National Public Radio gives Keratoconus some much-needed publicity today in the US. Sadly, they didn’t mention some of the most important points of the disease, such as DALK vs. PK, advances in contact lenses, or encouragement of organ donation. Still, it’s great to have such a big increase in awareness.
Yearly Archives: 2011
Well, I just returned from anther follow up with Dr. Holland post-corneal transplant. The graft and optic nerve look good, but my eye pressure is still too high – a condition known as “steroid-induced intraocular pressure.” I’m among a small number (8%) of people who seem to have steady, ongoing eye pressure rises with use of steroids.
We’ve adjusted the type of steroids I’m using, and I’ll be taking a drop to reduce eye pressure as well (the drop is normally used for Glaucoma patients.) I was also relieved to learn that there were no other reasons my eye pressure was rising (such as tissue or structural complications from surgery.) Apparently that can happen with full-thickness graft, though rare. I will be happy when the pressure is moderated – as I don’t like the sound of Glaucoma one bit! What I think is going on is that I will be using a tiny amount of steroids – far less than most people. This means I must be alert for any irritation symptoms.
Vision was stable, not that much better. They claimed astigmatism was down, but I’m not seeing it. I worked hard to see eye chart numbers. I wish I’d brought my glasses so they could have evaluated those. I think it will show I can see pretty damn good through them (despite the old prescription.)
But in terms of graft recovery, things looked good enough to remove a couple more sutures. This time, the removals had a bit more of a pinch and I was slightly sore afterwards. Tylenol and back to work. Next time I might ask them to delay the numbing drops until right before the process itself. There is this unpredictable delay between numbing drops and when Dr. Holland actually does the removal. Last time, it didn’t hurt at all. This is similar to how it went during surgery – my pain meds started wearing off before the procedure was done. Ouch!
One Niggle… I’m consistently impressed by the Cincinnati Eye Institute Staff, but sure wish they’d dump the blaring TV’s in the waiting room. It’s not just them, it’s everywhere. Doesn’t anyone else like to pull out a book to read anymore?
After you have DALK/Corneal Transplant, you start to notice some of life’s little conveniences that were out of reach when your eye was messed up.
So… Little Things #2, The ability to use a bike mirror… as a bike commuter, these small glasses-mounted mirrors have always been great. But with Keratoconus in my left eye, I’d not been able to use it. Naturally, these only work on the left side (in the USA) as this is where the traffic is.
During this visit I had usual vision checks, numbing drops, eye pressure check and topography taken of my grafted cornea. The eye pressure was a bit high, so I’m cutting back on steroids to a lower frequency. The topography was successful (first successful one I’ve had since around 2003, my cone was just too steep.) I tested to 20/60 with pinhole (which reduces effect of astigmatism.)
Corneal Roulette – Suture Removal to Adjust for Astigmatism, Tension
Dr. Holland identified some “tight” and “loose” areas on the sutures via the topography. He then showed me where he’d be removing sutures. I really like how Dr. Holland stops to let the patient view the diagnostic tactics. I have 24 stitches, and it’s impossible to keep them all at the same tension. Also, the cornea heals at different rates, meaning you might get tension in one area and “slack” in another.
Before the suture removal, the assistant gave me numbing drops and antibiotics. Then they gave me four more numbing drops, the comment being “you want your eye to be nicely numbed for this part.” Yikes.. Anyway, the anxiety was for nothing. I rested my chin on the rest and the assistant pulled open my eye gently with a swab. Dr. Holland viewed through the microscope and in literally 10-12 seconds, snipped two strategically placed sutures, almost before I realized it. He then used tweezers to pull out the microscopic threads and before I knew it this was over. He showed me the sutures – they are like butterfly eyelashes (as my daughter used to say) truly tiny. Then, antibiotic drops were used (and will be used for a few days) since the suture leaves behind an entry point for potential bacteria.
So, the removal of the sutures was 100% pain free.
Interestingly Dr. Holland told me that if we stabilize the astigmatism, we’d stop taking sutures out – leaving them in place for years. This would promote a very solid wound healing process. Some patients have sutures out more quickly based on astigmatism situations.
Droopy Eyelid after Corneal Transplant
After surgery, as my swelling went down, my wife and others noticed that my left eyelid was a bit droopy – a bit more closed than it should be. Dr. Holland explained that this is probably due to the spreader which was used during the operation which caused a contusion of the muscle. For most people, it will gradually recover within a year. If not, there is a simple procedure to adjust it. No matter what, he said you shouldn’t do anything until a year had passed. He said the bright side was that it provided slightly more protection to the eye.
Restasis is an Anti-Rejection Drug – News to Me
I think that I know quite a bit about corneas, DALK, etc, but today proved I have a long way to go. I thought I was taking Restasis for tear production, but actually it was to prevent rejection. Mark that down in your note book. Dr. Holland also told me that Restasis was good for combating allergies and is in FDA trials for that indication! Okay.. bottom line, use the Restasis whether or not your eyes are moist. Dr. Holland said that it was a steroid-sparing allergy drop. They’ve used it for hay fever conjunctivitis for a long time.
Eye Pressure Still a bit High
Dr. Holland told me that 8% of patients react to topical steroids, such as durasol, were prednisolone was a bit weaker and caused less pressure. It’s only a problem while I’m on steroids, which, for DALK, would taper steroids over a year or so. I was slightly concerned about what effect higher pressure might have on my eye. Dr. Holland explain that the only thing that would be a concern was the optic nerve – and mine was just fine and there was nothing to worry about. Postscript: eye pressure continues to rise, new drops started.
Astigmatism after DALK Surgery
How much astigmatism, and how it will progress during post-op recover, is highly variable. Some patients have high astigmatism until sutures are removed, while others have low astigmatism until they’re removed and suddenly have a lot. It’s all normal, and we just have to wait and see where it will go. If there is a lot of astigmatism after all sutures are removed, we will discuss PRK with a laser to fix it. For me, I’m minimally nearsighted right now, and will likely remain so for ever. My corrected vision is 20/60 at this moment. He said another patient at his office recovering from DALK was 20/25. Nice.
Okay, so I have my next follow up visit in 10 days, but thought I’d post a quick update with a few observations.
First, overall things are great. I am very pleased with the outcome. I am able to drive at night without even thinking about it. We’ve had lots of rain in KY lately, and I’m fine driving at night in the rain. Amazing. The vision alternates daily but never gets anywhere close to as bad as it was pre-surgery.
I’ve had some allergies lately, and they seem to be causing some discomfort in the DALK eye. My daily Zyrtec doesn’t seem to be enough to completely fix the problem. I have no added redness or vision changes, so I have little concern about it. I also may have a suture that’s grumpy. The Restasis makes me itch quite a bit – but I’m forcing myself to use it. I’m still not mowing grass or doing garden work. I’ve been paying someone to handle it.
TIP: When you have surgery, ask your Dr. for one of the physician samples of whatever steroid drop you’re using. It’s nice for carrying around in a purse or briefcase in case you leave the bottle at home. Yes you will.
So I’ll update again on the 26th or 27th after my visit to Dr. Holland.
I had my one month (and a week) visit to Doctor Holland today and all went very well. He said my transplant was healing better than most, and my vision continues to improve. The astigmatism is taking front and center but they said that this will begin to be addressed in my next appointment when a few sutures may be removed. This is done strategically based on the topology. Dr. Holland told me this was the reason he uses so many interrupted sutures… it allows for “Suture Roulette” where he can tweak things very precisely while keeping sutures in place to allow healing to continue.
I didn’t get the number, but could see some pretty small letters via pinhole. Interestingly, I learned that the pinhole is a measure of “potential” vision or “correctable” vision. So I have some seriously high hopes!
The only concern was a minor increase in interocular pressure (trend…18 to 20 to 27 mmHg) – both doctors say that this is due to the Durezol steroid (I have been on a high dose) and it was nothing to be alarmed about. They changed my steroid to Pred Forte – a weaker steroid – to manage this. I was told that around 8-10% of patients fall into a category “Steroid Responders” – a genetic condition… who have a pressure response to steroids. I had no inflammation on my eye so the reduction in steroid should not have any downside. They told me that I was out of the high risk timeframe for “RSVP” type symptoms and that the steroids are there just to prevent any chance of rejection.
I mentioned my itchiness and they said I could take Zyertec for it… but if that didn’t do the trick they’d subscribe an allergy drop. I don’t like adding variables to the mix if I have a working solution, so don’t plan to ask for the drop unless things get bad.
I was also told I could stop wearing a shield at night if I wanted.
As far as how I feel – It’s great! I can drive at night and have very, very little pain. I have no complaints at all and so far I’m very, very glad I had this done.
Back in six weeks!
I really never realized how much discomfort that my Keratoconus caused me – especially when it came to daily activities, routines, etc. I am thrilled with the way things are going. The drops are a hassle and so is the nightime shield, but every day is better. Things get itchy a couple of times daily, but that might just be due to Springtime in Kentucky rather than the sutures, etc. No pain, no redness. I am getting anxious to get a new prescription, but I know this would be wasteful as my vision fluctuates. I realize also that I am going to need reading glasses – more related to my age than my eyes.
The real risk I guess is that I’m constantly forgetting I had the graft – I must remind myself to wear the shield at night and to use the drops – I use my iPhone to remind myself (and my wife helps.) My eye used to be the focal point of each day – now it just focuses on life for me.
I saw on the web today that Cornea Day in San Diego happened yesterday. Edward J. Holland, MD and W. Barry Lee, MD did a panel on surgical techniques. Dr. Holland had told me that he planned to do this, specifically that there was a section about how more corneal surgeons need to master the DALK/Big Bubble technique in order to leverage its advantages.
“Despite the technically challenging aspects of deep anterior lamellar keratoplasty, the big-bubble technique can and should be mastered, a presenter said here. “Corneal surgeons must add DALK to their surgical scope,” W. Barry Lee, MD, FACS, said during a presentation at Cornea Day, which preceded the American Society of Cataract and Refractive Surgery meeting. “Get familiar with the big-bubble DALK steps.” Dr. Lee discussed Anwar’s big-bubble DALK technique, stating that the main goal is to place an air injection posteriorly into the stroma to provide contrast between residual stroma and Descemet’s membrane. The surgeon should create a paracentesis to release pressure and inject a small air bubble to confirm the successful placement of the big bubble, according to Dr. Lee.”
I hope to ask Dr. Holland how the event went – and perhaps even get a copy of the transcript.