A SLACK Incorporated® Publication EPIKERATOPHAKIA MAY STILL BE SURGICALLY REVERSED EVEN AFTER LONG-TERM HEALING The voice of 65,000 ophthalmologists worldwide™ Vol. 21, No. 7 • April 1, 2003 Epikeratophakia may still be surgically reversed even after long-term healing For an effective visual outcome, care should be taken to evaluate the patient’s underlying . JACKSONVILLE, Fla.—The sur- of Florida College of Medicine. Case report between the patient’s own cornea gical reversal of epikeratophakia He said the reversal procedure Epikeratophakia was originally and the epikeratophakia implant. is possible even 18 years follow- was possible because the epiker- intended as a so-called living con- ing , according to a sur- atophakia lenticule does not attach tact lens for aphakic patients who Surgical procedure geon located here. to the underlying corneal tissue. were unable to wear contact lens- Dr. Gulani performed the sur- Arun C. Gulani, MD, said he “An epikeratophakia lenticule es, Dr. Gulani said. Donor tissue gery with the pupil dilated, using was able to reverse an epiker- with the stromal side placed on the was lathed into the desired shape retroillumination. He said this atophakia procedure in one of a recipient’s Bowman’s membrane and sutured onto a de-epithelial- allowed better visualization of the patient with a decentered and never scars and can always be sep- ized recipient cornea with intact edges and features of the lenticule. scarred lenticule. Dr. Gulani is direc- arated. That’s one principle of Bowman’ layer and stroma. The Based on the confocal measure- tor of and chief of lamellar surgery: that lamellar sur- change in curvature produced by ments, Dr. Gulani used a diamond the cornea service at the University geries can always be separated,” the lenticule provided the desired knife of his own design, set to the he said. refractive correction. depth of the implanted lenticule, to The level of difficulty of In the present case, a female make the initial incision. the separation depends on patient had undergone bilateral Dr. Gulani gripped the lenticule the tissue-to-tissue apposi- epikeratophakia 17.8 years earlier and gently eased it off the patient’s tion, Dr. GuIani said. Stroma to correct . The lenticule in underlying cornea. The lenticule to Bowman’s layer, as in the left eye was decentered and was removed entirely from the epikeratophakia, is less diffi- scarred, which decreased the corneal bed, with no detached cult, whereas stroma to stro- patient’s uncorrected vision to edges remaining in the cornea. ma, as in LASIK is moder- 2O/4O0 and best corrected vision Once the lenticule was ately difficult but always to 2O/70. The patient also com- removed and a clear cornea was possible, he said. confirmed, Dr. Gulani used the A decentered and scarred epikeratophakia plained of intense blurring. She lenticule under retroillumination. This type of illumi- Dr. Gulani explained was referred to Dr. Gulani’s serv- Nordan-Gulani stitch-down tech- nation is useful for assessing the clarity of the that in LASIK, healing ice. nique to suture the over hanging patient’s cornea, the size of the epikeratophakia, the occurs only at the edge of Dr. Gulani performed a edge at the periphery of the junc- positioning of the epikeratophakia relative to the pupil the flap, due to cytokine- detailed evaluation preoperatively tion between the removed lentic- and the edge, which indicates the technique used. mediated stromal and using a specialized slit-lamp ule and the patient’s cornea. He epithelial interaction at the lighting system produced by AVI said this promoted reattachment edge of the cut. Once the Systems, of New York, and cross of the corneal edge and enhance healed tissue is broken illumination of the cornea. He recovery of the epithelium. The through, the lamellar flap visualized the epikeratophakia patient wore a bandage contact caIl be lifted. lenticule and determined the clar- lens while the cornea healed. “I’ve successfully lifted ity of the patient’s own cornea Postoperatively, the patient dis- flaps even 8 years postop in beneath the lenticule. played the potential for improve- LASIK,” he said. Dr. Gulani Orbscan measurements were ment in vision. Dr. Gulani said he devised his epiker- taken to determine corneal thick- removed the 10-0 nylon suture atophakia reversal tech- ness and lenticule depth. and monitored the patient’s nique along with Lee T. corneal surface. He planned a sec- Orbscan topography measurement shows corneal Confocal microscopy was used to thickness is around 900 um. Nordan, MD. locate the depth of the interface ondary IOL implantation after the Epikeratophakia may still be surgically reversed cont… anterior surface stabilized at Preop evaluations needed approximately 3 months postop. According to Dr. Gulani, pre- Epikeratophakia lenticule At the start of the secondary operative measurements are IOL implantation surgery, the important for locating the epiker- anterior hyaloid membrane atophakia lenticule. An epikeratophakia lenticule can always be removed showed potential for intruding “You may not get the right depth from a patient because the lenticule does not adhere to into the pupillary region. Dr. if you just start digging for the epik- underlying corneal tissue, according to ANn C. Gulani, Gulani performed a high-speed, eratophakia lenticule, It is impor- MD. Care should be taken to remove the lenticule in full closed-system under tant to sturdy the cornea and plan without tearing or breaking. Remaining fragments direct guidance with the Gulani your surgery. Special lighting, if could distort the edge of the cornea and lead to a poor IVI instrument from Volk needed, and confocal scans or in result if the fragments are close to the visual axis. Optical. The secondary IOL was the near future ultrasound biomi- then placed. crocopy or optical coherence The patient currently can see tomography, and even Orbscan, can Remaining fragments could dis- heal. This would result in longer 20/25 in the reversed eye. be used to plan depths,’ he said. tort the edge of the cornea and healing times, irregularity and ten- “She is ecstatic and wants it in “The second thing is to make lead to a poor result if they are dency toward repeated breaking. her other eye, which was in fact sure the patient’s cornea is clear close to the visual axis. Dr. Gulani acknowledged other seeing 20/50 with a well-centered underneath. Otherwise, you’ll end He said the Nordan-Gulani corneal surgeons for their previ- epikeratophakia,” he said. up with the patient’s scarred cornea stitch-down technique is also ous work, particularly Lee T. Dr. Gulani does not currently and you might as well do a pene- important for cases where a hinge is Nordan, MD, Eric D. Donnenfeld, plan to perform the procedure on trating keratoplasty,” he continued. located peripherally. He explained MD, Herbert Kaufman, MD, the fellow eye of this patient. Dr. Gulani said care should be the hinge would lift away from the Carmen Barraquer, MD, However, he said he does have three taken to remove the lenticule in corneal and leave a gap for the Marguerite B. McDonald, MD, additional cases waiting for surgery. full without tearing or breaking. epithelium to cover before it can and Robert Arfaa, MD. ■

Confocal microscopy image show the The epikeratophakia lenticule is grasped The epikeratophakia lenticule is fully interface and depth of the epikeratophakia. with forceps and removal from the patient’s removed from the cornea. cornea is begun.

Nordan-Gulani stitch-down technique is Patient’s clear cornea after stitches have Same eye after secondary implantation of IOL. used to suture the reversed cornea. been removed.