Abstract
We greatly thank Drs Hoerster and Cursiefen for their insightful comments on our recently published article.1Kitazawa K. Kayukawa K. Wakimasu K. et al.Cystoid macular edema after Descemet's stripping automated endothelial keratoplasty.Ophthalmology. 2017; 124: 572-573Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar They cogently pointed out that intensive topical steroid treatment early after posterior lamellar keratoplasty, and continuing for the first postoperative week, is important to prevent the occurrence of cystoid macular edema (CME).2Hoerster R. Stanzel T.P. Bachmann B.O. et al.Intensified topical steroids as prophylaxis for macular edema after posterior lamellar keratoplasty combined with cataract surgery.Am J Ophthalmol. 2016; 163: 174-179.e172Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar We completely agree with the importance of intensive anti-inflammatory treatment at the early postoperative period. Thus, in our department, all of the patients received a systemic dose of 125 mg methylprednisolone 1 hour before surgery, followed by a systemic dose of 4 mg betamethasone for 2 days postoperatively, and finally the administration of 1 mg betamethasone for 5 days. This may explain the relatively low prevalence of postoperative CME (7.1%) we have observed in the Fuchs' endothelial corneal dystrophy patients in our series, compared with that in previous reports (12%).2Hoerster R. Stanzel T.P. Bachmann B.O. et al.Intensified topical steroids as prophylaxis for macular edema after posterior lamellar keratoplasty combined with cataract surgery.Am J Ophthalmol. 2016; 163: 174-179.e172Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 3Heinzelmann S. Maier P. Bohringer D. et al.Cystoid macular oedema following Descemet membrane endothelial keratoplasty.Br J Ophthalmol. 2015; 99: 98-102Crossref PubMed Scopus (63) Google Scholar However, even under the systemic steroid treatment we found that in glaucoma patients with multiple surgeries, a much higher prevalence of postoperative CME occurred (i.e., 20.4%), possibly owing to the leakage of some protein from the damaged iris. Patients with glaucoma leading to bullous keratopathy often had a previous history of multiple ocular surgeries, including glaucoma surgeries. In these patients, pupil irregularity with severe iris damage was common, resulting in the disruption of the blood–aqueous barrier and leading to the accumulation of inflammation in the aqueous humor.4Higashihara H. Sotozono C. Yokoi N. et al.The blood-aqueous barrier breakdown in eyes with endothelial decompensation after argon laser iridotomy.Br J Ophthalmol. 2011; 95: 1032-1034Crossref PubMed Scopus (16) Google Scholar The anterior chamber directly connects with the posterior precortical vitreous pocket through Cloquet's canal. Thus, some inflammatory factors inside the anterior chamber can lead to a move into the macula, ultimately inducing the development of postoperative CME.5Itakura H. Kishi S. Li D. Akiyama H. Observation of posterior precortical vitreous pocket using swept-source optical coherence tomography.Invest Ophthalmol Vis Sci. 2013; 54: 3102-3107Crossref PubMed Scopus (80) Google Scholar We theorized that the administration of nonsteroidal anti-inflammatory drugs is another practical treatment, because nonsteroidal anti-inflammatory drug eye drops have been mostly used after intraocular surgery to prevent the occurrence of CME via the inhibition of cyclooxygenase. In our series, the effectiveness of nonsteroidal anti-inflammatory drug eye drops for CME after Descemet stripping automated endothelial keratoplasty is now under investigation. We are currently conducting further investigation on this matter. Re: Kitazawa et al.: Cystoid macular edema after Descemet's stripping automated endothelial keratoplasty (Ophthalmology. 2017;124:572-573)OphthalmologyVol. 124Issue 12PreviewWe read the report by Kitazawa et al1 with great interest. The authors describe an increased incidence of postoperative cystoid macular edema (CME) after Descemet stripping automated endothelial keratoplasty in association with possible causative clinical factors. Their finding of an increased rate of CME in a subgroup of glaucoma patients with multiple surgeries in their medical history led them to the conclusion of a possible inflammatory cause of CME. They attribute this to former trauma to the iris and a consecutively decreased blood–aqueous barrier for inflammatory cytokines. Full-Text PDF
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