Teaming Up for Surgically Complex Cases

Published in Wilmer - Annual Report 2019

Wilmer is known for the quality of its specialists, but what many don’t know is that these specialists often team up in the operating room to supercharge the treatment of patients with complex eye diseases.

One such team is Esen Akpek, M.D., the Bendann Family Professor of Ophthalmology; Pradeep Ramulu, M.D., Ph.D., the Sheila K. West Professor of Ophthalmology; and Jim Handa, M.D., the Robert Bond Welch, M.D., Professor of Ophthalmology. Together they partner on complex patients requiring surgery on more than one part of the eye.

Working together in close quarters breeds a familiarity with each other’s habits — and music preferences in the operating room. While Handa prefers classical and Ramulu favors Simon and Garfunkel, both acknowledge Akpek’s tastes run in a different direction: rap and hip-hop. “I have a 13-year-old,” she shrugs, as Handa and Ramulu laugh. Their camaraderie benefits patients because it facilitates their communication.

“I've been working with them for over 15 years, so we can very seamlessly integrate and do what we need to do. And it's very satisfying personally to see the patient benefit,” says Handa, who is the chief of Wilmer’s Retina Division.

One recent patient is Lyn Marchwinski, who was born with cataracts in both eyes. She had to undergo multiple surgeries during her childhood and youth, including removal of cataracts and surgery for glaucoma and cornea disease. By early 2019, when she finally came to Wilmer, Marchwinski was legally blind in her left eye and had very poor vision in the right eye.

“It was like when you get in your car in the morning and the windshield fogs over before the defrosters kick in,” Marchwinski says, describing the combined impact of her troubling eye conditions.

The resolute Marchwinski had reached her breaking point. Her ophthalmologist informed her that her case was beyond his expertise and suggested she look for a specialist. But the ophthalmologists that Marchwinski initially sought out could only offer suggestions, not the certainty she wanted. She recalls thinking, “I'm just going to go someplace where they can deal with this and stop messing around.”

Opening her search nationwide, she learned of Akpek, a leader in corneal transplantation. She scheduled an appointment with her.

“Dr. Akpek took one look and said, ‘I can fix that,’” Marchwinski remembers.

Akpek’s recommended solution was as complex as Marchwinski’s medical condition: a triple procedure she performs with Handa and Ramulu, who is the chief of Wilmer’s Glaucoma Division.

“We decided it's probably better to be proactive and do three surgeries— artificial corneal transplantation, glaucoma and retina — all at the same time to get the best clinical outcome,” Akpek says.

The four-hour surgery unfolded over a single day last May. Akpek removed Marchwinski’s donated cornea and sutured in a plastic implant known as a keratoprosthesis, or KPro. To head off the glaucoma, Ramulu inserted a small plastic tube in Marchwinski’s eye — a shunt, as it is known — that would relieve pressure inside her eye. Sandwiched between those two surgeries, Handa was on hand to repair any retinal damage and perform a vitrectomy, removing the vitreous gel from the eye to make room for both the prosthesis and the shunt, and to prevent the vitreous from plugging the tube.

“It takes a lot of coordination. Especially in the planning phase, when we need to figure out who is going to do what and how is it going to happen,” says Ramulu. The team begins its planning weeks before the surgery.

After the triple procedure, all three doctors monitor and follow up with the patient. “Dr. Akpek needs to follow the KPro and any kind of scar tissue that develops or infection. Whenever you put a plastic device anywhere in the body, you run the risk of infection,” says Handa. “So she needs to follow that and try to optimize the vision with glasses. And then I always make sure there are no surgical complications. The design of the KPro blocks where fluid drains out of the eye. That's why Dr. Ramulu puts in his tube. It’s important for him to keep the glaucoma manageable by monitoring the pressure.”

Despite a minor setback in June that required Handa to repair a small tear in Marchwinski’s retina, she has been doing well ever since. She was able to see better immediately, and the haziness has disappeared. Meanwhile, her vision continues to improve. She’s been told it could take a year to reach full potential.

“All the doctors I've seen since are really impressed with how far I’ve come,” she says.

Wilmer is among just a handful of ophthalmology centers in the nation with the expertise to do all three or four surgeries simultaneously.

“When you see a lot of patients who need complex solutions, like we do at Wilmer, a multistage procedure like this just happens organically,” Ramulu says. The skills of his colleagues make these procedures possible — and also make his life “easy,” he says, adding, “You can have a lot more confidence when you come in, and you have great people in other disciplines who will be backing you up.”