Medical Notes

[John Smith]

Well, I received an interesting letter in the post today from the consultant I saw on Friday.

Basically, it is a copy of the letters he is sending to my insurers and my current consultant.

Some of the details though remain a little clouded to me; can anyone shed any light please?

For the right eye (existing graft): "Steroid induced glaucoma". I think I can work that one out, but I'm surprised that the G-word has never been uttered to me in the last 4 years! He also commented though "Intra-ocular pressure normal" (it was 18 ). I thought that glaucoma was a high IOP?

For the left eye (ready for a DALK graft): "An advanced cone, with marked apical thinning, and apical sub-epithelial scarring."

Now, I was under the apprehension that scarring was a contra-indication for a DALK.

I'm more confused now than I was in the consulting room! Why he didn't tell me all this at the time I have no idea! Still, at least I can talk to my "normal" consultant next week and ask her!

[jayuk]

John

This is normal to be honest....what I mean is Consultants NOT telling patients exactly what they observe or know about the condition. Finding out other things in the letters is also normal and something i have also experienced

With regards to the scarring; you are permittied an element of scarring with the DALK, however it does depend on how many layers down the scarring occurs over.....however he has mentioned epithelial scarring........but do bear in mind that the top layers will be removed, and healing will occur by virtue of new tissue.........

Your IOP of 18 is fine, anything between 10-18 is meant to be ok, however I am led to beleive that a value exceeding 21 needs attention (mine has floated around between 14 and 19 since my graft)

It is of concern why you was not told of the Glaucoma.....best persue this with your reg consultant....but due bear in mind that not all Glaucoma consists of high pressure...

Take a look at this
http://hcd2.bupa.co.uk/fact_sheets/html/Glaucoma.html


Hope that helps

J

[Ali Akay]

John
I am assuming you're not on steroids at present, and I'd think at some stage in the past you had raised IOP while on steroids which gave the diagnosis of "steroid induced glaucoma". when the steroids are withdrawn the pressure goes down as raised IOP is a direct result of steroids in the susceptiple patients. You may or may not have suffered some optic nerve damage depending on how quickly the problem was realised and remedial action taken at the time.

Some degree of scarring is not necessarily a contraindication for DALK, it depends on how deep it is.All but a very thin layer of stroma and endothelium is spared in DALK, hence scarring in the top layers is not a problem. Hydrops is a different issue as it causes splits in the descemet's membrane (a very thin layer between the stroma and the endothelium) and usually full thickness graft is needed after hydrops.

I hope this reassures you

[John Smith]

Hi Chaps, thanks for the very fast response.

Jay - nice link, thanks. My IOP has at times been in the 20s and 30s, but has been around the 17-19 mark for some time now.

Ali - Actually, yes, I am on steroids, and have been on FML drops for most of the last 4 years post-graft. Every time I'm weaned off them I seem to have a rejection episode, so now I'm on FML and Timolol (to reduce the pressure), both twice daily.

My outstanding concern is how deep the apical sub-epithelial scarring is. Does the name give anything away? I suppose Apical (Apex) suggests the point of the cone... hence the front of the cornea and therefore the bit which would be removed in a DALK. Am I right?

[Andrew MacLean]

John

I once took a letter like the one you describe to my GP and asked him to help me translate it into English! It took a bit of doing, because he was unable to make head or tale of something that the consultant had said! In the end we got there.

Not even access to a classical dictionary helped me! Words like sub-epithelium aqurie a meaning in use, but if you look at their etymology, they actually do not mean anuthing.

sub UNDER
epi UPON, BEYOND OR BESIDE
thele NIPPLE

any the wiser? I doubt it. Yet we all recognise the word epithelium to mean the surface tissue of any part of the body, in the case of KC it is the cornea.

And that's a word you started off recognizing!

All the best, John.



Andrew

[Knight]

Steroid Induced Glaucoma is defined as an increase in eye pressure of equal to or greater than 15 mmHg with topically (eye-drop) applied steroids. The condition may also occur with systemically administered steroids (e.g. prednisone)... in most cases, development of increased eye pressure takes one to two weeks after initiation of steroids. However, in some cases, the increase in eye pressure may occur as soon as a few hours or as long as months to years following the administration of steroids.
Source

Apical thinning described by Stallard is believed to represent an actual reduction in the number of stromal lamellae rather an overall thinning process. Polack believes that collagen lamellae are released from their attachments and slide, giving a thinning of the cornea.
Apical sub-epithelial scarring
Sub-epithelial corneal scarring, not generally seen early, may occur as keratoconus progresses because of ruptures in Bowman's membrane which is then filled with connective tissue ... Deep opacity of the cornea are not uncommon in keratoconus. It has also been reported that flat-fitting contact lenses may produce or accelerate corneal scarring ... raised "callous" is possible but is easily treated by simple debridement or laser ablation. In addition apical scarring with an overlying epithelial defect and surrounding edema can be confused for ulcerative keratitis in this disease process.
Source

[Ali Akay]

John
I know terminology can be very confusing.We still have to explain to patients every day what long and short sight means-pretty meaningless words really! Coming to "sub-epithelial scarring", technically all scarring is sub-epithelial ie involves the layers of the cornea below the epithelium!The epithelial(surface layer) cells are constantly replenished and hence do not get any scarring of the epithelium. To indicate the depth of a corneal lesion, terms like "superficial", "sub-epithelial", "deep stromal", etc are used and "sub-epithelial" means involving the surface layers of the stroma immediately below the epithelium. Hence, in my opinion, sub-epithelial scarring is not a contraindication for DALK because the deeper layers of cornea are not affected.

Regarding FML, as long as you have your pressures monitored regularly you should be OK.In acute steroid-induced glaucoma the IOP could rise to 40-50 from a single instillation and I thought perhaps you had such an episode in the past.You obviously have to carry on with FML and the corresponding rise in IOP could be controlled with drops as you know.You say you are on Timoptol but no one mentioned the G word. They probably felt better to tell you you need drops because the pressure is a bit high rather than saying the steroids you have to have have caused glaucoma. As you will appreciate not all patients want to know exactly what's going on and it can be difficult to gauge how much information to part without causing undue anxiety to some patients.It may help to tell your new consultant that you'd like to be informed of everything going on! There's also the general problem of poor communication and often patients ask the friendly community optometrist to try to explain what's going on as the doctor at the hospital hasnt said very much!

[Andrew MacLean]

Another one to listen out for is the word "Iatrogenic". This can be related to words like "Glaucoma" and means, literally, Doctor Induced Glaucoma" That is Glaucoma caused by the intervention of Physicians, as in your case, by instillation of steroid drops.

It is a great benefit to have a grounding in Classics. Doctors use "technical" language in order to be precise in conversations with other physicians, and also to keep patients from following what is being said.

I always interrupt and make it clear that I speak that language and ask them if they really mean what they are saying.

In fairness, no doc has ever tried to bluff me after that sort of intervention, and they have always settled down and spoken to me as if I had an IQ bigger than their shoe size. But I do not know how sensible they would have been if I had just pretended not to understand what they were saying.

Andrew

[John Smith]

Thanks very much to all who have posted above. I really do feel now that I understand what is going on.

I know that in IT, some of the "super-specialists" can talk a language all their own, and it's left to the more general IT bods like myself to translate their utterings to managers.

I suppose that what Ali is saying is pretty much the same thing.

Thanks for taking the time to answer.

[Knight]

...I know that in IT, some of the "super-specialists" can talk a language all their own, and it's left to the more general IT bods like myself to translate their utterings to managers...

Indeed! I recall a situation when in my job as the tech admin for a local college, we were designing the new network architecture setup. I was with the sourced technicians who were installing the fibre optics and the conversation got really specific speaking in acronyms ... the Head of the IT Dept, teacher, tapped me on the arm with that bemused look.
It was his 'job' to oversee, the new setup, but honestly the guy was out of his depth and it was up to me to translate, but I was surprised he didn't know some simple key aspects of networking and kept asking about where the internet would go - holy $%^& that made me laugh for days - but its no joke, a little information can go a long way, translating and getting the definations understandable for everyone isn't easy, can lead to confusion and sometimes not knowing is better heh ...