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EW SHOW DAILY 8 Saturday, May 6, 2017 by Ellen Stodola EyeWorld Senior Staff Writer It avoids the need for immu- nosuppression, she said. There is also faster visual rehabilitation, and it's available worldwide. She did note that this type of KPro requires corneal tissue as a carrier, and there is a risk of sight-threatening com- plications. It's best approached by a multidisciplinary team. Dr. Cortina said that the Boston type 1 KPro has good visual acuity results and long-term retention in patients with LSCD. It avoids the long-term risk of systemic immuno- suppression needed for allogeneic transplantation. Patients should be followed closely and managed by an experienced team, since some sight-threatening complications may occur. Though there is limited evi- dence, Dr. Cortina said the evidence available suggests that long-term KPro outcomes are superior to cell- based therapies. However, she noted that more long-term studies and/or a randomized clinical trial would be helpful to further guide treatment choices in cases of bilateral LSCD. The second section of Cornea Day highlighted corneal controver- sies and complications in cataract and refractive surgery. This section featured point-counterpoint discus- sions on a variety of topics. Keith Walter, MD, Winston-Sa- lem, North Carolina, and Melissa Daluvoy, MD, Durham, North D uring the first section of this year's Cornea Day, presentations focused on "Global Hot Topics," which was a joint session with the Asia Cornea Society. Topics included ocular surface reconstruc- tion, Zika virus and the eye, the Asia Cornea Society Infectious Keratitis Study, management of bilateral limbal stem cell deficiency, address- ing corneal blindness, global eye bank development, bioengineered corneas, transplantation of ex vivo expanded human corneal endothe- lial cells, producing corneal cells from induced pluripotent stem cells (iPS), and using long-term preserved corneas for DALK. Maria Cortina, MD, Chicago, spoke about why she thinks the Bos- ton KPro is the treatment of choice in bilateral limbal stem cell deficien- cy (LSCD). Surgical options for bilateral LSCD treatment fall into two cate- gories: cell-based therapies and ker- atoprosthesis. Cell-based procedures can be broken down into allogeneic and autologous, Dr. Cortina said. For keratoprosthesis, there are different devices for dry ocular surface and wet ocular surface. Dr. Cortina specifically highlighted the Boston type 1 KPro for wet ocular surface, which she said is the clear winner. Carolina, spoke on either side of "Fuchs' Dystrophy and Cataract: Combined EK Triple vs. Staged Pro- cedure." Dr. Walter argued for a com- bined procedure, which he said makes life easier for everyone. Dr. Walter noted that when the cataract is done first, you make the patient's vision worse either imme- diately or in the near future. You could also cause the patient unnec- essary pain or an infection from ruptured bullae. When Descemet's stripping endothelial keratoplasty (DSEK) or Descemet's membrane endothelial keratoplasty (DMEK) is done first, Dr. Walter said you aren't doing the patient any favors with that either. This could still result in cataract formation and a risk for graft failure from the additional ultrasound trau- ma to the new graft. Dr. Walter said there are many advantages of combined procedures. Combining can save the patient and family an extra trip to the OR. There is also faster visual recovery with a combined procedure. Dr. Walter noted that you can use the same in- cision for both procedures, you just have to slightly enlarge it. It's easy to accomplish both procedures with minimal additional instrumentation or skill. It saves OR time when com- bined versus two separate events. Dr. Walter stressed a number of things to consider when combining procedures. First, he said it's import- ant to know how the view will be during surgery. Severe edema may obscure view. "You need to consider astigmatism management because the incision is a little larger," he add- ed. Accurate Ks and IOL selection are also important factors to consider. "You can keep the pupil dilated after the phaco," Dr. Walter said, adding that the surgeon can easily plan for topical anesthesia for a combined procedure. Meanwhile, Dr. Daluvoy argued that "less is more," sharing her reasons for separate procedures. A staged procedure means less surgery time, less risk of IOL instability, less risk of DSEK/DMEK graft complica- tions, less special positioning, and less risk of rejection. Maybe you just need cataract surgery, Dr. Daluvoy said, adding that it's possible to perform an "en- dothelial-friendly" cataract surgery. With no EK needed, this would mean no risk of rebubbling and no risk of rejection, she said. When you perform cataract surgery first, she said there are a number of advantages. Intraoper- atively, you can perform the cata- ract in a normal fashion. The CCC sizing and capsular tears are less of an issue, and the IOL complex/AC is more stable. Postoperatively, Dr. Daluvoy said that there is no special positioning required and no risk of graft detachment. The patient may be happy with the vision as well. Meanwhile, some patients may only need an EK procedure. Intraop- eratively, there is less pupil manage- ment required and less likelihood of leaky paracentesis incisions. Postoperatively, there is lower risk of graft dislocation and low risk for subsequent CE. Additionally, a clear cornea and known refractive error can help ensure more accurate IOL choices. Accommodation can also be preserved and there may be better quality of vision, Dr. Daluvoy said. To conclude, she again stressed that "less is more." EW Editors' note: Dr. Walter has financial interests with SightLife (Seattle). Drs. Cortina and Daluvoy have no financial interests related to their comments. ASCRS News Today Cornea Day sections highlight global hot topics, corneal complications and controversies Dr. Daluvoy discusses why she prefers separate procedures in Fuchs' dystrophy and cataract.

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