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Cxl Co-Management and Clinical Pearls

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Cxl Co-Management and Clinical Pearls CXL CO-MANAGEMENT AND SPONSORED BY CLINICAL PEARLS Avedro gathered leading refractive surgeons and eye care professionals for a roundtable discussion during the 2018 annual meeting of the American Society of Cataract and Refractive Surgery in Washington, DC. The discussion centered around the co-management of keratoconus patients with your optometric network, as well as corneal cross-linking (CXL) clinical pearls. IMPORTANCE OF EARLY DIAGNOSIS I examine the patient’s history thoroughly. I ask about last year’s eye- BRANDON D. AYRES, MD AND TREATMENT n Surgeon on the Cornea Richard L. Lindstrom, MD: Now that glass prescription and how fast the Service, Wills Eye Hospital, we have an FDA-approved treatment for patient’s vision is changing. If a patient Philadelphia patients with progressive keratoconus, has had to change eyeglasses four times n Financial disclosure: it is crucial that we educate diagnosing in one year, for example, the keratoco- Consultant (Avedro) providers on the importance of early nus is clearly progressing. diagnosis and treatment to give patients I also use sensitive diagnostics, such as the best chance for a good outcome. tomography and topography, to exam- ine the posterior cornea. I look at the Kathryn M. Hatch, MD: I completely pachymetry and the posterior float maps, KATHRYN M. HATCH, MD agree. Another key component of early which may show early signs of progres- n Director, Refractive Surgery Service, Massachusetts detection is having proper screening sion or corneal ectasia following refractive Eye and Ear; Site Director, tools and more widespread use of such surgery. Anything that I believe shows Massachusetts Eye and Ear, tools. Not all eye care providers have the disease is worse now than it was six Waltham, Massachusetts; Placido-based corneal topography, and months or a year ago is enough for me to Assistant Professor of they are even less likely to have tomog- document progressive keratoconus. Ophthalmology, Harvard raphy. We need to educate diagnos- Medical School, Boston ing providers, as well as pediatricians, Dr. Lindstrom: We also need to coun- n Financial disclosure: Consultant (Avedro) regarding early screening and detection sel patients on what outcome they can so they can refer patients early. Doctors expect from CXL. How are you doing who will monitor and manage keratoco- this in your practice? nus patients, most likely cornea-trained ophthalmologists, will have these tech- Dr. Ayres: I tell patients the best I can RICHARD L. LINDSTROM, MD nologies in their practices. Other eye care do right now is maintain the status quo. n Founder and Attending professionals need to understand the I explain the goal of this treatment is Surgeon, Minnesota Eye Consultants, Minneapolis, importance of screening and sending to to prevent progression, so they will not Minnesota corneal specialists early, so patients can need more invasive surgery such as a n Financial disclosure: have the proper intervention. corneal transplant in the future. Consultant (Avedro) DEFINING PROGRESSIVE KERATOCONUS Dr. Lindstrom: That usually means Dr. Lindstrom: CXL is approved patients will resume wearing eyeglasses for treating progressive keratoconus, or contact lenses, whatever type of RAJESH K. RAJPAL, MD but the FDA did not define that term. vision correction they wore before the n Founder, See Clearly Vision Dr. Ayres, how do you determine if a procedure, and they will return to their Group Tysons Corner, Virginia patient has progressive keratoconus? diagnosing provider for long-term care. n Financial disclosure: Chief Medical Officer, Avedro Brandon D. Ayres, MD: Identifying Dr. Ayres: Exactly. I tell patients we take progressive keratoconus is extremely a team approach. I do my best to stop this important. We do not want to delay process from worsening by performing treatment until the cornea becomes too the CXL procedure, and their diagnosing Photrexa and KXL are registered trademarks of Avedro. thin to cross-link. provider will optimize their vision. MA-01199A NOVEMBER/DECEMBER 2018 | INSERT TO CATARACT & REFRACTIVE SURGERY TODAY 1 MINIMUM CORNEAL THICKNESS Dr. Lindstrom: In most communities, Rajesh K. Rajpal, MD: Because some corneal surgeons have the equipment for corneal thinning may occur during CXL, and we are cooperatively managing the Photrexa Viscous loading phase, patients with other diagnosing physi- pachymetry is measured prior to initia- cians. Our job is to educate them regard- tion of UV light.1 What is your process ing which patients they should refer to for using Photrexa to thicken the cornea? us and what we will be doing. Dr. Ayres, how do you do this in your practice? Dr. Ayres: The cornea should be 400 microns before you turn on the Dr. Ayres: Patients used to be sent KXL UV light, and you can expect some to us when they had progressed to the thinning during the Photrexa Viscous point of needing a corneal transplant. portion of the procedure. Photrexa is We need to change that mindset among used to thicken the cornea to reach the eye care providers in the community. minimum thickness, and it is instilled We are working to spread the word that at 5- to 10-second intervals until the we want to see their patients early to corneal thickness increases to at least track progression because we now have 400 microns. We allow patients to close Corneal cross-linking procedure. an FDA-approved procedure for pro- their eyes between Photrexa drops to gressive keratoconus and corneal ectasia facilitate this thickening. their eyes, their disease can progress in following refractive surgery. Our mes- spite of the treatment. CXL is not a cure sage is: “We want to see your patients CLINICAL PEARLS for the condition, and therefore, contin- when keratoconus is first diagnosed, not Dr. Rajpal: Please share some clinical ued monitoring is required. after you have tried multiple contact pearls related to the healing process and/ lenses and you think the patient might or additional postoperative considerations. CO-MANAGEMENT WITH DIAGNOSING need a corneal transplant.” PROVIDERS We are having more success get- Dr. Lindstrom: The critical issue is to Dr. Rajpal: What do you tell your ting CXL covered by insurance, so it promote re-epithelialization, which usu- patients to expect following the CXL pro- is no longer a financial issue for most ally requires lubricants, a bandage con- cedure, specifically about their relation- patients. We want to see them early, tact lens, and careful follow up. ship with their primary eye care provider? treat them, and send them back to their diagnosing physician for the Dr. Hatch: Haze is a normal healing Dr. Hatch: I tell patients they will con- remainder of their refractive treatment. response of the cornea and is expected. tinue to see their primary eye care pro- CXL has changed the algorithm that we It does fade with time. viders as before, but during the first two use for eye care providers in the com- Also, we know patients with kerato- weeks after CXL, they will see me. This is munity and specialty practices in treat- conus are often excessive eye rubbers. assuming the eye care provider is com- ing progressive keratoconus. n We should talk with them about this fortable monitoring the condition. Once 1. Rosenblat E, Hersh PS. Intraoperative corneal thickness change and clinical out- habit and suggest antihistamine therapy the eye is healed, typically six weeks to comes after corneal collagen crosslinking: Standard crosslinking versus hypotonic to help alleviate the itch. I explain to three months after CXL, I send patients riboflavin. J Cataract Refract Surg. 2016;42(4):596-605. patients that we can perform the CXL back to their optometrists for contact procedure, but if they continue to rub lens fitting or spectacle correction. IMPORTANT SAFETY INFORMATION INDICATIONS PHOTREXA® VISCOUS (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa® (riboflavin 5’-phosphate ophthalmic solution) are indicated for use with the KXL System in corneal collagen cross-linking (CXL) for the treatment of progressive keratoconus and corneal ectasia following refractive surgery. LIMITATIONS OF USE The safety and effectiveness of CXL has not been established in pregnant women, women who are breastfeeding, patients who are less than 14 years of age and patients 65 years of age or older. Photrexa Viscous and Photrexa should be used with the KXL System only. WARNINGS AND PRECAUTIONS Ulcerative keratitis can occur. Patients should be monitored for resolution of epithelial defects. ADVERSE REACTIONS In progressive keratoconus patients, the most common ocular adverse reactions in any CXL treated eye were corneal opacity (haze), punctate keratitis, corneal striae, corneal epithelium defect, eye pain, reduced visual acuity, and blurred vision. In corneal ectasia patients, the most common ocular adverse reactions were corneal opacity (haze), corneal epithelium defect, corneal striae, dry eye, eye pain, punctate keratitis, photophobia, reduced visual acuity, and blurred vision. These are not all of the side effects of Photrexa® Viscous, Photrexa® and the CXL treatment. For more information, see Prescribing Information (http://avedro.com/wp-content/uploads/ML-00043B.pdf). You may report an adverse event to Avedro by calling 1-844-528-3376, Option 1 or you may contact the U.S. Food and Drug Administration (FDA) directly at 1-800-FDA-1088. 2 INSERT TO CATARACT & REFRACTIVE SURGERY TODAY | NOVEMBER/DECEMBER 2018 MA-01199A.
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