Transcript cxl vs. Tratamento medicamentoso em ceratite bilateral por

The authors have no financial interest
in the subject matter of this poster
Introduction
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Experienced surgeons outcomes are well
documented but 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.
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.
Patients and Methods
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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.
Patients and Methods
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
applanation tonometer.
 Computer assisted videokeratography was performed using
ATLASTM (ATLASTM 9000 Corneal Topography System, Carl
Zeiss Meditec 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.
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Results
Three hundred and seventeen PK were performed during thirdyear residency program by five residents. Among this, 118 were
included in this study and others were excluded: (1) 115 have
not completed at least 6-month follow-up; (2) 23 were
emergency keratoplasty; (3) 50 lost follow-up; (4) 7 primary
graft failure; (5) 4 secondary graft failure before 6-month followup.
 The mean patient age was 43 ± 20 years (range, 12-84 years);
60 (50.8%) were men and 58 (49.2%) were women. The most
common indication was keratoconus (58 eyes [49.1%]) followed
by corneal scarring (18 [15.2%]), failed PK (16 [13.5%]), bullous
keratopathy (15 [12.7%]), corneal dystrophies (5 [4.2%]), postRK ectasia (3 [2.5%]), descemetocele (1 [0.84%]) and pellucid
marginal degeneration (1 [0.84%]).
 The most common surgery was PK alone (98 [83%]), followed
by PK with extracapsular cataract extraction and posterior
chamber IOL placement (14 [11.85%]) and PK with
transsclerally sutured posterior chamber IOL implantation (6
[5.05%]).
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Results
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Mean follow-up time was 8.5 ± 1.8 months (range, 6 to 12
months).
Mean preoperative BCVA was 1.84 ± 0.47 (range, 3 to
0.54).
Mean postoperative BCVA = 0.33 ± 0.35 LogMAR (range,
2 to 0 LogMAR).
Mean topographic astigmatism = 3.88 ± 2.64 D (range,
0.5 to 20.45 D).
Mean astigmatism at manifest refraction = 3.29 ± 1.53 D
(range, 0 to 8 D).
Colored axial map analysis (Karabatsas et al.)
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Unclass. = 34 (28.8%)
PABT (prolate asymmetric bow tie) = 24 (20.3%)
PSBT (prolate symmetric bow tie) = 23 (19.4%)
PI (prolate irregular) = 15 (12.7%)
LS (localised steep) = 13 (11%)
TRIPLE = 9 (7.6%)
Results
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Ten (8.4%) patients had previous diagnosis of increased
IOP or glaucoma and 9 (90%) were well controlled with
hypotensors and 1 (10%) had a trabeculectomy.
No intraoperative complications were reported.
The most common postoperative complication was
elevated IOP (20 eyes [16.94%]), in which 17 patients
(85%) were controlled by hypotensors, 2 patients (10%)
needed trabeculectomy and 1 patient (5%) an Ahmed
valve.
Other complications: wound dehiscence (12 eyes
[10.1%]); posterior capsule opacity (9 eyes [7.6%]);
allograft rejection (8 eyes [6.7%]); cataract (3 eyes
[2.5%]), infectious keratitis (1 eye [1.6%]); cystoid macular
edema (1 eye [0.8%]).
Six (75%) allograft rejections were controlled with topical
steroids and 2 (25%) ended in graft failure.
Comments
Residents in our program have excellent exposure to PK
with each resident performing an average of 60 PK
procedures during their third-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.
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Comments
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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.
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.