CXL Eyes Stable After 10 Years

in Review News commentary and perspectives

phthalmologists at University Hospital in Dres-

den, Germany, have reported long-lasting effec-

tiveness of corneal collagen cross-linking (CXL)

in halting progression of keratoconus.1 ENDURING EFFECT. Researchers in Germany found that the O treatment effect of CXL in eyes with keratoconus persisted Treatment benefits. CXL alternative to more costly for at least 10 years. significantly reduced the and complex corneal trans- maximum and minimum plantation. (At time of press, evidence of disease progres- keratoconus patients (34 corneal curvatures, as well CXL was not approved in sion, Dr. Raiskup said. eyes), with a mean age of as the curvature at the apex, the United States, but an Additionally, to prevent 28.4 years. Preoperatively, in eyes with progressive ker- FDA ruling on one system damage to the corneal en- five eyes (14.7 percent) were atoconus. These benefits en- was expected in March.) dothelium, central corneal in an advanced stage of dured in most eyes after 10 In CXL, the corneal stro- thickness should be at least keratoconus, showing cor- years. “Until now, nobody ma is exposed to riboflavin 400 µm after removal of the neal scarring; nevertheless,

knew how long the positive (vitamin B2) and ultravio- epithelium during the treat- all eyes still had good cor- effect of the CXL procedure let light, and the ensuing ment. In this study, in which rected distance visual acuity would last,” said lead author photochemical reaction mean corneal thickness was (CDVA). Frederik Raiskup, MD, PhD, strengthens and stabilizes 488 µm, no clinical signs of Among the statistically FEBO. corneal stromal collagen endothelial decompensation significant results at 10 years Although keratoplasty fibers. were apparent, and endo- compared with baseline: remains the definitive treat- Indications and cautions. thelial cell counts remained • The mean apical kera- ment for advanced kerato- CXL is indicated for kera- constant. tometry value decreased conus, this study adds to a toconus patients who have Significant study find- from 61.5 D to 55.3 D. body of literature suggesting visual acuity “that allows ings. The retrospective • Mean astigmatism was that CXL is a promising, good functioning in daily interventional case series reduced from 5.7 D to 4.0 D.

frederik raiskup, md, phd, febo less invasive therapeutic life” and also have solid involved 24 progressive • Mean CDVA improved

eyenet 17 News in Review from 0.40 to 0.26 logMAR; baseline, these two eyes had The anterior stroma in 13 Given this natural stiff- this outcome was attributed maximum K values higher eyes showed a persistent ening process, in combina- to a reduction in astigma- than 58 D and thinner haze at 10 years, but it did tion with effective CXL tism and corneal distortion corneas, which the authors not affect the CDVA. therapy that “overlaps” the and to a better fit of hard believe predisposed them to The benefit of aging. The very active stage of corneal contact lenses. further progression. In both enduring effect of CXL was ectasia, the probability is Retreatment is possible. cases, retreatment stabilized something of a surprise, high that the majority of If progression of ectasia progression and did not cre- Dr. Raiskup said. It may be suitable candidates will resumes, CXL can be re- ate additional side effects attributable, in part, to the remain stable after the first peated, as long as CDVA is compared with the initial natural stiffening of the cor- treatment, Dr. Raiskup said. still good, said Dr. Raiskup. treatment. nea that occurs over time. —Miriam Karmel In this study, two eyes need- Complications. No seri- “There is an ongoing ‘cross- ed retreatment—one after ous complications occurred, linking’ process in all of the 1 Raiskup F et al. J Cataract Re- five years, the other after although one eye developed tissues in our body,” he said. fract Surg. 2015;41(1):41-46. 10—due to increases in the a permanent stromal cor- “With age, collagen in the K value following a period neal scar that limited visual ectatic cornea will become Dr. Raiskup reports no related of long-term stability. At acuity following treatment. naturally stiffer.” financial interest.

Surgical News Cataract Wound Leaks: Sealant vs. Sutures

prospective random- a cataract surgeon in Los ized study of 500 Angeles. The type of wound Aeyes at 24 sites has construction will determine found that a hydrogel seal- the surgical course. ant (ReSure) was signifi- He noted that previous cantly better than sutures in investigations revealed that stopping leakage following a paracentesis-type incision clear corneal incision (CCI) without a groove is most cataract surgery.1 Patients likely to leak. That common who were found to have type of wound construc- wound leaks, either spon- tion—single-plane CCI of taneous or with application 3.5 mm or less—was used UNDER PRESSURE. Drawing shows egress of fluid from cor- of calibrated pressure, after for all eyes in this study. neal incision on pressure from the calibrated force gauge. uneventful surgery were The sealant’s value is in randomized to receive either covering and hermetically large proportion of inci- are a concern,” he said. sealant or sutures. At follow- sealing the incision in the sions—488 of the overall “Surgeons should take the up visits, leakage occurred postoperative period while 500, or 97.6 percent—that opportunity to carefully with pressure provocation the epithelium is healing, initially leaked, either spon- test the incision. And don’t in 12 of 295 eyes of the Dr. Masket said. “While taneously or with provoca- leave the table with a leaking sealant group (4.1 percent) sealant cannot make up for tion equivalent to forced wound.” —Miriam Karmel versus 60 of 176 sutured eyes poor incision construction, blinking or eye touching. (34.1 percent). in this investigational model “This is a sobering piece of 1 Masket S et al. J Cataract A role for both. But it proved to be more effec- information that surgeons Refract Surg. 2014;40(12):2057- cataract surgeons should tive than sutures.” should heed,” Dr. Masket 2066. not abandon their needles. A high incidence of leak- said. “Sealant and sutures each age. Though the research- Key takeaways. “Incision Dr. Masket is a consultant to, play a different role,” said ers anticipated leakage, construction definitely mat- shareholder of, and medical mon-

author Samuel Masket, MD, they were surprised by the ters, and leaking wounds itor for Ocular Therapeutix. samuel masket, md

18 april 2015 News in Review

Glaucoma Risk Factors Meta-analysis Confirms Diabetes-Glaucoma Link

lthough diabetes has Most robust association. long been proposed Longer duration of diabetes Aas a risk factor for was consistently associated glaucoma, epidemiologic with higher risk of glau- studies have yielded incon- coma across cross-sectional, sistent results, making the case-control, and longi- RISK OVER TIME. Graph shows the relative risk for glaucoma association controversial. tudinal studies and was with increasing duration of diabetes in a dose-response Over the past decade, there independent of age, race, meta-analysis. Circle areas are inversely proportional to has been no systematic re- gender, and other confound- the variance of the log relative risks. The pooled linear risk view of the literature on the ers controlled in the original trend (thick solid line) and its 95 percent confidence band correlation between diabetes studies. Patients with longer (shaded region) were obtained using a random-effects dose- and glaucoma or between duration of diabetes par- response meta-analysis. glaucoma risk and other ticularly need to be aware of metabolic abnormalities. the importance of glaucoma dividuals from 16 countries. glaucoma has an important This gap has recently screening and management, Other strengths include the clinical impact. been filled by Myung Hun according to the authors. evaluation of multiple dia- Areas for future research. Kim, MD, at Saevit Eye Authors’ perspective. betes-related exposures and Dr. Kim said that additional Hospital in Goyang, Korea, “We were not surprised to glaucoma-related outcomes, longitudinal studies are and his colleagues, who find an association between as well as the inclusion of needed. In particular, the conducted an updated sys- diabetes and the risk of prospective studies. Dr. Kim authors noted a scarcity of tematic review and meta- glaucoma,” said Dr. Kim, noted that prospective stud- studies on the relationship analysis. They found that “but we were somewhat ies are important in provid- between glaucoma and glu- diabetes, duration of dia- surprised by the degree of ing estimates of incidence cose biomarkers, prediabe- betes, and fasting glucose heterogeneity of the associa- and temporal trends and tes, and metabolic syndrome levels were associated with tions and the variability be- helping to establish the tem- and its components. Given a significantly higher risk of tween studies. We were reas- poral sequence required for the high prevalence of these primary open-angle glau- sured that even longitudinal causal inference. metabolic abnormalities, coma and that diabetes and studies, which are less prone The main weakness of the authors recommended fasting glucose levels were to bias than cross-sectional the meta-analysis was the that future research evalu- associated with slightly in- or case-control studies, substantial variation in the ate the association between creased levels of intraocular found positive associations. methods and quality of the altered glucose metabolism pressure (IOP).1 “However, since patients original studies. “This likely and glaucoma risk.1 Proposed mechanisms. with diabetes are more like- contributed to the high de- “Once the association is The mechanisms relating ly to be in contact with eye gree of heterogeneity in the clearly understood, specific diabetes to glaucoma are care providers, diagnostic results,” Dr. Kim said. guidelines for glaucoma not clear. Various studies bias is still an issue that will Clinical implications. screening and management have suggested that diabetes require additional research. The results support the rec- in patients with diabetes can causes microvascular dam- That said, the associations ommendation that patients be developed,” said Dr. Kim. age and vascular dysregula- seen in our study were from with diabetes be referred to —Gabrielle Weiner tion of the retina and the population-based preva- ophthalmologists to check optic disc, increasing the lence studies, which should for glaucoma. “In addition 1 Zhao D et al. Ophthalmology. susceptibility of the optic remove this bias.” to diabetic retinopathy, pa- 2015;122(1):72-78. nerve head to glaucoma- Strengths and weak- tients with diabetes should 2 Nakamura M et al. Ophthal- tous damage. Diabetes also nesses. A notable strength also receive education about mologica. 2005;219(1):1-10. may disrupt the trabecular of this meta-analysis is the glaucoma,” said Dr. Kim. He meshwork function, thereby large sample size: 47 studies added that the coexistence Dr. Kim reports no relevant fi- 2 zhao d et al. ophthalmology. 2015;122(1):72-78. elevating IOP. that included 2,981,342 in- of diabetic retinopathy and nancial interests.

eyenet 19 News in Review

HIV in Children acuity (mean best-corrected visual acuity, 20/22). Unanswered questions. Early HAART Tx May Spare In an unexpected result, “We did find that 18 percent of these patients had strabis- Youth From Ocular Disease mus, which is higher than the general U.S. prevalence,” said Dr. Rutar. “Also, we recent study reports leagues found that when the study was performed. noted that, worldwide, the some good news for HAART treatment results The researchers exam- visual health of millions of Ayoung patients with in long-term survival in ined 22 patients, treated at children with perinatally perinatally acquired HIV: these patients, most are the UCSF pediatric HIV acquired HIV is likely to be Those who receive highly likely to avoid cytomegalo- clinic, who had survived to impacted by whether they active antiretroviral therapy virus (CMV) retinitis, HIV age 12 years or older (range, receive early, intensive treat- (HAART) and survive into retinopathy, and keratocon- 12-23 years) to determine ment that enables long-term adolescence may avoid the junctivitis sicca into their whether they had ophthal- survival. Both questions ocular diseases typically teen years and possibly be- mic manifestations of HIV. warrant further study.” found in adults with chronic yond. Dr. Rutar is a pediat- All but one of the patients —Mary Wade HIV.1 In the United States, ric ophthalmologist with the had a CD4 count of at least most children affected Cataract and Laser Institute, 200 cells/µL, and five had 1 Rutar T et al. Br J Ophthalmol. by perinatal HIV receive Medford, Ore.; at the time an AIDS-defining illness. 2014 Nov. 21. [Epub ahead of HAART; this has been the of the study, she was associ- Surprisingly, the research- print.] doi:10.1136/bjophthal care standard since 1999. ate professor of ophthalmol- ers found no CMV retinitis mol-2014-305557. Eye findings in young ogy and pediatrics at the or HIV retinopathy, little HIV patients. The study by University of California, San vision-threatening disease, Dr. Rutar reports no related fi- Tina Rutar, MD, and col- Francisco (UCSF), where and generally good visual nancial interests.

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