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Group 7

Group 7. Case Presentation. 32 y.o male RE HSV related keratitis- past 3 years Vs RE – Counting fingers 40 cm. IOP RE – 25 mm Hg despite nyolol gel+xalatan Cornea- central disciform scar Cup/Disc ratio=0.5 LE- Normal. Commitment. Trabeculectomy followed by penetrating Keratoplasty.

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Group 7

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  1. Group 7

  2. Case Presentation • 32 y.o male • RE HSV related keratitis- past 3 years • Vs RE – Counting fingers 40 cm. • IOP RE – 25 mm Hg despite nyolol gel+xalatan • Cornea- central disciform scar • Cup/Disc ratio=0.5 • LE- Normal

  3. Commitment Trabeculectomy followed by penetrating Keratoplasty

  4. Goal: • Corneal graft for good vision • Maximizing graft survival • Current medical treatment not optimal

  5. Pathogenesis of glaucoma after HSV Keratitis • Stromal keratitis associated with Uveitis (Keratouveitis) • 28% of HSV Keratouveitis IOP ↑1 • HSV has the ability to infect the trabeculum2 • Falcon, MG et al Herpes simplex keratouveitis and glaucoma Trans Ophthalmol Soc UK 1978 • Tiwari et al, A Role for HSV entry mediator as the … J. Virology 2005

  6. Cons: Discform scar – can cause inaccurate measurements of IOP1 Pros: IOP 25mmHg under current treatment Current treatment should be changed since Xalatan is relatively contraindicated ProTon tonometer determination of IOP…Indian Journal of ophthalmology, 2006 Our patient has uncontrolled IOP

  7. Medical treatment for elevated IOP • Xalatan is a relative contraindication for Herpes patients due to reactivation 1, 2 • Topical CAI is controversial due to corneal edema.3 • Alpha-agonist will reduce the IOP ~20% • Long term systemic CAI in a young male is not realistic  Optimal medical treatment will not be sufficient • Latanoprost increases the severity and recurrence of herpetic keratitis in the rabbit. Journal of American Ophthalmology Kaufman, 1999. • Latanoprost and herpes simplex keratitis Martin Wand MD American Journal of Ophthalmology, 1999. • Brinzolamide induced revirsible corneal decompensation Zhao; Chen, BJO 2005

  8. Trabeculectomy for better control of IOP • Lower IOP • Less diurnal fluctuations • No compliance demands • No need for topical glaucoma treatment with preservatives

  9. PKP  elevated IOP • PKP causes 10-30% early IOP and 25-35% late IOP1 • Angle distortion (suture technique) • Post-operative inflammation • Peripheral ant. synechia • Post operative steroid treatment • Penetrating Keratoplasty and Glaucoma: Ayyala: Survay of Ophthalmology 2000

  10. Elevated IOP  Graft failure • IOP is the second leading cause for corneal graft rejection 1,2 • Graft survival 2 years after PKP 3 • 66% with history of glaucoma • 87% without glaucoma • Corneal graft survival and IOP control after PKP: Arroyave et al; Ophthalmology 2001 • Penetrating Keratoplasty and Glaucoma: Ayyala: Survay of Ophthalmology 2000 • Williams KA et al: Factors predictive of corneal graft survival, Ophthalmology 99:403-414, 1992.

  11. Glaucoma surgery after PKP is unfavourable • High rate of graft failure because of operation following PKP1 • Corneal graft survival and IOP control after PKP: Arroyave et al; Ophthalmology 2001

  12. Topical Glaucoma Meds Cause Graft Failure1 • Endothelial decompensation • Ocular surface disease • Immunological Rejection • Risk factors for various causes of failure in intial corneal grafts; Price et el; Arch of ophthalmology; 2003

  13. Trabeculectomy first  The right choice • For … • Better IOP control • Long term graft survival • Best long term prognosis

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