Global Consensus on Keratoconus

in Review News commentary and perspectives

t took the participation of cornea specialists from 21

countries; multiple rounds of Delphi-style questions,

responses, and revisions; and face-to-face discussions. IWhat emerged from that complex international project was worth the effort: a glob- cians.” Here are some of the al consensus on keratoconus highlights of the consensus (KC) and ectatic diseases.1 document. Christopher J. Rapuano, To manage KC, first DUAL SCHEIMPFLUG. Imaging shows KC features, such as define it. MD, said that the idea was In order to deter- inferocentral anterior corneal steepening (top left) and infe- talked about at meetings for mine what interventions are rocentral posterior elevation (bottom right). years, but he credits José A. effective—and when they P. Gomes, MD, PhD, in São should be attempted—the ence tomography, which history, connective tissue Paulo, Brazil, for putting the condition and its progres- can detect posterior corneal disorders, ocular allergy, talk into action. “He real- sion must be consistently abnormalities. Indeed, the and mechanical factors such ized that there’s a discon- defined. panel agreed that the man- as eye rubbing and floppy nect between what’s in the Moderate to severe KC datory findings for KC diag- eyelid syndrome. literature and what people is easy to diagnose, said Dr. nosis include posterior cor- Treatment algorithm. are doing, not only in South Rapuano: “You can see it neal elevation abnormalities, The group developed a America, but around the at the slit lamp; you don’t in addition to abnormal dis- treatment flowchart that world,” said Dr. Rapuano, even need topography.” But tribution of corneal thick- proceeds from nonsurgical who is chief of the cornea recognizing mild, subclini- ness and noninflammatory steps through corneal trans- service at Wills Eye Hos- cal disease depends on more corneal thinning. plant surgery, as needed. pital. “The idea was to as- recently developed technolo- The panel also identified Dr. Rapuano noted that, in similate all this information gies, such as Scheimpflug risk factors for KC, includ- this schema, the progression

christopher rapuano, j. md and make it useful to clini- imaging or optical coher- ing Down syndrome, family to more invasive therapy

eyenet 17 News in Review is based on whether the nea specialists around the rior lamellar keratoplasty Consideration of CXL ap- patient can achieve satisfac- world, that eye rubbing is an (ALK), especially deep ALK, pears early in the treatment tory vision. “One important important component of ei- (DALK), and penetrating flowchart and is sometimes point was that even though ther causing keratoconus or keratoplasty are the most used together with other a patient can see 20/30 in making it worse. But I think commonly performed sur- therapies for KC. “Out in your office with a contact that message is not fully geries for KC. Some type of the rest of the world, it’s lens, it’s not necessarily appreciated by the general ALK is now attempted in a standard treatment for satisfactory BCVA. If the ophthalmology commu- more than 60 percent of KC patients with keratoconus,” patient can’t tolerate the lens nity,” said Dr. Rapuano. patients eligible for surgery. said Dr. Rapuano, “even for more than an hour, sur- The second is to pre- Role of cross-linking. before documented progres- gery may be indicated.” scribe topical antiallergy Although corneal cross- sion, if they are deemed to An underappreciated medications and lubricants linking (CXL) is not FDA be at high risk for progres- recommendation. Two for patients with allergies, approved in the United sion.” —Peggy Denny nonsurgical measures were he said, because allergic States, it is available to and graded as “most important.” itching promotes eye rub- performed by almost 85 1 Gomes JA et al. Cornea. 2015; The first is deceptively bing and, thus, contributes percent of the panelists, 34(4):359-369. simple: Counsel the patient to KC progression. who rated it “extremely im- to avoid eye rubbing. “I feel Surgical choices. The portant” for patients of any Dr. Rapuano reports no related strongly, as do many cor- group found that ante- age who have progression. financial interests.

Intravitreal Injections that the technique is easy to learn, but implementing it depends on having a Bimanual Lid Retraction trained technician available to lend a hand—or, in this case, both hands. At Wills, Is a Comfortable Choice the technician in charge of prepping the patient for IVT injection is the one who per- s the number of in- Atlantic Retina, a number forms the lid retraction. travitreal (IVT) in- of patients informally ex- Dr. Chiang sees this in jections has skyrock- pressed their discontent- the context of ongoing “tin- A SPECULUM ALTERNATIVE. eted over the past decade, ment with the speculum, kering” in the retina com- With this bimanual tech- the retina community has “so we set out to analyze munity in developing nu- nique, care should be taken continued to refine injec- their experience more for- ances in the IVT injection to avoid pressure on the tion protocols to increase mally.” procedure. “While this may globe or eyelid glands. safety and efficiency and Eye-to-eye comparison. not be a huge game-chang- reduce treatment burden on In this prospective study survey immediately after er,” he said, “we wanted to patients. A group of retina of 36 patients (72 eyes) both injections, and had show an alternative method specialists at Wills Eye Hos- undergoing bilateral IVT a telephone interview two of retraction that allows one pital recently reported on an injections, 22 patients re- hours later. The responses less manipulation with a eyelid retraction technique ceived an injection in the bore out earlier anecdotal foreign object and that was that appears to increase pa- first eye with use of the observations: 30 patients preferred by patients in this tient comfort without com- speculum, while the other (83.3 percent) preferred bi- study with regard to pain promising safety.1 14 had bimanual retraction manual retraction, six had and discomfort.” Genesis of study. An ear- for the first-eye injection. no preference (16.7 percent), —Peggy Denny lier study had described this The retraction technique and none preferred the spec- bimanual technique of lid was switched for the second ulum. Each patient served as 1 Rahimy E et al. Ophthalmol- retraction and also observed eye. All other aspects of his or her own comparator, ogy. 2015 Feb. 26. [Epub ahead that it was not associated the procedure—including thus avoiding the problem of print.] with an increased endoph antisepsis with povidone- of differing levels of pain 2 Fineman MS et al. Retina. thalmitis rate.2 According iodine and use of topical perception between indi- 2013;33(9):1968-1970. to Allen Chiang, MD, an anesthetic—were identical viduals. attending retina surgeon at for both eyes. Implementing the tech- Dr. Chiang reports no related

Wills Eye Hospital and Mid Patients completed a pain nique. Dr. Chiang noted financial interests. rahimy e et al. ophthalmology. 2015.

18 june 2015 News in Review

Cataract Surgery Prophylaxis tracameral cefuroxime. tect against endophthalmi- “Patients not receiving in- tis, and yet this is the only tracameral antibiotics have antibiotic administration More Strong Evidence for nearly six times the risk of used by most surgeons. The endophthalmitis compared rate of endophthalmitis in with patients who receive the USA is twice of that in Intracameral Antibiotics intracameral antibiotics,” Europe,” said Dr. Kessel. said coauthor Line Kessel, A possible substitute. If MD, PhD, FEBO, an oph- cefuroxime is not an op- nce more, and with at the end of surgery might thalmologist and researcher tion, she recommended that compelling statisti- prevent 0 to 1 case of en at Copenhagen University surgeons use intracameral Ocal significance dophthalmitis per 1,000 Hospital Glostrup, in Glos- moxifloxacin instead of (p < .00001), a research cataract surgeries. trup, Denmark. a topical antibiotic, even study has concluded that Danish public health “In our study, we found though evidence for the ef- intracameral cefuroxime initiative. Working on be- that the rate of endophthal- fectiveness of this substitu- markedly reduces the inci- half of Denmark’s public mitis was 1 out of 485 sur- tion is limited. dence of endophthalmitis health authority, the authors geries when intracameral “The difference between after cataract surgery.1 This reviewed endophthalmitis antibiotics were not used, the effectiveness of moxi- systematic review of a de- studies published during compared with 1 out of floxacin and cefuroxime cade of published studies a 10-year period ending 2,855 when intracameral appears to be much smaller also looked at the effective- in 2014. The researchers antibiotics were used.” than the difference between ness of two other prophylac- analyzed outcomes from But the review contained no intracameral antibiotics tic antibiotic regimens. randomized clinical trials of little comfort for surgeons and cefuroxime,” Dr. Kessel • Topical antibiotics: There intracameral cefuroxime, as in the United States and said. —Linda Roach is no evidence they are ef- well as relevant nonrandom- other countries where, in fective for this use, the re- ized studies of antibiotic use the absence of a commer- 1 Kessel L et al. Acta Ophthal- searchers concluded. in cataract surgery. cially available cefuroxime mol. 2015 March 16. [Epub • Intracameral moxifloxa- Contrasting rates of product, topicals remain ahead of print.] cin: They found low-quality endophthalmitis. The re widely used. evidence that intracameral view bolstered the evidence “There is no evidence Dr. Kessel reports no related fi- injection of moxifloxacin supporting the use of in- that topical antibiotics pro- nancial interests.

Glaucoma Risk Factors and temporal short poste- mology at Indiana Univer- rior ciliary arteries sity School of Medicine. • End diastolic velocity in “Look beyond their eye Ancestral Lineage Linked the central retinal artery and see if you can consider Further research is need their whole health and per- ed to determine what role sonal profile. A ‘sick body’ To Ocular Blood Flow these differences might play elevates the risk of a ‘sick in glaucoma progression. eye’ and vice versa, while study of retrobul- were identified in all retro- Focus on the person a ‘healthy body’ may help bar circulation in bulbar blood vessels in OAG first. Meanwhile, regardless maintain a ‘healthy eye,” Dr. Apatients with open- patients of African descent of ancestry, OAG patients Harris said. —Linda Roach angle glaucoma (OAG) has compared with those of should be treated foremost found differences suggest- European descent, despite as individuals, “each with 1 Siesky B et al. J Glaucoma. ing lower blood flow as a similar IOP and visual field a unique set of risk pro- 2015;24(2):117-121. possible reason for greater parameters between the files to consider,” said the disease severity and faster groups.1 study’s senior author, Alon Dr. Harris has received lecture progression in patients of Color Doppler ultra- Harris, MS, PhD, FARVO. fees from Alcon and MSD; is a African descent. sound revealed lower mean Dr. Harris is professor of consultant for Biolight, Isarna Ethnic differences in values among patients of ophthalmology and cellular Therapeutics, Merck, Nano- blood flow. Researchers African descent in: and integrative physiology, retina, ONO Pharmaceuticals, from Indiana University • Peak systolic velocity of director of clinical ophthal- Pharmalight, and Sucampo; and reported that significantly blood in the ophthalmic, mic research, and Letzer has equity interest in Adom and lower blood flow values central retinal, and nasal Endowed Chair in Ophthal- Oxymap.

eyenet 19