 So the questions are number one, which of the following past medical history as well, allow us a potential donor cornea for transplant, so another way to do that, which would not. Number two, we're going to go over the answers so, post-op complications and pediatric PK would include glaucoma, embliopia, slow or delayed healing, graft rejection, all of the following except which of those, slightly tricky question, I'm not going to read this part. According to the cornea donor study, how did donors over 66, or under 66 compared to donors over 66 years of age, higher rate of early graft failure of five years, no difference in rate of graft failure of five years, lower rate of graft failure of five years, higher rate of late graft failure of five years. I wouldn't know this unless you read about this. Based on curatoscopy, which is just what, this is a placido image, right? This is what standard topography is generated from, it's just a computer analysis. Which suture would you take out, 80, 170, 360, 350? There could be more than one right answer. Which of the following types of rejection is most detrimental to survival? This patient presents with increased irritation of his eye. What is the best management? So it's a transplant, sutures, you can see that the eye is red, and then this line is kind of what you're supposed to be looking at. You could see better if there would be some edema below that line. And so like that, again, could be a board's question, and you would try to elucidate, say, well, I think this is what I know, and this is what it could be, a world board's meeting. So you could repeat the transplant, increase the pred drops to every hour, increase the pred to three times an A, culture and start fortified antibiotics. Where would you place a PI to prevent pupillary block after endothelial keratoplasty, superior temporal infir, or nasal? Think about how fluid circulates, probably all of this, and then also the patient's going to be upright, and there's going to be an air bubble in the eye, those are the clues. Which type of refractive shift would you see after desec, myopic, hyperopic, or no refractive shift? Not intuitive, you wouldn't know unless you're right. It had a history of three failed transplants, and two in the right eye, and two in the left eye. It also has a long-term hospitalization after taking a back room, which would be the next, the best, next, best, I can't talk. Repeat for penetrating keratoplasty and desec, let's use this word de-mech. This could be a board's question. Which of the following does not increase the risk of rejection? Intergraph science, older recipient age, presence of peripheral anterior synechia, or at least suture? Which of the following past medical histories will allow the use of potential donor cornea used for transplant? Not a very good question, Annie, bad wording. We'll have to do that. So breast cancer, it's okay, even metastatic cancer, as long as it's not to the eye, is okay for transplant. Leukemia, active septicemia, it's kind of obvious you wouldn't want to potentially transplant bacteria, or, you know, grossly cancerous cells into an eye, and leukemia, the cells can circulate and get into the eye tissue. Parkinson's disease is kind of an interesting one. Most people don't feel like Parkinson's disease is transmissible, but it is on the list of, you know, it's more probably, people would not, there's no known transmission of Parkinson's disease, let's put it that way, but it is on a list of exclusions. There's a fair amount of eye banking in this chapter, we won't go into a lot of it, but we'll go into some really basic stuff. So kids heal fast, sometimes you can take their stitches out, literally you can have all the stitches out in a penetrating caroplasty in three weeks, I've done that before. All of the others are actually higher risk or pediatric corneal transplant. The corneal donor study was a big center trial, I was actually one of the investigators and compared donor tissue from younger and older donors, and the correct answer was there's no difference in graft failure. And there was about an 80, well 86% survival rate of transplants, I mean younger tissue, it's kind of intuitive, younger tissue, maybe a little better, but really this was a very important study to kind of validate the use of older donor tissue, which is obviously a higher supply because older people pass away. So it was really helped for surgeons to be able to be accepting of using older corneas, not just looking for young trauma victims or unfortunately we see a lot of suicide victims. So which suture would you take out? One where the mires are most flattened, the one opposite could be a correct answer because you do have a coupling. We aren't going to really talk about that this year, but in the refractive surgery lectures of the alternate year we talk about that. So if you took this suture out here, you would actually see a lot of effect overall probably, but taking this one out where it's most flattened is the correct one. That will be on OCAPS and board, I mean it just won't be, it always is. Endothelial rejection obviously, endothelial cells don't regenerate, so that's the most important type of rejection to prevent. This is a crudidose line, not a very easy one to see, but you'd want to increase the top of steroids to hourly and you can do other things, but that's the best answer. Inferior perfilarotomy, so that fluid can circulate, the air will be on top, fluid can circulate around through the iris to help prevent pupillary block. If you don't understand that at a more junior level, don't worry about it because it will be something that you'll understand. You get hyperopic shift with desec surgery, it has something to do with kind of a, maybe minus lens on the, maybe kind of the shape of the tissue, no one really knows exactly why that is. We published a paper on it with some kind of ray tracing suggestions, but we don't really know for sure, but generally it's hyperopic. You can get any, but if that's worth to a test question, you would say hyperopic. Three failed transplants in the right eye, two in the left, and then this implies what? Any resident, hospitalization, this person was in the burn unit after taking a Sulfa drug, he wanted to make it have a surface, acetic actinosis, and the prognosis would be crappy for that. So the best answer might be none, one that was available. So older recipient age actually is associated with less rejection, because the recipient immune system is weaker, so the less likely you're dead. So now we're just going to move into a lecture. So why would we do, and this says for PK, but also could apply to some of the other cornea transplants, particularly lamellar, anterior lamellar keratoplasty. The most obvious reason is that the patient can't see, and there's something in the way. So a visual or optical reason, it could be an actual scar that's blocking the vision, or it could be a deficit in the curvature of the cornea that can be overcome by a contact lens of severe thinning, severe irregular stigmatism. Things like edema, obviously, would also block vision. Structural refers more to that shape part, or could refer to patient with trauma, or infection, perforation, that kind of thing. But number two is related to number one, because if you don't have good structural cornea, you can see very well. And that therapeutic is the least commonly performed, but would be for an infection that can't be controlled, and you're going to get this out before it spreads. And then sometimes just tectonic to restore the globe, but maybe a temporary thing as well. So perforation, things like that, which are rheumatoid mel, would be a good example of something where you're just going to have to do a patch graft and then try to do a definitive repair. So this just shows right even indications. I won't quiz you guys, but slip meme, showing thickness, that's herpetic stromal edema. You would call that down before you. So this is a classic disco form, herpetic edema. You would call that down. You wouldn't do a transplant if they have that active edema. Fluke's dystrophy with goutte, obviously, perforation, keratinonus or pollucid. Granular dystrophy, herpes simplex. All kinds of, this could be interstitial keratitis or infection. Veiled graft is a very common one. This would be more of a possible therapeutic indication. I'm not even sure what that is. It's probably an infection, as we read. But I mean, there's all kinds of different reasons. So just a little bit about eye banking. The book says 2 to 75, and I think that's fairly, each eye bank has its own acceptable criteria, but that's pretty standard. Again, the cornea donor study, justify and validate using older tissue. Cell count, most people use a higher cell count than 2000, but that's kind of what is written in the EBAA, Eye Bank Association of American Standards. We generally use tissue over about 2,300 cells in our eye bank. I feel like we have a surplus of tissue. And then for endothelial careplasty, because there's so much manipulation, we usually use a little bit higher cell count, 2,500. And so as a surgeon, you can kind of specify to your eye bank what your own criteria are within reason. Death preservation is really, the standard is really 12 hours, but most of the time, most eye banks go out to 24 hours if the body is not too warm. And many, many people die in the hospital or they might be transported to the coroner's office, so very common practice. You guys might have seen this rotating on medicine or whatever to put the ice and gloves, and close the eyes and put the ice over the eyelids. And the idea there is to help preserve the corneal tissue. So usually out to 24 hours is totally fine. If somebody passed away out in Death Valley in the summer and it was 19 hours, you probably would not use their tissue because the heat just speeds up all of the enzymatic degradation of the tissue. There are different storage media. The book goes into this a little bit. We don't use organ culture in this country, but you should know about it. The common way of storage here is cold storage might be good to know that the temperature ranges. You don't want to freeze the tissue. There are a couple of different preservation media. Preservation media, I don't know that that would be a really important thing to memorize, but GS stands for gentamicin and streptomycin, so it has antibiotics in it, it has some nutrients in it. There was another study that, again, I was an investigator and called the Corneal Preservation Time Study, which was a DSEC study that proved that it really was safe and effective to use tissue out to 14 days, although the corneas really did the best when they were used by 11 days, so that's kind of my preferred. We had a cornea last week, or the week before the function was doing fine. So we still use them. And that was in response to surgeons not wanting to use the tissue after those. I think it is one area where there really has been some good prospective studies to help surgeons understand what's advisable or clinically appropriate. So the required testing is HIV, hepatitis B and C and RPR. There are other tests, for example, California Requirements Testing for HDLV 1 and 2. We had a donor recently, Maddie, again. Organ donors are tested for CMV and EBV, and often those titers are positive and we still accept the tissue. They just want to know for their organ donor patients. Things like Zika, I don't think Zika has been transmitted by corneal transplantation, but that is a really important recent infection, where people might not be sick, they might be past the sick phase of the illness, but still be able to pass it. So fortunately, the Zika thing kind of died off. I'm not aware of any, but you can kind of foresee other infections. West Nile virus is another one that people can get and maybe not know that they have, which could be important and detrimental to at-risk recipient. It tells you what diseases people have transmitted. AIDS has not been transmitted. No known transmission. Hepatitis B has C probably. Rabies, interestingly, when I was in practice in Idaho, the guy, I was only in private practice for two years before I came back here, but the guy whose practice I took over was the first guy to report a death from a re-stoner. His patient died from corneal transplant from somebody who had died from rabies, so that wasn't really known, then it was the first case. So that was awful, obviously. So when we're looking at the tissue in the eye bank, we look at it with the microscope for all these things, pretty obvious, then we do blood work. The social and medical history is really important. I'm not gonna go into that, but the book kind of talks about it again. That's maybe not as important as some of the other stuff. But for example, people who've been incarcerated or are very promiscuous, we don't use the tissue. And most of this screening is done via a coordinator over the phone with a family member or sometimes with a physician. And it doesn't talk at all about consent, but in Utah, most of you probably have Utah driver's licenses, there's a registry and so there's an implied consent law. Consent from the family is not required in many, many states now if the person has signed up to be a donor. Now, as a kind of a nicety, the donation coordinators will usually try to verify that with the family, make sure everybody's on board, but if the person signs up for it, they can legally take the tissue. So one of the most important things that's not really emphasized in this chapter is when you're thinking about doing a transplant, just think about the whole patient. We have two eyes, many times you can't restore a perfect function to the eye in question. So if you do a lot of complex surgery and try to make them better, is it still gonna be kind of a crappy eye compared to their good eye? That's a really important consideration. I cannot overemphasize this. Affair people are a defect. Many times you cannot see the pupil, but you can still do a subjective affair or reverse affair test. I get referred to so many people that are blind from glaucoma that have cladincornea and you're like, well, we had one last week that we didn't have serious retinal problems. We didn't have very high hopes that he would restore, have his vision restored based on testing. And then chart review is really helpful to try to figure out, mostly for glaucoma and retinal disease, and you can kind of try to go back if you get old records, kind of see if they could see a few years ago and kind of what's been going on since. And that's really helpful in my opinion. So you wanna do a little detective work. You have to pay attention to what else is going on the eye, particularly glaucoma surgery, really important. If you're gonna change or remove an IOL, you gotta think about, is it scarred in there, et cetera, et cetera. Pretty common sense stuff. If you're gonna do IOL surgery, how do you do IOL calculations? If you're gonna do a cornea transplant, that is for another day, but basically you have to estimate the curvature of the new cornea. Sometimes if they have really bad, we had a patient just recently with really bad, well, it was last week also, really bad edema on his cornea so we couldn't get any K values at all. So we kind of estimated from the other eye, you know. They kind of look back and say, well, your two eyes were pretty similar. Sometimes you just have to, because it was a combined DMACC and FACO. You really have to plan ahead. You have to know all your equipment that you might need. Think of plan A, B, and C when you're doing cornea transplants. It's nice to have an assistant. Even if it's a scrub nurse who can kind of help, you know, sometimes if there were a more emergent situation or something, just kind of help know what's going on. Ultrasound is really useful. If you have an opaque cornea, you can see how thick and nasty that cornea is. But, you know, there's a paroidal infusion. There's lenses right up against, right up in the front of the eye. This person has an RD. So we're very spoiled to have Dr. Harry here. But even if you do your own ECM, which we find really, you know, bad stuff that maybe need to be addressed, either during surgery or possibly, even as a contraindication for surgery. The criteria for success for corneal transplantation is very dependent on the premorbid diagnosis or pre-surgery diagnosis. So, for example, Stevens-Johnson syndrome would have a horrible prognosis and curative bonus would have a great prognosis. There's a whole spectrum in between. Recipient age is really one of the things that is perhaps counterintuitive, but generally the older the recipient, the better they do. Because, again, they don't have such a strong immune system. But all of these other things can factor in. And I would just really, really, really emphasize this one. Patients with poorly controlled ocular surface disease do not do the treating care of plastic or anterior lamellar care of plastic. With EK, they do better. And pretty much all old people in Utah have dry eye. So you gotta kind of think about that and try to control it. That's usually one of the biggest uphill battles. It's not rejection. It's just trying to get the ocular surface rehabbed. Compliance also is huge, huge, huge. Anesthetic, generally, we do mostly blots, but also general anesthesia, nothing fancy there. Certain types of surgery, namely EK, can be done with topical anesthesia very effectively. But I wouldn't wanna do penetrating curative plastic with topical anesthesia just because the eye can squeeze and move and you're more likely to have expulsion of contents. So we'll do a couple of little videos of operative technique, hopefully this plays. So that wasn't care to call this patient, so we cauterized to flatten the hand chair profile of the cornea so that the tree fine cuts more vertically. Maddie, what do you hear in your head when you're at this step? Yeah, trying to keep the scissors vertical, kind of hug the wall where the tree fine is. We use viscote. We talk a lot about tissue distribution. You can already kind of see that this tissue kind of fits in the hole well. That's one of the goals, especially with keratoconus, you wanna flatten the profile of the cornea. So again, really the first two sutures and the first four are kind of determined where that tissue's gonna be. So simple interrupted running sutures are also used. That's pretty fast transport. So just to kind of go through the steps more, sometimes a fixation ring can be used. Maddie, what have you learned about how to suture the fixation ring? And to have it loose, right? Because you don't really wanna create a lot of astigmatism, but the idea is, I don't know if any of you have seen the eye collapse, probably in retina surgery you see it. Sometimes if you drain, you're doing a buckle or whatever. But you know, you don't want the eye to collapse. So if you have that kind of scaffolding on there, at least you'll have some structure, but it's, the eye can just, it can just turn inside out almost. It's really nasty. So having a, this is called a McNeil Goldman ring. It's incorporated into the lid speculum, but we often use what's called a fluorine ring. This is like Dacron suture, but we usually use silk. Handheld trefine, but most of the time we use suction trefines. Entering, we enter in flight with viscote. One important thing on the cutting is to, again, try not to leave a ledge. So most of the time the trefine will bevel out just a little bit. So if you have the dome of the cornea, the trefine's gonna bevel out a little bit. So if you're not careful to get your blade of your scissor in the groove that's already established, you're gonna leave a rim. And so I always say, hug the outer wall. So you get your blade of your scissor in there and you're kind of coming down. And then you're just kind of pushing centripetally a little bit to try to get that, get the, the suturing is just something that is fairly straightforward. But it's good to practice. So you guys should all practice on styrofoam. You don't need an eye bank eye. Syrofoam works great. Just practice passing angles. We would again offer to all of you the microscope out at mid valley in the minor room on the first floor is just like our microscope foot pedal everything. So that's a really good place to practice. So this just shows a combination of running in interrupted sutures, just different ways of suturing. So interoperative complications, I was kind of, I thought it was interesting in the book. They kind of minimize the most dreaded complication or don't really discuss it that much, which is what Maddie? Supercroyal hemorrhage. I mean, that is horrible if you get it because it's usually blinding. So as you get into, you know, kind of cornea rotations or whatever, we can talk about how to help minimize that. I'm not gonna spend too much more time on this. This is important for you guys because you take call. So the early post-op care, you see these patients unfortunately, I apologize for that, but you know, they might have pressure issues that they could have. You know, it seems like abrasions are common or you know, there can be pain or what have you. But if you kind of just follow these principles, then the first stages are really to get that barrier function back to make sure the eye's not leaking, make sure the epithelium's intact. And one thing to really remember is try to avoid too aggressive topical medications. Many of these patients from glaucoma medications, for example, carbonic and hydrase inhibitors are pretty toxic to the surface. So if you're trying to promote epithelialization, you might even wanna stop their co-sops for a week and you know, watch their pressure closely, that kind of thing. Obviously pressure. Pressure is really a huge thing and many transplant patients, many, many, many of these patients have glaucoma and it's usually complex, so that's important. Don't forget about the macula. A lot of patients with IOL problems or other complications that cause corneal problems will have either acute or chronic macular edema. It's amazing what OCT can pick up pre-operatively even through cloudy corneas. So somebody comes in with kind of a cloudy cornea and you're like, yeah, your endothelium is bad but your vision's really horrible. It's good to get an OCT and I've picked up CME many, many, many times and you can still treat them and just know you can rinse up on steroids. What have you. This just emphasizes that you wanna try to get the cornea. I thought this was funny, it popped up on my, just one of those spontaneous random things, the backward d-sec and I just took a picture because I thought that was, it never, I don't know if they have kind of a random thing but it would keep up. I thought that was cool. 20, 50 line. So in the middle phase, which would be, I would consider that somewhere between one month and two months out to maybe six months out, you're just trying to make the stigmatism less, maybe get the patient into glasses or contact, you're starting to taper your immunosuppression, you're starting to take sutures out and usually the patients on cruise control unless they get stuck in the eye by a laundry basket and rupture their eye at day 10 like one of our recent patients. It was now a fake, but seeing .25 with her sclerolins, so she's doing all right. Anyway, eye protection, you know what I said. And then late care, really one of the most important thing is just trying to decide what to do with immunosuppression, you know, we, a lot of that. I really think having been in practice for 25 years now and seeing all different styles of managing transplant patients, if you see your patients more often and you keep them on a little bit of steroid, they do better. The rejection rate is definitely lower on low dose steroid, but also just compliance. I mean, people can, and kind of compliance implies that you need to see them too. The doctor needs to put forth effort to keep seeing their patients. We usually see them every six months or every year, but part of the visit is just saying, wow, you know, if your eye gets blurry for a few days or if it gets a little red or lights incident, you need to call us and commit because many, many rejections can be reversed if caught early in their death to the transplant if they're not caught early. And it's kind of like macular degeneration, you know, people have two eyes, maybe it's not their preferred eye anyway, so they're just going to kind of ignore it. So really educating the patient is important. Prevention of a problem is much easier than fixing it in most cases. So there's all kinds of reasons that graphs can fail. We'll kind of scoot through some of this. And I've seen this multiple times where, you know, the patient's IOL is kind of hanging out of their eye. This isn't actually my patient. This is a file photo, but this is probably the most common blinding complication of corneal transplantation is trauma with glaucoma being probably a close second. But all of these other things are important. Cataracts are fixable rejection, you know, depending on when you catch it. The book says endothelitis is much more common than cataract surgery. I don't know that that's actually true because, you know, endothelitis rates for cataract surgery vary a lot, but I've seen some studies saying endothelitis after corneal transplantation is at as high as 2%. And, you know, that could be in India where there's lots of, you know, awfulness and there are lots of, you know, in the U.S. it's not that high. But, you know, if you're endothelitis rate for cataract surgery is 0.1%, then probably just based on volume, endothelitis is more common. I don't look on when, I've never had a patient with endothelitis in 25 years. You know, I've had patients with suture abscats get endothelitis years out, but it's uncommon. Yeah? Rimcultures, the EBA recommends them. I don't perform them routinely, Dr. Lin does. And, you know, they give a lot of erroneous information and so it's hard because we don't sterilize the eye when we do surgery anyway, but rimcultures are thought to be useful just in case you get a bad infection then you maybe have, you know, a head start. Fungal endothelitis with EK is really the pertinent issue because, you know, if somebody has a candidate on their rimculture and they're getting endothelitis, and that's probably where it would be helpful to put them in for a year or so, so the fungal infection is opposed to a, so anyway, you know, we just don't get as many. Yes? No, no problem. Agent Aventurer, we're in transplant. Is that solely related to the steroid use or is that something else? You know, a lot of it is just their pre-transplant state because many, many patients have other complications which give them secondary glaucoma, and many, many patients, their glaucoma surgery has given them a failed cornea. So, but, you know, even though it's kind of not directly related to the transplant, that is like, you get really frustrated when you've done this beautiful surgery and you put a nice clear window on the eye and then they're blind from glaucoma because their pressure was 17 and you weren't really thinking about it. You were kind of managing their transplant, and so that's the point. It's like, you just really need to, once you kind of get through this, you know, first few months, you really need to think about, okay, what else is gonna blind this person? Trauma for sure, so eye protection. Glaucoma is a good close second. So, and that is just, again, it's not really, if you're seeing your patients, you're gonna recognize steroid responder issues. These patients, you know, sometimes you'll get somebody, and their pressure's just 40 after you do a transplant. You gotta keep them on steroid, you have them on load of Pratt and Hall. You know, they're not rejecting, but you can't go lower. You know, they just need to send them. They get a tube, gets their pressure down to 22. They're on three drops and they're fine, usually. But there are those instances. And then there are certainly instances where the high pressure is just not recognized for whatever reason. You know, you may have a patient where you can't check pressure very well, or, you know, not compliance or what have you. But I just would say that personally, for me, that is like one of my, one of the things that I really hate is when I haven't been aggressive enough on somebody's glaucoma and then they're, you know, lost their central vision because of it. Measurement of glaucoma, parameters after corneal transplant can sometimes be difficult. If they don't have a great surface, you may not get great pictures for your RNFL. Sometimes they can't see well enough to do a great visual field. Checking pressure itself can be a little more difficult sometimes in these patients with sutures in, et cetera. Corneal thickness can be a factor. Cataracts, pretty obvious. One thing that's really, again, Maddie, hard-bun, you can give a person a cataract with fairly uncomplicated surgery just by not being gentle with the lens. So I always tell my helpers, you know, squirt the saline back towards the iris, not towards the center of the eye, like we're always used to doing. You have to be kind of careful when the eye's open not to push too much on the lens. But generally, most of the cataracts that are transplanted are caused by steroids. And the rate is not actually that high comparatively to, like if you compare it to the tractomy surgery or something like that would be more close. Many, many, many patients get corneal transplants in their 20s and don't get cataracts until their 60s despite being on a drop a day of pretty slow for life, pretty much. Graph rejection, there was quite a bit in the book about graph rejection. I don't know why that picture didn't copy, but this is supposed to be subepithelial infiltrates. And that's supposed to be an epithelial rejection line. And those are KP. I won't, I mean, rejection is pretty straightforward. You can kind of learn about it. One thing, again, in the book, and this is kind of propagated in the literature, if you, epithelial rejection, I'm not sure is even a real thing because the donor epithelium usually dies off and the recipient epithelium should push it out eventually. But subepithelial infiltrates, there's kind of a thought that those don't need to be treated. Usually they will progress into a more serious rejection. So if you see somebody with subepithelial infiltrates, then you should probably bump up their steroid. You don't need to like do hourly bread like the question, but you know, you might want to, if they're on once a day, you might want to put them on twice a day and have them come back in three weeks. So steroids just kind of know basically the categories. Many patients don't need much steroid, even fluoromethalone, which is, it's a strong steroid, but doesn't penetrate the eye well, is, you know, one drop a day will often be enough to prevent rejection. Durazol is stronger than prednisolone or dexplosone, but we don't, I don't use it as much just because it tends to be a little bit more expensive. Pred's pretty cheap. Prednisolone acetate is what we use on those patients. Lodopretinol is a great drug. There is a 1% Lodopretinol now, but it's a little more expensive, but it's a really good drug. Medium strength steroid, much lower incidence of steroid responder, elevated pressure. So I didn't really talk at all about, back to that other slide, HSV or Zoster Prophylaxis, but we generally keep anybody who has those diseases. We keep them on oral acyclovir or, you know, similar for at least three months after surgery, sometimes a year, because you're having a lot of steroids and you may cause recurrence of disease. So this is just some reasons that graphs fail. Dislocated DSEC, swollen button. This is also a DSEC with a fluid cleft that's not attached. It's just showing microcystic and stromal edema, failed PK. Suture problems, all kinds of suture problems, including a suture abscess leading to it. In this case, a pseudomonasculcer and loss of the graph. I have had two patients, one patient and not that long ago lost her eye due to a suture abscess which became, it was kind of chronic, she didn't really come in. This was my patient, I did her transplant. She lives out of town. She's a very compliant patient but was treated by local doctors and unrecognized, formal lost her eye. Unfortunately, so I was only a couple of years ago. So you gotta manage these degrading sutures. So we already talked about astigmatism a little bit. What about wound healing? I mentioned in babies, you can take them out really early. Kind of wanna take them out before you get a lot of vascularization because vascularization can bring blood vessels to the new donor tissue and bring the immune system to the donor tissue. So blood vessels in general are a reason to take sutures out. You have to balance that with the risk of trauma. If you have a young active person, sometimes you wanna keep the sutures in a little bit longer. Sutures are a risk factor for rejection even if they're not loose because they're a little bit of an immune stimulus. So even if they're not vascularized or loose, I usually would rather have a patient on some steroid if they still have sutures in. This is hugely important because sometimes you take that one or two last sutures out and they go from two diopters of the stigmatism to 12 and then you need to do a wound revision. So sometimes if it ain't broke, don't fix it. If they're seen and functioning, you like to leave the sutures in. So you have all these kind of balancing acts of how to manage sutures. And then the most important one is once they start to break, you just gotta get them out because they can cause really bad complication. All different kinds of contacts. We often use soft bandage contact lenses early in healing. They improve comfort and promote epithelialization. Scleral lenses are awesome. Even a regular gas permeable contact could be used as soon as one month after. And if you guys ever work with me, you just know that I hate hybrid lenses. Don't ever suggest a hybrid lens because I'll just delete it from the epic. But they're just horrible. I mean, in the age of sclera, either an RGP or a scleral lens, hybrid lenses just cause a lot of hypoxia. They're particularly bad in transplants because they get vascularization of their lumbus and they're really, oh, let's see what else. You can do refractive surgery on cornea transplant patients. We don't do LASIK much anymore, but PRK works fairly well. The patients don't really hold that well sometimes, but you can get rid of lots of nearsightedness and stigmatism. And I definitely have patients that are 20, 20-ish years out from PRK after either penetrating or even anterior lumbar. Cateract surgery is really an ace up our sleeve and many patients to kind of get rid of large spherical or sometimes even astigmatic refractive errors. And we do use torx, a fair amount, on transplant patients if their sutures are out and their stigmatism is manageable. What else? You just have to do really careful FACO. And I always use viscote and I use a soft shell technique, so if you don't know what that is, you'll learn it when you get to cataract surgery, but you squirt the viscote in there, which is a dispersive OVD, and then you put proviscin, you have dooviscin. The provisc comes out really easy when you FACO, but you inject a blob of it and it just pushes a layer of viscote up against the cornea. So then when the cohesive OVD comes out, I know some of this is over, you guys have said, so don't worry, but the more senior you are, the more you'll understand. You still have a nice layer of viscote in there to protect the donor tissue. So that's called a soft shell technique. Tube shunts are better than traps just because you don't get hypotony and flat chambers and stuff as much. But you have to be careful to keep the tube. Our glaucoma surgeons are great in getting the tube in a good position. I won't go into this too much. There's the safety glasses. You can do EK after PK. This is just a picture of a patient he's had. EK, you can see the EK, in this case, desec inside the old PK wound, you know, it works great. So I often call it a retread, but you can also do other surgeries. You can do K-Pro. Sometimes the eye doesn't have much potential, but they have a failed graft and other issues where you might do a caulching type of flap or all kinds of other things. Sometimes when a graft fails, we just keep it as a, we know that the eye has potential, but it might be an uphill battle in trying to get a clear graft to get in. So we just kind of manage it medically and keep it as a spare tire, knowing that it can be rehabilitated if they need it. And that happens a lot in transplant patients. You have one, you know, quite good eye and one not so good eye. It's just like uphill battle and try to keep that eye with a clear transplant. But as long as you manage their pressure and things like that, you can say, well, we could do it again. And then sometimes when they're older, they do better. Just a little eye banking stuff. We can use LASIK tissue for EK, which is nice because they're a lot of refractive recipients. I'm just gonna go through some slides. Obviously a dendrite. The disease can recur in the graft. Another broken suture, kind of vascularization along sutures. How do we get the suture out? Another kind of suture vascularization with some thinning. This is crystalline keratitis in a graft patient, which the book mentions is strep veridansis, fairly common. You can kind of sit on these and just treat them. And many times if you have them on vanco for a long time, they'll go away. Vanco in a little steroid, but it's a little scary. Sometimes when you see something like that, you're like, oh, I got to take this graft out and replace it to a therapeutic keratoplasty, but most of the time you can clear it medically. Just a suture abscess. Broken and running suture. Probably an interrupted suture. Wound dehesants. Maddie, we've done at least one wound revision, right? It's amazing how easy you can cut into a cornea transplant when we get it to open up. So it's not surprising that you see these patients on call with dehistornias. They'll get eye protection. Even dalk patients can get dehesants pretty easy. They're just graft failures. The book talks a little bit about vascularization. Certainly that is a risk factor for rejection. If this person, you can see there's some edema there. This person had a repeat transplant. You would kind of worry about this ingreeness over here or maybe try to calm that down with lots of topical steroids before repeating the graft. You can use other modalities. You can use HGF inhibitors. You can use laser. But generally, corticosteroids weren't the best. You need to slime them with topical steroids and the blood vessels will often regress. KP, rejection. Bimodal, cododose line, KP. This one has everything. I think it has sub-epithelial infiltrate, cododose line, KP, sub-epithelial infiltrates. Quote epithelial rejection, but I'm not sure that it really is. That's another quote epithelial rejection. Just failed graft with stromal edema. Another bunch of failed grafts. Perforation from recurrent herpes, patch graft. So just a quick word about, because I want to get to EK, we can use a femtosecond laser to cut our donor and recipient tissue. Not really better than traditional methods, but it's kind of cool. I've done it on several patients. Just adds expense. KPRO, we're not gonna really talk about that, but it's a PMMA button. You can kind of see there, kind of screwed into a rim of a donor cornea and then sutured onto the eye. Glaucoma is really the main problem with these, but you can also get infection or melting. This is just, I'm not gonna talk about that because we talked about an ocular surgery. This is a grainy video. You couldn't find a short, this is a dalk. You can find a short dalk. So I had to go to this really old video. You can see it says infinity cataract machine. I think it's been like 15 years since we've had an infinity cataract machine. So this is a keratoconus patient. So for deep anterior lamellar keratoplasty, as you read about in the book, endothelial rejection is not a problem. So it's a really good surgery for young patients who need cornea transplants. So you do a trefination, a lamellar dissection. You wanna take off about maybe 50% or a little bit less. And then the idea is you, this is a paracentesis to put some to relieve the pressure a little bit. And then I'm just making a track. I'm trying to be as close to the top of decimates without perforating. And then I'm gonna inject air. That's just air in the interior chamber for an indicator. You'll see in a second here when we get the big bubble that you're pushing decimates back with air. And so those bubbles in the AC will kind of, they'll peripheralize again. They'll move out. And you can kind of see the interior chamber bubbles kind of move perforately. So you know that you've actually achieved your big bubble. It's not as easy as it looks. I would say my success rate is only 50% probably. Getting the big bubble. Most of the time the fellows are doing it in cases. If I did them all myself, it'd probably be a little bit higher. Even so, like internationally, when I go I see maybe two thirds of the time again. But you can do lamellar dissections and to your lamellar keratoplasty. That was just putting the viscote on there was just so the air bubble wouldn't escape so fast when I cut through that last layer of stroma. This is like the most nerve-racking surgery when you're, all you have is decimates membrane and you're trying to cut off the residual stroma without popping decimates. But it's really a cool surgery when you get it all cleaned off. You have just this beautiful, clear, perfect decimates membrane. So less chance of endothelial rejection. It's kind of thought initially that maybe these eyes are stronger but I don't think they really are. Maybe if you do lamellar dissection where you just leave a thin lamella of stroma. Sometimes with the air it's really hard to see the rim so I'm just trying to put some ink on the rim so I can kind of see where the edge of the treflination is. And we cleaned it all off. And then we're going to prepare our donor tissue. Sorry, the video's so crappy, it's just really old. But we have it stained with Tri-Pemble. You can't really see it on this exposure. And I just kind of scraped it a little bit and then I wiped it off in the WECSO. And then we put the donor cornea minus SMAs and then just sutured on. The suturing is very similar and that's awesome but sometimes the next day this is a picture of a double anterior chamber. So I didn't leave any air in the sigh and you can see the donor tissue is the convent, that's the recipient decimals. But the good news is even without, I didn't even put an air bubble in the sigh, I just waited. And this guy's like a nurse manager over at Primary Children's and he just reattached. Wasn't completely reattached in one week but by two weeks he was and he has really good vision. He's like 10 years out now. This is a DSEC surgery and again, I didn't really have any really short edited clips so this is a little bit older surgery, older video. We stripped SMAs. This is really easy and fuchs patients and can be really hard in pseudo-faking corneal and even patients. We've prepared the donor tissue by punching it and then we're putting it on a little glide and we make it into a taco, taquito, roll it up. And then we can put this through, you can put them through, you know, maybe a lot of people use injectors. This is called a Booson Glide. But you can put it through an injector. You can put it through about a three and a half millimeter incision. I usually make a four and a half millimeter incision. Most of the time we have a chamber maintainer but I think this was early enough in DSEC days. I didn't put it in, I was just having my assistant put it in, which actually works too. You don't want to open up a Finko machine. So anyway, a little painstaking. Put it in there. The nice thing about the glide is it's very easy to make sure that you don't flip it over. We don't usually mark DSEC tissue with S-stamps. We're going to show you a D-mech here in a bit. But then once you get it in there and kind of get it centered, you just inflate it. This step just, there's some venting incisions to try to remove the fluid from the interface. And just make sure it sticks well. Detachment rate is actually really low with DSEC with modern techniques. A little bit higher with D-mech. Again, there are tables and things in the book. So this is Dr. Betts doing a, I didn't have a short D-mech video. There are some good videos in the links in the book though. It was just too hard to put it all through the S-stamps there, this is kind of D-mech surgery. It's very interesting how that S-stamp is created. It's a gentian, violent guy. It's actually toxic. So you can imagine, you wouldn't have stamped it right on the, in the anterior stroma and replaced that little, you could kind of see that on. I was like, I don't know, you're so antsy to read, right? Yeah, oh yeah, it was programmed. Well anyway, so we saw most of it. And this is like your D-mech where it's in the eye and it's nice, these fold tabs and it opens up. But it's not always that easy, right, Matty? Matty did her first two last ones, and she developed a new technique. But personally, the camera was broken, so we don't have it with us. We had a constricted, myocall constricted pupil and she was able to shoot that D-mech tissue into the pupil. That sucked her out. So there was a mistake in the book. It seems like there wouldn't be, but one of the tables said that, for contraindications for PK donor tissue, that hepatitis C and hepatitis B surface antigen would have, it was just a dumb thing. I don't know if you guys noticed that, but table 15-3, that wrong statement's wrong. It said positive HIV and negative hepatitis surface antigen, whatever. So I still want to do some clinical conferences, hopefully this year. This is an ad for La Sportiva. We hike, four of my kids, I have five kids, one couldn't become, but we hike to the top of King's Peak and we kind of all looked and said, hey, we all have La Sportiva, so let's take a picture and see if we can sell it to the company. So that's our La Sportiva ad. So my financial disclosure. We're also going to do some corny and journal clubs and we'll try to invite you guys. We don't really expect you to be there because we do most of them at Mid Valley, but they're usually pretty good. So thanks, any questions?