, MD sorocaba Ophthalmological hospital Sorocaba eye bank Brazil.

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  1. penetrating keratoplasty performedbysurgeons in trainingGuilherme A N Rocha, MDReinaldo F Silva, MDMayana F Lopes, MDNicolas C pereira, MDLuciene B Sousa, MDsorocabaOphthalmological hospitalSorocaba eyebankBrazil Theauthorshave no financial interest in thesubjectmatterofthisposter

  2. Introduction • Experienced surgeons outcomes are well documentedbut there are few studies about results of residents and cornea fellows performing penetrating keratoplasty (PK). These results are important to determine how effective is surgical technique teaching and what could be changed for better outcomes and less complications. • Other studies showed that well assistance during training surgery produces surgical success and intraoperative and postoperative complication rates similar to experienced surgeons.

  3. Purpose Review the indications for surgery and to analyze clinical outcomes and complications of PK performed by surgeons in training at our institution and show that when assisted by experienced surgeons, residents achieved results comparable to literature.

  4. PatientsandMethods • All patients were examined by a resident or cornea fellow and surgery were approved by a member of cornea department. • Medical records of all patients that underwent PK performed by third-year residents at Sorocaba Ophthalmological Hospital (Sorocaba, Sao Paulo, Brazil) from December 2008 to December 2009 were reviewed for the following data: (1) age; (2) gender; (3) diagnosis; (4) best-corrected visual acuity (BCVA) before procedure; (5) postoperative refraction, topography and BCVA after selective suture removal; (6) preoperative and postoperative intraocular pressure and (7) intraoperative and postoperative complications.

  5. PatientsandMethods • Postoperative regimen included topical 4th-generation quinolone, topical prednisolone acetate 1% and topical artificial tears. Other medications were used depending of each case. • Patients were seen on postoperative day 1, day 7, day 30 and then monthly until one year follow-up. This schedule changed depending on complications or follow-up needs. • Visual acuity measured through Snellen’s table was converted to LogMAR values and IOP was measured using Goldman’s applanationtonometer. • Computer assisted videokeratography was performed using ATLASTM (ATLASTM 9000 Corneal Topography System, Carl ZeissMeditec AG, Jena, Germany) and colored axial map was analyzed using suggested criteria from Karabatsas et al and sutures were selected removed according to astigmatism at videokeratography and manifest refraction.

  6. Results • Threehundredandseventeen PK wereperformedduringthird-yearresidencyprogrambyfiveresidents. Amongthis, 118 wereincluded in thisstudyandotherswereexcluded: (1) 115 havenotcompletedatleast 6-month follow-up; (2) 23 wereemergency keratoplasty; (3) 50 lost follow-up; (4) 7 primarygraftfailure; (5) 4 secondarygraftfailurebefore 6-month follow-up. • Themeanpatient age was 43 ± 20 years (range, 12-84 years); 60 (50.8%) weremenand 58 (49.2%) werewomen. Themostcommonindicationwaskeratoconus (58 eyes [49.1%]) followedbycornealscarring (18 [15.2%]), failed PK (16 [13.5%]), bullouskeratopathy (15 [12.7%]), cornealdystrophies (5 [4.2%]), post-RKectasia (3 [2.5%]), descemetocele (1 [0.84%]) andpellucid marginal degeneration (1 [0.84%]). • Themostcommonsurgerywas PK alone (98 [83%]), followedby PK withextracapsularcataractextractionand posterior chamber IOL placement (14 [11.85%]) and PK withtranssclerallysutured posterior chamber IOL implantation (6 [5.05%]).

  7. Results • Mean follow-up time was 8.5 ± 1.8 months (range, 6 to 12 months). • Meanpreoperative BCVA was 1.84 ± 0.47 (range, 3 to 0.54). • Meanpostoperative BCVA = 0.33 ± 0.35 LogMAR (range, 2 to 0 LogMAR). • Meantopographicastigmatism = 3.88 ± 2.64 D (range, 0.5 to 20.45 D). • Meanastigmatismatmanifestrefraction = 3.29 ± 1.53 D (range, 0 to 8 D). • Colored axial mapanalysis (Karabatsaset al.) • Unclass. = 34 (28.8%) • PABT (prolate asymmetricbowtie) = 24 (20.3%) • PSBT (prolate symmetricbowtie) = 23 (19.4%) • PI (prolate irregular) = 15 (12.7%) • LS (localisedsteep) = 13 (11%) • TRIPLE = 9 (7.6%)

  8. Results • Ten (8.4%) patientshadpreviousdiagnosisofincreased IOP or glaucoma and 9 (90%) werewellcontrolledwith hypotensors and 1 (10%) had a trabeculectomy. • No intraoperative complicationswerereported. • Themostcommonpostoperativecomplicationwaselevated IOP (20 eyes [16.94%]), in which 17 patients (85%) werecontrolledby hypotensors, 2 patients (10%) neededtrabeculectomyand 1 patient (5%) an Ahmed valve. • Othercomplications: wounddehiscence (12 eyes [10.1%]); posterior capsule opacity (9 eyes [7.6%]); allograftrejection (8 eyes [6.7%]); cataract (3 eyes [2.5%]), infectiouskeratitis (1 eye [1.6%]); cystoid macular edema (1 eye [0.8%]). • Six (75%) allograftrejectionswerecontrolledwith topical steroidsand 2 (25%) ended in graftfailure.

  9. Comments • Residents in our program have excellent exposure to PK with each resident performing an average of 60 PK procedures duringtheirthird-year training. • The most common indication for PK in our series was keratoconus (58 patients [49.1%]). This is consistent with some series in the literature where keratoconus has surpassed pseudophakic corneal edema as the leading indication for PK. • Mean postoperative BCVA was 0.33 ± 0.35 LogMAR. This compares favorably with all published results comparing experienced and training corneal surgeons. • Mean ±SD postoperative cylinder was 3.29 ± 1.53 D. This also compares well with previously published data looking at postoperative astigmatism by cornea fellows and corneal specialists.

  10. Comments • The most common postoperative complication was elevated IOP (16.94%) • The second most common complication was wound dehiscence occurring in 12 eyes (10.1%). This was both traumatic and spontaneous in the immediate postoperative period related to unstable sutures. • Allograft rejection occurred in 8 eyes (6.7%) and 2 of this (25%) ended in graft failure. • Seven grafts (2.2%) ended in primary graft failure among all performed 317 PK.

  11. Conclusion In summary, results of this series indicate that with excellent supervision residents can be safely introduced to PK and achieve surgical success and intraoperative and postoperative complication rates similar to those previously published.

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