A selection of case studies relating to cataract surgery and LASIK procedures

2. Cataract Surgery and LASIK
Update 2013
Random Case Studies
Jeffrey Martin, M.D. FACS
Managing Partner
North Shore Eye Care
Assistant Clinical Professor of Ophthalmology at SUNY Stony Brook

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

6. CASE STUDY
• 23 year old male
• One day post PRK
• Presents with 20/40 vision
• Moderate discomfort
• Contact lens in place

7. CASE STUDY

8. 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

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

10. CASE STUDY #2
• 32 year old hospital worker
• Presents 5 days post LASIK with pain,
redness, and photophobia
• Vision of 20/40
• Pt on Durezol and Zymaxid

11. CASE STUDY #2

12. 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

13. 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

14. BACTERIAL KERATITIS
• Symptoms
– Red eye
– Moderate to severe pain
– Photophobia
– Decreased vision
– Discharge

15. 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

16. DIFFERENTIAL OF 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

17. 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

18. FUNGAL KERATITIS

19. 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

20. 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

21. ACANTHAMOEBA

22. 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.

23. 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

24. HERPES SIMPLEX KERATITIS

25. HERPES SIMPLEX
• Neurotrophic ulcer
– Sterile ulcer with
smooth borders
– May be associated
with stromal melting
and perforation

26. HERPES SIMPLEX
• Stromal disease
– Disciform keratitis
• Disc shaped stromal
edema with intact
epithelium
• Mild iritis
• Keratitc precipitates
• Increased IOP

27. 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

28. NECROTIZING IK

29. HERPES SIMPLEX
• Uveitis
– As a result of stromal involvement
– Less common
• Anterior chamber reaction and granulomatous KP
without corneal disease
• High IOP

30. 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

31. 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

32. ATYPICAL MYCOBACTERIA KERATITIS

33. BACTERIAL KERATITIS
• Which is not one of the most common bugs?
1. Staph
2. Strep
3. Pseudomonas
4. Moraxella
5. Atypical mycobacteria

34. BACTERIAL KERATITIS
• Etiology
– Most common
• Staph
– Well defined graywhite stromal infiltrate
– May enlarge to form
dense stromal
abscess

35. BACTERIAL KERATITIS
• Etiology
– Most common
• Strep
– Purulent
» Severe anterior chamber reaction and hypopyon
common
– Crystalline
» Patients on chronic topical steroids

36. BACTERIAL KERATITIS
• Strep keratitis
• Strep Crystalline keratitis

37. BACTERIAL KERATITIS
• Etiology
– Most common
• Pseudomonas
– Rapidly progressive
supprative and necrotic
– Hypopyon and discharge
– Soft contact lens use

38. BACTERIAL KERATITIS
• Etiology
– Most common
• Moraxella
–
–
–
–
–
Preexisting ocular surface disease
Immunocompromised
Indolent infiltrates in the inferior cornea
Full thickness
May perforate

39. 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

40. 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

41. 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

42. BACTERIAL KERATITIS
• Treatment
– Sometimes topical steroids are used
•
•
•
•
Sensitivities are known
Infection under control
Severe inflammation persists
Keratitis may worsen
– Fungus
– Atypical mycobacteria
– pseudomonas

43. STAPH HYPERSENSITIVITY
• Symptoms
–
–
–
–
Mild pain
Mild photophobia
Localized red eye
Chronic blepharitis
• Eyelid crusting
• History of chalazia or styes
• Foreign body sensation

44. STAPH HYPERSENSITIVITY
Blepharitis

45. 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

46. STAPH HYPERSENSITIVITY
• Treatment
– Antibiotic and steroid
• Recurrent episodes
– Oral doxy or tetracycline
– Restasis
– Blepharitis treatment

47. 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

48. • 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

49. RHEUMATOID PERIPHERAL CORNEAL THINNING

50. 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

51. 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

52. • 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

53. TERRIEN MARGINAL DEGENERATION
• 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

54. TERRIEN

55. • 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

56. MOOREN ULCER

57. MOOREN ULCER
• Which is true about Moorens Ulcer?
1. Treatment is rarely necessary
2. Is a diagnosis of exclusion
3. Oral immunosuppressives not necessary

58. MOOREN ULCER
• Treatment
–
–
–
–
–
–
–
Rule out underlying systemic disease
Topical corticosteriods
Topical cyclosporine
Oral steroids
Oral immunosuppressives
Corneal glue
Lamellar keratoplasty

59. • Peripheral Corneal Thinning
– Furrow Degeneration
•
•
•
•
•
•
Painless
Adjacent to area of arcus
Elderly
Noninflammatory without neovascularization
Perforation is rare
Does not require treatment

60. FURROW DEGENERATION

61. • Peripheral corneal thinning
– Dellen
•
•
•
•
Painless oval corneal thinning
From corneal drying and stromal dehydration
Epithelium intact
Adjacent to abnormal conjunctiva or corneal
elevation

62. DELLEN

63. DELLEN
• Audience participation question
1. Stop with the corneal thinning already
2. I find corneal thinning so interesting,
please continue
3. Mauro, please intervene

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. THANK YOU