陨灶贼允韵责澡贼澡葬造皂燥造熏灾燥造援 8熏晕燥援 6熏 Dec.18, 圆园15 www.IJO.cn 栽藻造押8629原愿圆圆源缘员苑圆 8629-82210956 耘皂葬蚤造押ijopress岳员远猿援糟燥皂 窑LettertotheEditor窑 Phacoemulsificationinararecaseofkeratoconuswith Fuch'sendothelialcornealdystrophy

1AdvancedEyeCentre,PostGraduateInstituteofMedical becauseofthedensecataractinbotheyes.Pentacam EducationandResearch,Chandigarh160012,India (Oculus)ofbotheyesrevealedinferiorsteepeningconsistent 2DepartmentofOphthalmology,UttarPradeshRuralInstitute withkeratoconus.Basedonclinicalparametersand ofMedicalSciences&Research,Saifai,Etawah20130,India investigations,patientwasdiagnosedtohave bilateral Correspondenceto: JayaKaushik.AdvancedEyeCentre, keratoconusgradeII(PentacamR derivedAmsler-Krumeich PostGraduateInstituteofMedicalEducationandResearch, stage)[4] withFECDgradeIV [5,6] andcorticonuclearcataract Chandigarh160012,[email protected] gradeV(LensOpacityClassificationSystemIII)[7]. Received:2014-10-19 Accepted:2014-12-19 PatientwasplannedforphacoemulsificationwithPCIOL implantationintherighteye.Herpreoperativework-up DOI:10.3980/j.issn.2222-3959.2015.06.32 includedbiometry (IOLMasterV.5CarlZeissMeditek) whichrevealedODaxiallength29.40mm,keratometryK1: KaushikJ,JainAK,JainVK,ChakmaP.Phacoemulsificationina 50.45D(Diopters),K2:55.88D,cylinder-5.43D×26,IOL rarecaseofkeratoconuswithFuch'sendothelialcornealdystrophy. power-6D;andpachymetryof337 m.Herendothelium 滋 2015;8(6):1253-1254 cells(SpecularMicroscopeSP-3000P)were1631inOD. Patientunderwentphacoemulsification(AlconInfinityR DearSir, visionsystem)with-5.0DAcrysofmultipieceIOL amDr. JayaKaushikfromtheDepartmentof implantationinOD.Surgicalstepsforphacoemulsification I OphthalmologyofthePostGraduateInstituteofMedical included2.2mmclearcornealincisionatsteeperaxis,useof EducationandResearch,Chandigarh,India.Iwritetopresent cohesiveunderneathdispersivetocoatendothelium,useof acasereportofphacoemulsificationinararecaseofcataract torsionalpoweraround50%,andlimbalrelaxingincisionat associatedwithkeratoconusandFuch'sendothelialcorneal theendofthesurgeryto minimizeastigmatism.No dystrophy(FECD). intraoperativecomplicationswerereported.Inthesettingof KeratoconuswithFECDiswelldescribedinliterature [1,2]. cataractsurgeryalone,thepossibilityofpostoperativecorneal MissensesubstitutioninZEB1proteinislinkedwith oedema,cornealdecompensationandneedforpenetrating keratoconusandFECDinarecentstudybyLechner [3]. keratoplastyinfuturewasdiscussedthoroughlywiththe Thisstudyfurtherrevealedthedysregulationof -typeIV patient. 琢 collagenwhichisacommonlinkbetweenZEB1mutation Onthefirstpostoperativeday,patienthadmildcorneal andclinicalphenotype(keratoconus,FECDandposterior oedema.Neitherocularinflammationnorinfectious polymorphouscorneal dystrophy).Thebothcoexisting complicationswerereportedintheoperatedeyeofthe cornealdiseasesposeagreatchallengeforcataractsurgeryas patientduringfollow-up.Hercornealoedemagradually cornealpachymetryislessreliabletoassesstheseverityof resolvedfrompostoperativefirsttosixweekswithBCVA disease.Currently,therearenopublishedguidelinesfor improvedto20/50(Figure1C,1D).Atlastfollow-up(3mo) cataractsurgeryinpresenceofcoexistingbothkeratoconus BCVAreportedwas20/40withrefractiveerrorof-1.50/ andFECD.Inthiscasereportwedescribeagoodoutcomein -0.50 90andpachymetryof393 mOD. 伊 滋 afemalewithkeratoconusandFECDwhounderwent CataractsurgeryinpatientswithkeratoconusandFECD phacoemulsificationandposteriorchamberintraocularlens posesasignificantchallengeasbothdiseasescanmaskeach (PCIOL)implantation. other.JurkunasandAzar [8] publishedaretrospectivecase A60-year-oldfemalepresentedwithcomplaintsofblurring seriesandreportedthepotentialcomplicationsofcataract ofvisionfor1y.Ocularexaminationrevealedbestcorrected surgeryinpatientswithcoexistentkeratoconusandFECD:4 visualacuity(BCVA)20/200inbotheyes(OU),andfeatures outof5eyesdevelopedcornealoedema/ectasiapostcataract ofkeratoconuswithendothelialguttae,deepanterior surgery.PreoperativeCCTwasavailableinonlyonecase chamber,cataractwithnormalintraocularpressure(OU) with666and649 minODandOSrespectively,and 滋 (Figure1A,1B).Theanteriorchamberdepthwas3.21mm preoperativeendotheliumcellcountswerenotperformed. (Pentacam)inrighteye(OD).Fundusdetailswerenotvisible However,thiscaseseriesshowedthecornealpachymetryas 1253 PhacoemulsificationinkerataconuswithFuch'sendothelialcornealdystrophy

Figure1ClinicalphotographsofpatientundergoingphacoemulsificationinkeratoconuswithFuch'sendothelialcorneal dystrophy A:Intraoperativephotographofrighteyeshowingcataract;B:Centralguttaeovertheposteriorsurfaceofcornea;C: Postoperative(1wk)slit-lampphotographdemonstratestheverticallyorientedstromallinesattheapexoftheconeasseeninkeratoconusand guttaecanbeseenjustbelowandtotherightofthelines;D:Postoperative(6wk)diffuseilluminationphotographshowingminimalcorneal haze,wellcentredpupilandposteriorchamberintraocularlens(IOL). lessreliablemeasuretoassesstheseverityofboththe ACKNOWLEDGEMENTS diseasesandrecommendstheroutineuseofpreoperative ConflictsofInterest:KaushikJ, None; JainAK, None; cornealtopographyandspecularmicroscopyinsuchcases.In JainVK, None; ChakmaP, None. ourcase,itwasplannedtogoaheadwithcataractsurgery REFERENCES alone asthevisualrehabilitationwithkeratoplastyis 1LipmanRM,RubensteinJB,TorczynskiE.KeratoconusandFuchs' associatedwithmultipleissueslikeprolongvisualrecovery, cornealendothelialdystrophyinapatientandherfamily 1990;108(7):993-994 multiple hospitalvisits,managementofpostoperative 2OrlinSE,RaberIM,EagleRCJr,ScheieHG.Keratoconusassociated astigmatism,sutureremovalandpotentialgraftrejection.Use withcornealendothelialdystrophy. 1990;9(4):299-304 oflowtorsionalpoweralongwithmeticuloususeof 3LechnerJ,DashDP,MuszynskaD,HosseiniM,SegevF,GeorgesS, dispersiveaswellascohesiveagentwasthekeyfactorto FrazerDG,MooreJE,KayeSB,YoungT,SimpsonDA,ChurchillAJ,Heon reducethe endotheliumcellcountlossduringthe E,WilloughbyCE.MutationalspectrumoftheZEB1geneincorneal phacoemulsificationinourcase.Onediopterofpostoperative dystrophiessupportsagenotype-phenotypecorrelation myopiawastargetedtocompensateforhyperopicshiftthat 2013;54(5):3215-3223 canoccurintheeventoffuture Descemetstripping 4KanellopoulosAJ,AsimellisG.Revisitingkeratoconusdiagnosisand endothelialkeratoplasty [9].Hydrophobicacrylicmultipiece progressionclassificationbasedonevaluationofcornealasymmetryindices, derivedfromscheimpflugimaginginkeratoconicandsuspectcases. IOLwasimplantedinviewofmoreuvealandcapsular 2013;7:1539-1548 [10] biocompatibility .Recommendationforcataractsurgery 5KrachmerJH,PurcellJJJr,YoungCW,BucherKD.Cornealendothelial aloneinFECDwithoutectasiahasexpandedinpatientswith dystrophy.Astudyof64families. 1978;96(11): preoperativepachymetryof600 mto640 mwithcurrent 2036-2039 滋 滋 surgicalmethods,earlierforwhich(>600 m)tripleprocedure 6GottschJD,SundinOH,LiuSH,JunAS,BromanKW,StarkWJ,Vito 滋 (keratoplastywithcataractextractionandIOLimplantation) EC,NarangAK,ThompsonJM,MagovernM.Inheritanceofanovel wasrecommended [11].Tillnow,nosuchguidelinesreported COL8A2mutationdefinesadistinctearly-onsetsubtypeoffuchscorneal forthephacoemusificationinpatientswiththeco-existent dystrophy 2005;46(6):1934-1939 7ChylackLTJr,WolfeJK,SingerDM,LeskeMC,BullimoreMA,Bailey keratoconusandFECD. IL,FriendJ,McCarthyD,WuSY.Thelensopacitiesclassificationsystem Thiscasereporthighlightstheimportanceofcomprehensive III.Thelongitudinalstudyofcataractstudygroup. 1993; ophthalmicevaluationespeciallycornealtopographyand 111(6):831-836 specularmicroscopy,toplanforfurtherlineofmanagement 8JurkunasU,AzarDT.Potentialcomplicationsofocularsurgeryin insuchcases.Withcurrentmodifiedsurgicalprotocol,good patientswithcoexistentkeratoconusandFuch'sendothelialdystrophy. visualoutcomecanbeexpectedinphacoemulsificationand 2006;113(12):2187-2197 PCIOLimplantationformaturecataractwithcoexisting 9EghrariAO,DaoudYJ,GottschJD.CataractsurgeryinFuchscorneal keratoconusandFECD, wherepostoperativecorneal dystrophy. 2010;21(1):15-19 10BarbourW,SaikaS,MiyamotoT,OhnishiY.Biologicalcompatibilityof oedema/ectasiaandneedforcornealtransplantationisthe polymethylmethacrylate,hydrophilicacrylicandhydrophobicacrylic usualexpectedoutcome.Ithighlightsaneedofprospective intraocularlenses. 2005;37(5):255-261 interventionalstudyshowingtheoutcomeandguidelinesfor 11SeitzmanGD,GottschJD,StarkWJ.Cataractsurgeryinpatientswith phacoemulsificationinpatientswithcoexistentkeratoconus Fuch'scornealdystrophy:expandingrecommendationsforcataractsurgery andFECDinnearfuture. withoutsimultaneouskeratoplasty. 2005;112(3):441-446

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