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ii Planning Group 2017 Subspecialty Day | Cornea
CME vi
Presenter Index 54
vi CME 2017 Subspecialty Day | Cornea
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viii Faculty Listing 2017 Subspecialty Day | Cornea
Faculty
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■ Access at www.aao.org/mobile
Saturday, Nov. 11
7:00 AM CONTINENTAL BREAKFAST
8:00 AM Welcome and Introductions Bennie H Jeng MD*
Carol L Karp MD
Jennifer Y Li MD
* Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest.
xiv Program Schedule 2017 Subspecialty Day | Cornea
* Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest.
2017 Subspecialty Day | Cornea Program Schedule xv
* Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest.
2017 Subspecialty Day | Cornea Section I: Corneal Infections—Old Bugs, New Drugs 1
Bacterial Keratitis:
Are Fortified Antibiotics Still Necessary?
Shahzad I Mian MD
NOTES
2 Section I: Corneal Infections—Old Bugs, New Drugs 2017 Subspecialty Day | Cornea
Acanthamoeba is an organism widely dispersed naturally in ment of AK has not been standardized and can vary between
water and soil. Acanthamoeba keratitis (AK) is considered one different specialized outpatient services. The use of antimicro-
of the most difficult infections to diagnose and treat. The prog- bial drops for AK treatment depends on previous authorization
nosis is related to the precision of the clinical laboratory diagno- and certification by the health regulatory agency regarding the
sis and precocity of the treatment. marketing of medicines in each country. Basically, 2 classes of
drugs are used: biguanides and diamidines. Among the bigu-
anides, polyhexamethylene biguanide (PHMB) is used in con-
Clinical Features
centrations ranging from 0.02% to 0.06%; and chlorhexidine,
Patients with AK present with a chronic history of mild keratitis in concentrations ranging from 0.02% to 0.2%, depending on
with nonspecific symptoms of intolerance to contact lens (CL) the response. Among the diamidines, propamidine isethionate
use. Left undiagnosed, the condition can progress to red eye, (Brolene) and hexamidine diisethionate (Désomédine) are used
photophobia, tearing, and usually pain that is disproportionate at a concentration of 0.1%. The primary therapeutic profile for
to the clinical findings, although some patients do not report AK includes topical antimicrobial eye drops hourly around the
pain. The biomicroscopic signs include limbitis; dotted and clock, generally for 2 days according to toxicity, with gradual
dendritic keratitis; perineural infiltrates; epithelial defects; and reduction as the symptoms and clinical signs improve. The
corneal thinning, which can evolve to nonspecific perforation treatment time can vary from case to case (average duration:
and nonspecific or ring-shaped stromal infiltrates and uveitis 4-6 months). The tissue chemical toxicity caused by continu-
with varying degrees of severity, with or without hypopyon. ous use of antimicrobial drops should be evaluated frequently
Nonspecific mydriasis and cataract and glaucoma syndrome throughout treatment. If necessary, the medication can be
can be observed in severe and advanced cases. Acanthamoeba reduced or stopped for a certain period until the tissue toxicity
coinfection, mainly infectious crystalline keratopathy, has been abates. The USFDA recently approved topical miltefosine for
described in the literature. treating AK in the United States.
Therapeutic / tectonic corneal transplantation is indicated
only in cases of refractory AK, which is characterized by persis-
Diagnosis
tent positive cultures; in difficult-to-control abscesses; in per-
The clinical diagnosis of AK is confirmed through complemen- forations that cannot be managed with adhesive tissue; and in
tary laboratory tests such as culture (the gold standard); direct cases of mydriasis, cataracts, and glaucoma, in which combined
examination; and molecular biology analysis, such as poly- corneal transplantation, lens extraction, IOL implantation, and
merase chain reaction (PCR), confocal microscopy, and histo- iridoplasty might prevent development of secondary glaucoma
pathology. Culturing is performed using non-nutrient agar and/ refractory to treatment. Anterior lamellar keratoplasty should
or soy agar supplemented with Escherichia coli avirulent as a be performed with caution, since the protozoa tend to reach
nutrition source for protozoan proliferation. In the direct exam- the deep corneal layers. Different studies have shown that the
ination, the Acanthamoeba species cysts on the slide containing corneal crosslinking technique using riboflavin associated with
the smear of the clinical sample can be visualized using different application of ultraviolet-A light is ineffective for treating AK.
staining methods, with fluorescent dye calcofluor white being
the most suitable for microscopic analysis of specific structures,
Prevention
such as cyst size, pleomorphism, and morphology. Other pos-
sible dyes are Giemsa and Acridine orange. PCR generally has Prevention is essential because the disease has great potential to
high sensitivity (> 80%) and specificity (100%). Histology iden- cause marked visual acuity loss and blindness. Patients should
tifies with reasonable ease the protozoa in the cystic form that be instructed to always wash and dry their hands thoroughly
is characterized by rounded, pleomorphic structures. From the before handling the CL. A multipurpose cleaning and disinfect-
specific characteristics of the cellular refraction of the proto- ing solution should not be “topped-off” or reused in the CL
zoa, confocal microscopy allows observation of the cystic form case. The CL case should be washed daily with the multipur-
and also the keratoneuritis pattern associated with infection. pose solution, not tap water. The CL should not be exposed
Depending on the clinical picture, apparatus, and observer, to nonsterile solutions or water from the faucet, pool, pond,
confocal microscopy might facilitate significant sensitivity and bathtub, shower, or sauna, among others. The CL should be
specificity. rubbed for at least 15 seconds before and after use, because this
increases the effectiveness of cleaning and disinfection. The
CL and CL solutions should not be used beyond the expiration
Treatment
date; expired solutions should be discarded. If symptoms or
Early treatment, preferably within 2 to 3 weeks of the onset of signs of eye irritation occur, the CLs should be removed imme-
symptoms and signs, is mandatory for a better disease prog- diately from both eyes and emergency medical attention sought.
nosis. The trophozoites are sensitive to most chemotherapeutic
agents; however, the cysts have greater resistance. The treat-
2017 Subspecialty Day | Cornea Section I: Corneal Infections—Old Bugs, New Drugs 5
Selected Readings
1. Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diag-
nosis and treatment update 2009. Am J Ophthalmol. 2009;
148(4):487-499.e2.
2. Alkharashi M, Lindsley K, Law HA, Sikder S. Medical inter-
ventions for Acanthamoeba keratitis. Cochrane Database
Systematic Reviews 2015, Issue 2. Art. No. CD010792. doi:
10.1002/14651858.CD010792.
3. Siddiqui R, Khan NA. Biology and pathogenesis of Acantham-
oeba. Parasit Vectors. 2012; 5:6.
4. Robaei D, Carnt N, Minassian DC, Dart JK. Therapeutic and
optical keratoplasty in the management of Acanthamoeba kera-
titis: risk factors, outcomes, and summary of the literature. Oph-
thalmology 2015; 122(1):17-24.
5. Tu EY, Joslin CE, Nijm LM, Feder RS, Jain S, Shoff ME. Polymi-
crobial keratitis: Acanthamoeba and infectious crystalline kera-
topathy. Am J Ophthalmol. 2009; 148(1):13-19.e2.
6. Polat ZA, Obwaller A, Vural A, Walochnik J. Efficacy of milt-
efosine for topical treatment of Acanthamoeba keratitis in Syrian
hamsters. Parasitol Res. 2012; 110(2):515-520.
6 Section I: Corneal Infections—Old Bugs, New Drugs 2017 Subspecialty Day | Cornea
3. Culture positivity after starting treatment is a 5. Ray KJ, Lalitha P, Prajna NV, et al. The utility of repeat culture
predictor of eventuating to TPK and may be used in fungal corneal ulcer management: a secondary analysis of the
as an early indicator of response to therapy.5 MUTT I Randomized Clinical Trial. Am J Ophthalmol. Epub
ahead of print 2017 Apr 03.
6. Tan DT, Janardhanan P, Zhou H, et al. Penetrating keratoplasty
in Asian eyes: the Singapore Corneal Transplant Study. Ophthal-
mology 2008; 115(6):975-982 e971.
C ase
Background Discussion
Keratitis or ophthalmia nodosa is an entity attributed to expo- Ophthalmia nodosa was first described in 1906 as a reaction to
sure to the urticating hairs that cover the dorsal abdomen of the sensory setae of caterpillars. Most contemporary cases have
New World tarantula species, which are catapulted into the air been described in relation to tarantulas (Theraphosidae family),
by the arachnid as a protective mechanism when it is threat- which are popular household pets.
ened. The tarantula vibrates its hind legs across the dorsal The clinical course commonly begins with involvement of
abdomen, projecting the hairs into the surrounding air. The the skin and conjunctiva, followed by sometimes deep corneal
urticating hairs are sturdy, sharp-pointed shafts, 0.3-1.2 mm in stromal infiltrates and anterior chamber reaction.
length, and with reverse barbs. They are capable of penetrating
the skin, conjunctiva, and cornea. Hairs may be embedded in
the cornea either directly through the air or by transfer from the
surface of the fingers after contact with the spider or its enclo-
sure. Over time, the hairs with reverse barbs can migrate into
the deep cornea or anterior chamber. The corneal findings are
characteristic, and management consists of removing protrud-
ing hairs and controlling inflammation.
Case Presentation
■■ 17-year-old male, owner of a pet tarantula
■■ Negative past medical and ocular history
■■ History of present illness:
●● Two-week history of foreign body sensation
■■ Examination Tarantula hairs have been classified, and the Type III hair is
●● Diffuse conjunctival injection; no discharge sharp and barbed, facilitating its penetration and hindering its
●● Nummular stromal opacities extrusion or extraction. If possible, hairs should be removed.
However, the mainstay of therapy is topical corticosteroid.
Selected Readings
1. Hamill MB. Mechanical injury. In: Mannis M and Holland E,
eds. Cornea. Philadelphia: Elsevier; 2017:1100-1102.
2. Cooke J, Miller F, Grover R, et al. Urticaria caused by tarantula
hairs. Am J Trop Med Hyg. 1973; 22:130-133.
3. Chang PCT, Soong HK, Barnett JM. Corneal penetration by
Figure 1.
tarantula hairs [letter]. Br J Ophthalmol. 1991; 75(4): 253-254.
●● Anterior chamber: 2+ cell and flare 4. Watts P, Mcpherson R, Hawksworth N. Tarantula keratouveitis.
●● IOP = 17 mmHg Cornea 2000; 19(3):393-394.
●● Normal posterior segment
■■ Management
●● Topical corticosteroids
●● Follow-up observation
10 Section II: Keratoplasty—Are We Doing the Right Thing? 2017 Subspecialty Day | Cornea
Endothelial keratoplasty (EK) techniques have evolved rapidly Ultrathin DSAEK (UT-DSAEK) involves donor preparation
in recent years, and Descemet membrane endothelial kerato- with a deep microkeratome pass to produce donor grafts near to
plasty (DMEK) has gained in popularity.1 Recent studies sug- or less than 100 μm thick. A recent randomized controlled trial
gest that near anatomic replacement of endothelial tissue pro- demonstrated excellent results with UT-DSAEK that outper-
duces more rapid recovery and improved visual acuity results formed thicker DSAEK in visual acuity outcomes up to 1 year
with DMEK than with Descemet-stripping automated endo- after surgery, with no difference in endothelial cell densities or
thelial keratoplasty (DSAEK).2,3 Yet according to the Eye Bank graft dislocation.6 This procedure may have similar results to
Association of America, DMEK still accounted for only ~23% DMEK but without the technical difficulties.
of endothelial keratoplasties in the United States in 2016 (up A recent survey suggested that there is an interest among
from 15% in 2015), while DSAEK accounted for about 46% EK experts to understand UT-DSAEK’s role in current EK sur-
of all corneal transplants involving endothelial replacement, gery.12 We previously proposed a randomized controlled trial to
including penetrating keratoplasties.4 compare UT-DSAEK with DMEK.5 Randomized controlled tri-
Thus a majority of EK surgeries in the United States are still als are the gold standard in determining preferred surgical and
DSAEK. This is true for various reasons. Many surgeons have medical interventions and therefore are a necessary next step in
not yet adopted DMEK or are early on the DMEK learning the DMEK / DSEK literature.
curve. Experienced EK surgeons without fellowship training We have since completed enrollment in the 2-year DETECT
in DMEK may be reluctant to adopt the newer technique since (Descemet Endothelial Thickness Comparison Trial; Clinical-
they have excellent and reliable results with DSAEK. Donor Trials.gov identifier NCT02373137). DETECT is an interven-
preparation, increased intraoperative times, and problems tional, randomized, patient- / assessor-masked clinical trial.
with donor detachment in DMEK can create reluctance among We report here on the 6-month data of this trial in 50 eyes with
experienced DSAEK surgeons. In addition, many surgeons still either Fuchs dystrophy or bullous keratopathy that were treated
feel that DMEK is not applicable to all eyes that require EK, either with UT-DSAEK (graft thickness: 70-90 microns) or
including those that have undergone pars plana vitrectomy, tra- DMEK. The study has an 80% power to detect 1 line of differ-
beculectomy, or aqueous shunt devices or that have significant ence in BSCVA between the study groups with an alpha of 0.05.
anterior chamber abnormalities, such as peripheral anterior syn- The patient and the refracting technician are masked to the sur-
echiae, or iris loss. Even in routine cases of Fuchs dystrophy and gery type for a 2-year follow-up. Our primary outcome measure
bullous keratopathy, the complication rate, including iatrogenic is BCVA (ETDRS) at 6, 12, and 24 months. Secondary outcome
graft failure and graft detachments, is expected to be higher, at measures include endothelial cell loss, immunological rejection,
least on the surgeon’s learning curve, which could be anywhere graft thickness (pre- and postop), corneal higher-order aber-
from 20-75 cases.2,5 rations, interface haze / light scatter, NEI visual functioning
In my DMEK learning curve experience, there were signifi- questionnaire (NEI VFQ), and complications, including graft
cantly higher numbers of primary graft failures and successful detachments and rebubble rates. Other outcome measures will
grafts with low endothelial counts as compared to the contem- also be assessed.
poraneous DSAEK surgeries I was performing.5 Since many
U.S. surgeons are still on that learning curve, we may experi-
References
ence a higher range of iatrogenic graft failures in the United
States over the next several years. 1. Price FW, Price MO. Evolution of endothelial keratoplasty. Cor-
However, DMEK may produce better outcomes. There are nea 2013; 32(suppl 1):S28-32.
3 potential mechanisms by which DMEK may provide better 2. Phillips PM, Phillips LJ, Muthappan V, Maloney CM, Carver
visual acuity outcomes than DSAEK: graft thickness,6,7 inter- CN. Experienced DSAEK surgeon’s transition to DMEK: out-
face haze,8 and corneal higher-order aberrations.9 Graft thick- comes comparing the last 100 DSAEK surgeries with the first
ness has been correlated with BSCVA outcomes among thinner 100 DMEK surgeries exclusively using previously published tech-
grafts. One retrospective case series found that 71% of thin niques. Cornea 2017; 36(3):275-279.
endothelial grafts (defined as < 131 μm) had BSCVA of 20/25 3. Droutsas K, Lazaridis A, Papaconstantinou D, et al. Visual out-
or better, while only 50% of thick grafts (defined as ≥ 131 μm) comes after Descemet membrane endothelial keratoplasty versus
achieved this.7 In addition, higher-order aberrations, in particu- Descemet stripping automated endothelial keratoplasty: compari-
lar of the posterior cornea, are increased after DSAEK.9 Theo- son of specific matched pairs. Cornea 2016; 35(6):765-771.
retically, given the decreased tissue thickness transplanted after 4. Eye Bank Association of America. 2016 Eye Banking Statistical
DMEK, this would be lessened; however, 1 retrospective series Report. Washington, DC: Eye Bank Association of America; 2016.
looking at higher-order aberrations in DMEK compared with
5. Rose-Nussbaumer J, Alloju S, Chamberlain W. Clinical outcomes
DSAEK found no difference in posterior aberrations between
of Descemet membrane endothelial keratoplasty during the sur-
the 2 groups.10 Finally, interface haze may be increased in geon learning curve versus Descemet stripping endothelial kerato-
DSAEK and has been correlated with BSCVA.11 plasty performed at the same time. J Clin Exp Ophthalmol. 2016;
7(5):599.
2017 Subspecialty Day | Cornea Section II: Keratoplasty—Are We Doing the Right Thing? 11
6. Dickman MM, Kruit PJ, Remeijer L, et al. A randomized mul- 10. Maier AK, Gundlach E, Gonnermann J, et al. Retrospective
ticenter clinical trial of ultrathin Descemet stripping automated contralateral study comparing Descemet membrane endothelial
endothelial keratoplasty (DSAEK) versus DSAEK. Ophthalmol- keratoplasty with Descemet stripping automated endothelial kera-
ogy 2016; 123(11):2276-2284. toplasty. Eye (Lond). 2015; 29(3):327-332.
7. Neff KD, Biber JM, Holland EJ. Comparison of central corneal 11. Mencucci R, Favuzza E, Tartaro R, Busin M, Virgili G. Descemet
graft thickness to visual acuity outcomes in endothelial kerato- stripping automated endothelial keratoplasty in Fuchs’ corneal
plasty. Cornea 2011; 30:388-391. endothelial dystrophy: anterior segment optical coherence tomog-
raphy and in vivo confocal microscopy analysis. BMC Ophthal-
8. Kobayashi A, Yokogawa H, Yamazaki N, Masaki T, Sugiyama
mol. 2015; 15:99.
K. In vivo laser confocal microscopy after Descemet’s membrane
endothelial keratoplasty. Ophthalmology 2013; 120(5):923-930. 12. Chamberlain W, Austin A, Terry M, Jeng BH, Rose-Nussbaumer
J. Survey of experts on current endothelial keratoplasty tech-
9. Chamberlain W, Omid N, Lin A, Farid M, Gaster RN, Steinert
niques. J Clin Exp Ophthalmol. 2016; 7(5):608.
RF. Comparison of corneal surface higher-order aberrations after
endothelial keratoplasty, femtosecond laser-assisted keratoplasty,
and conventional penetrating keratoplasty. Cornea 2012; 31(1):6-
13.
12 Section II: Keratoplasty—Are We Doing the Right Thing? 2017 Subspecialty Day | Cornea
I. Challenges for Repeat PK for Failed PK D. Generally better BCVA in PK-EK groups (4 studies)
A. Higher allograft rejection rate E. Ang et al: Retrospective analysis within the Singa-
pore Cornea Transplant Study (SCTS)
B. Higher graft failure rate, shorter graft survival
period: Studies show long-term survival rates to 1. 113 eyes, all pseudophakic bullous keratopathy
range between 21% and 70% (8 studies). (PBK) with failed PKs: 81 PK-PKs, 32 PK-EKs
II. Current Alternatives to Repeat PK for Failed PKs 2. Five surgeons, EndoGlide DSAEKs, same ste-
roid regimes
A. Endothelial keratoplasty (EK): Descemet-stripping
automated EK (DSAEK) or Descemet membrane 3. Cumulative graft survival probability: PK-PK,
EK (DMEK) 51.3% vs. PK-EK, 86.5% (P = .013)
B. Boston type 1 keratoprosthesis a. 1-year survival: PK-PK, 91.9%; PK-EK,
96.2%
III. Advantages of Performing DSAEK (or DMEK) in
Failed PKs b. 2-year survival: PK-PK, 82.6%; PK-EK,
91.6%
A. Potentially lower risk of rejection
c. 3-year survival: PK-PK, 66.8%; PK-EK,
B. EK advantages: tectonically stronger eye, closed eye
86.4%
surgery, sutureless, faster visual rehabilitation
d. 5-year survival: PK-PK, 51.3%; PK-EK,
IV. Disadvantages of Performing DSAEK in Failed PKs
86.4%
A. More complex surgery
4. More rejection episodes in PK-PK group: 13.6%
B. Higher risk of donor dislocation compared to stan- vs. 3.1%
dard DSAEK
5. Multivariate Cox regression analysis: Repeat PK
C. Residual PK stromal haze or distortion may limit was the only significant risk factor for graft fail-
visual acuity. ure; hazards ratio, 10.17 (95% CI, 1.10-93.63; P
= .041)
D. Adoption of original ametropic status of the PK
6. Study conclusion: Performing DSAEK for failed
V. Advantages of Performing Boston Type 1 KPro in
PK is far superior to repeat PK for PBK eyes.
Failed PKs
VIII. Current Suggested Approach
A. No risk of donor rejection affecting central vision
Attempt to perform DSAEK for failed PKs, unless
B. Minimal astigmatism, enhanced visual acuity
there is significant pre-existing, irreversible stromal
C. Relative ease of performing surgery (compared to damage or distortion in the PK, as studies show less
complex EK surgery) rejection, and longer-term graft survival.
VI. Disadvantages of Performing Boston Type 1 KPro in IX. Should We Still Be Performing Repeat PK in Eyes with
Failed PKs a Previously Failed PK?
A. Complications of Boston type 1 KPro (extrusion, Yes, but generally only in eyes with end-stage chronic
infection, etc.) stromal scarring or distortion in the PK.
B. Shorter follow-up rates in literature; longer follow- X. What about the Role of Boston KPro Type 1 for
up, more complications Repeat PKs?
VII. Comparative Studies Comparing Repeat PK (PK-PK) Current short-term studies comparing graft survival
with DSAEK for Failed PK (PK-EK) rates between repeat PK and Boston KPro surgery
for failed PKs suggest that graft survival is better for
A. PK-EK 1-year failure rates ranging from 55% to
the Boston KPro, but graft survival for EKs after PK
100% (3 studies)
appears better than Boston KPro results; more long-
B. Anshu et al: EK-PK graft survival of 74% at 4 years term KPro results are needed to compare Boston KPro
with EK for failed PK.
C. Kitzmann et al: Trend toward better 3-year sur-
vival in PK-EK group
14 Section II: Keratoplasty—Are We Doing the Right Thing? 2017 Subspecialty Day | Cornea
References
1. Weisbrod DJ, Sit M, Naor J, Slomovic AR. Outcomes of repeat 5. Kitzmann AS, Wandling GR, Sutphin JE, et al. Comparison of
penetrating keratoplasty and risk factors for graft failure. Cornea outcomes of penetrating keratoplasty versus Descemet’s strip-
2003; 22(5):429-434. ping automated endothelial keratoplasty for penetrating kerato-
plasty graft failure due to corneal edema. Int Ophthalmol. 2012;
2. Patel NP, Kim T, Rapuano CJ, et al. Indications for and outcomes
32(1):15-23.
of repeat penetrating keratoplasty, 1989-1995. Ophthalmology
2000; 107(4):719-724. 6. Ang M, Ho H, Wong CW, Htoon HM, Mehta JS, Tan D. Endo-
thelial keratoplasty after failed penetrating keratoplasty: an
3. Ezon I, Shih CY, Rosen LM, et al. Immunologic graft rejection
alternative to repeat penetrating keratoplasty. Am J Ophthalmol.
in Descemet’s stripping endothelial keratoplasty and penetrat-
2014; 58:1221-1227.
ing keratoplasty for endothelial disease. Ophthalmology 2013;
120(7):1360-1365. 7. Lee WB, Shtein RM, Kaufman SC, et al. Boston keratoprosthesis:
outcomes and complications—a report by the American Academy
4. Anshu A, Price MO, Price FW Jr. Descemet’s stripping endothelial
of Ophthalmology. Ophthalmology 2015; 122:1504-1511.
keratoplasty under failed penetrating keratoplasty: visual rehabili-
tation and graft survival rate. Ophthalmology 2014; 92(2):167-
170.
2017 Subspecialty Day | Cornea Section II: Keratoplasty—Are We Doing the Right Thing? 15
Methods Summary
A literature search was performed to identify publications that The Boston type 1 keratoprosthesis is the evidence-based pro-
reported the outcomes of PK for corneal transplant failure. In cedure of choice for the management of corneal graft failure.
addition, data were collected from surgeons at 5 centers regard- However, superior visual outcomes must be weighed against
ing the outcomes following implantation of the Boston type 1 greater risk of sight-threatening complications.
keratoprosthesis for corneal transplant failure. The primary
outcome measure was the percentage of eyes with corrected
Selected Readings
distance visual acuity (CDVA) ≥ 20/200 at 2 years after surgery,
while secondary outcome measures included the percentage of 1. Akpek EK, Alkharashi M, Hwang FS, Ng SM, Lindsley K. Artifi-
eyes with CDVA ≥ 20/40 at 2 years after surgery; the incidence cial corneas versus donor corneas for repeat corneal transplants.
of graft failure or keratoprosthesis retention failure at 1, 2, and Cochrane Database of Systematic Reviews 2014, Issue 11. Art.
No.: CD009561.
5 years after surgery; and the incidence of postoperative compli-
cations, such as infectious keratitis and development or progres- 2. Ahmad S, Mathews PM, Lindsley K, et al. Boston Type 1 kerato-
sion of glaucoma. prosthesis versus repeat donor keratoplasty for corneal graft fail-
ure: a systematic review and meta-analysis. Ophthalmology 2016;
123:165-177.
Results
3. Akpek EK, Cassard SD, Dunlap K, Hahn S, Ramulu PY. Donor
The literature search revealed 26 studies that described the corneal transplantation vs Boston type 1 keratoprosthesis in
results of repeat PK for corneal transplant failure in approxi- patients with previous graft failures: a retrospective single center
mately 5600 patients. During the specified study period, 104 study (an American Ophthalmological Society Thesis). Trans Am
eyes (98 patients) underwent implantation of the Boston type 1 Ophthalmol Soc. 2015; 113:T3.
keratoprosthesis for corneal transplant failure at the 5 centers. 4. Hager JL, Phillips DL, Goins KM, et al. Boston type 1 keratopros-
thesis for failed keratoplasty. Int Ophthalmol. 2016; 36:73-78.
Visual Acuity
Two years after surgery, the percentage of eyes with CDVA
≥ 20/200 following repeat PK vs. keratoprosthesis implantation
were 42% vs. 57%, while the percentage of eyes with CDVA
> 20/40 were 16% vs. 20%, respectively.
16 Section II: Keratoplasty—Are We Doing the Right Thing? 2017 Subspecialty Day | Cornea
NOTES
2017 Subspecialty Day | Cornea Section II: Keratoplasty—Are We Doing the Right Thing? 17
Management of extensive corneal and limbal melts from auto- A 46-year-old indigent woman with history of “scratch” 6 days
immune disease or infection can be more challenging than ago presented with total corneal infiltrate and necrosis involv-
managing more central ulcerations and/or perforations. Due ing the limbus inferiorly. There was near perforation of the
to the proximity of a graft to the scleral vasculature, any large inferior third of the cornea and a 95% hypopyon. There was no
penetrating keratoplasty procedure in this area puts the graft view of the anterior chamber. Patient had been on moxifloxacin
at higher risk of rejection and vascularization. When replacing (Vigamox) from the E.R. for 3 days. Seidel-negative with pres-
full-thickness tissue in close proximity to the anterior chamber sure B-scan showed no involvement of the posterior segment.
angle, there is a high risk of extensive iridocorneal adhesions, Preop vision was light perception only. IOP was by palpation,
angle closure, and resultant intractable glaucoma. In this pre- and the eye was felt to be “soft.”
sentation, I will present a case for the panel members to discuss
regarding their approach to saving the eye, preserving vision, Medical therapy
and preventing glaucoma. I will then show a unique surgical Cultures and Gram stain were taken and patient was placed on
strategy to minimize common complications following repair of fortified drops of vancomycin and tobramycin every half hour,
total corneal melts with limbal involvement. as well as oral doxycycline. Cultures grew out Streptococcus
pneumoniae. After 2 days of antibiotics, perforation seemed
imminent, and so the patient was taken to the operating theater.
What Do I Do with This Cornea?
Surgical therapy
What are the options here?
1. Penetrating keratoplasty with a 12-mm limbus-to-limbus
graft?
2. Lamellar keratoplasty?
3. Keratoprosthesis?
4. Descemet membrane endothelial keratoplasty?
5. Corneal crosslinking?
6. Enucleation?
7. Referral to your competition?
Figure 1.
18 Advocating for Patients 2017 Subspecialty Day | Cornea
Ophthalmology’s goal to protect sight and empower lives ■■ Derailed the onerous global surgery data collection
requires active participation in and commitment to advocacy proposal
from every ophthalmologist. Contributions to the following ■■ Preserved global surgical payments
three critical funds are a part of that commitment: ■■ Halted the Part B Drug Demonstration
■■ Continued efforts in collaboration with subspecialty soci-
■■ OPHTHPAC® Fund
eties to preserve access to compounded and repackaged
■■ Surgical Scope Fund (SSF)
drugs such as Avastin
■■ State Eye PAC
Contributions to OPHTHPAC can be made here at AAO
Please join the dedicated community of ophthalmologists
2017 or online at www.aao.org/ophthpac by clicking “Join.”
who are contributing to protect quality patient eye care for
Leaders of the Cornea Society are part of the Academy’s
everybody. The OPHTHPAC Committee is identifying Con-
Ophthalmic Advocacy Leadership Group (OALG), which
gressional Advocates in each state to maintain close relation-
meets every January in the Washington, D.C., area to provide
ships with federal legislators in order to advance ophthalmology
critical input and to discuss and collaborate on the Academy’s
and patient causes. At Mid-Year Forum 2017, we honored nine
advocacy agenda. The topics discussed at the 2017 OALG
of those legislators with the Academy’s Visionary Award. This
agenda included panel discussions on the Merit Based Incen-
served to recognize them for addressing issues important to
tive Payment System (MIPS) and APM implementation, as well
us and to our patients. The Secretariat for State Affairs is col-
as Academy analysis initiatives related to the IRIS® registry. In
laborating closely with state ophthalmology society leaders to
addition, meeting participants discussed the changing paradigm
protect Surgery by Surgeons at the state level. This year has seen
for optometric scope battles, held a roundtable to discuss chal-
an unprecedented effort by optometry to advance its scope of
lenges for surgical subspecialties, and considered opportunities
practice via legislation rather than education. Our mission of
to ensure physician and patient choice regarding access to phar-
protecting sight and empowering lives requires robust funding
maceuticals.
of both the Surgical Scope Fund and the OPHTHPAC Fund.
At Mid-Year Forum 2017, the Academy and the Cornea
Each of us has a responsibility to ensure that these funds are
Society ensured a strong presence of cornea specialists to sup-
strong.
port ophthalmology’s priorities, and a record number of oph-
thalmologists visited members of Congress and their key health
OPHTHPAC® Fund staff to discuss ophthalmology priorities as part of Congressio-
nal Advocacy Day. The Cornea Society remains a crucial part-
OPHTHPAC is a crucial part of the Academy’s strategy to pro-
ner with the Academy in its ongoing federal and state advocacy
tect and advance ophthalmology’s interests in key areas, includ-
initiatives.
ing physician payments from Medicare and protecting ophthal-
mology from federal scope of practice threats. Established in
1985, OPHTHPAC is one of the oldest, largest, and most suc- Surgical Scope Fund
cessful political action committees in the physician community.
The Surgical Scope Fund (SSF) provides grants to state ophthal-
We are very successful in representing your profession to the
mology societies to support their efforts to derail optometric
U.S. Congress.
surgery proposals that pose a threat to patient safety. Since
As one election cycle ends, a new one starts, yet the pres-
its inception, the Surgery by Surgeons campaign and the SSF,
sure to remain vocal on our issues remains. Advocating for our
in partnership with state ophthalmology societies, has helped
congressional issues is a continuous battle, and OPHTHPAC
32 state / territorial ophthalmology societies reject optometric
is always under financial pressure to support our incumbent
scope of practice expansion into surgery.
friends as well as to make new friends with candidates. These
In 2017, your colleagues serving on the Academy’s Secre-
relationships allow us to have a seat at the table with legislators
tariat for State Affairs, along with State Governmental Affairs
willing to work on issues important to us and our patients.
staff and the leaders of state ophthalmology societies, have been
The relationships OPHTHPAC builds with members of
put to the task while dealing with an unprecedented number of
Congress is contingent on the financial support we receive from
simultaneous legislative battles. Eleven states have been affected
Academy members. Academy member support of OPHTHPAC
so far this year:
allows us to advance ophthalmology’s federal issues. We need to
increase the number of our colleagues who contribute to OPH- ■■ Alaska ■■ Maryland
THPAC and the other funds. Right now, major transformations ■■ California ■■ Massachusetts
are taking place in health care. To ensure that our federal efforts ■■ Florida ■■ Nebraska
and our PAC remain strong, we need the support of every oph- ■■ Georgia ■■ North Carolina
thalmologist to better our profession and ensure quality eye ■■ Illinois ■■ Pennsylvania
care for our patients. ■■ Iowa
The significant impacts that OPHTHPAC has made include
the following:
2017 Subspecialty Day | Cornea Advocating for Patients 19
Patient safety setbacks as well as victories will be reviewed Please respond to your Academy colleagues and be part of
during the presentation, but do know that in each of these the community that contributes to OPHTHPAC, the SSF, and
legislative battles, the benefits from SSF distributions are abun- your State Eye PAC. Please be part of the community advocat-
dantly clear. The best lobbyists and public relations consultants ing for your patients now.
are contracted as necessary, and media campaigns (including
TV, radio, and social media) to educate the voting public are
*OPHTHPAC Committee
launched when needed to secure success and stop optometry
from expanding its scope of practice to include surgery. Each Jeffrey S Maltzman MD (AZ)–Chair
of these endeavors is very expensive, and no one state has the Janet A Betchkal MD (FL)
resources to wage one of these battles on its own. Ophthal- William S Clifford MD (KS)
mologists must join together and donate to the SSF to fight for
Sidney K Gicheru MD (TX)
patient safety when a state faces a scope battle over optometric
surgery. Sohail J Hasan MD PhD (IL)
The Academy relies not only on the financial contributions Gary S Hirshfield MD (NY)
to the SSF from individual ophthalmologists and their practices, David W Johnson MD (CO)
but also on the contributions made by ophthalmic state, sub-
Stephanie J Marioneaux MD (VA)
specialty, and specialized interest societies. The Cornea Society
contributed to the SSF in 2016, and we thank them and look Dorothy M Moore MD (DE)
forward to their contribution in 2017. Contributions to the SSF Niraj Patel MD (WA)
can be made here at AAO 2017 or online at www.aao.org/ssf. John D Roarty MD (MI)
Diana R Shiba MD (CA)
State Eye PAC Woodford S Van Meter MD (KY)
It is also extremely important for all ophthalmologists to sup- John (“Jack”) A Wells 3rd MD (SC)
port their respective State Eye PACs because campaign contribu-
tions to legislators at the state level must come from individual Ex-Officio Members
ophthalmologists and cannot come from the Academy, OPH- Cynthia A Bradford MD (OK)
THPAC, or the SSF. The presence of a strong State Eye PAC Daniel J Briceland MD (AZ)
providing financial support for campaign contributions and
Michael X Repka MD MBA (MD)
legislative education to elect ophthalmology-friendly candidates
to the state legislature is critical, as scope of practice battles and George A Williams MD (MI)
many regulatory issues are all fought on the state level.
**Surgical Scope Fund Committee
Action Requested: ADVOCATE FOR YOUR Kenneth P Cheng MD (PA)–Chair
PATIENTS Amalia Miranda MD (OK)
Academy SSF contributions are used to support the infrastruc- Matthew F Appenzeller MD (NE)
ture necessary in state legislative / regulatory battles and for Vineet (“Nick”) Batra MD (CA)
public education. PAC contributions are necessary at the state
Cecily A Lesko MD FACS (NJ)
and federal levels to help elect officials who will support the
interests of our patients. Contributions to each of these three C Blake Myers MD (SC)
funds are necessary and help us protect sight and empower William (“Chip”) W Richardson 2nd MD (KY)
lives. SSF contributions are completely confidential and may be David E Vollman MD MBA (MO)
made with corporate checks or credit cards, unlike PAC contri-
butions, which must be made by individuals and are subject to Ex-Officio Members
reporting requirements. Daniel J Briceland MD (AZ)
Kurt F Heitman MD (SC)
20 Section III: Conjunctival Tumors—What’s Old, What’s New? 2017 Subspecialty Day | Cornea
B. 5-fluorouracil 2. Wilson MW, Hungerford JL, George SM, Madreperla SA. Topical
mitomycin C for the treatment of conjunctival and corneal epithe-
1. 1% q.i.d. for 1-2 weeks; may be repeated lial dysplasia and neoplasia. Am J Ophthalmol. 1997; 124:303-
311.
2. May be used if refractory to MMC
3. Grossniklaus HE, Aaberg TM Sr. Mitomycin C treatment of con-
C. Interferon (IFN) α2B junctival intraepithelial neoplasia [editorial]. Am J Ophthalmol.
1997; 124:381-383.
1. 10 million IU/10 cc (compounded) q.i.d. topi-
cally for 3-4 months
2017 Subspecialty Day | Cornea Section III: Conjunctival Tumors—What’s Old, What’s New? 21
4. Yeatts RP, Engelbrecht NE, Curry CD, et al. 5-fluorouracil for the
treatment of intraepithelial neoplasia of the conjunctiva and cor-
nea. Ophthalmology 2000; 107:2190-2195.
5. Yamamoto N, Ohmura T, Suzuki H, Shirasawa H. Successful
treatment of conjunctival intraepithelial neoplasia refractive to
mitomycin-c. Ophthalmology 2002; 109:249-252.
6. Maskin SL. Regression of limbal epithelial dysplasia with topical
interferon. Arch Ophthalmol. 1994; 112:1145-1146.
7. Karp CL, Moore JK, Rosa Jr RH. Treatment of conjunctival and
corneal intraepithelial neoplasia with topical interferon α-2b.
Ophthalmology 2001; 108:1093-1098.
8. Karp CL, Galor A, Chhabra S, Barnes SD, Alfonso EC. Subcon-
junctival / perilesional recombinant interferon α2b for ocular sur-
face squamous neoplasia: a 10-year review. Ophthalmology 2010;
117:2241-2246.
9. Grossniklaus HE, Bergstrom C, Hubbard GB, Wells JR. Surgi-
cal techniques. In: Grossniklaus HE, ed. Pocket Guide to Ocular
Oncology and Pathology. Berlin: Springer; 2013:47-69.
10. Brown HH, Wells JR, Grossniklaus HE. Tissue preparation for
pathological examination. In: Grossniklaus HE, ed. Pocket Guide
to Ocular Oncology and Pathology. Berlin: Springer; 2013:61-67.
22 Section III: Conjunctival Tumors—What’s Old, What’s New? 2017 Subspecialty Day | Cornea
J.
Palpate the neck for enlarged lymph nodes. 3. Toivonen P, Kivela T. Infiltrating macrophages in extratumoural
tissues after brachytherapy of uveal melanoma. Acta Ophthalmol.
III. Investigations 2012; 90:341-349.
Introduction Evidence
Pterygium surgery is an underappreciated art. It is frequently The evidence regarding the superiority of the various surgical
treated as a trivial procedure, often being the first surgery options is somewhat flawed. Published studies vary with regard
one performs during residency. Recurrent pterygia, however, to patient populations, pterygium severities, surgical techniques,
can be highly problematic for patients and difficult to repair. postoperative care, and recurrence criteria. That being said, all
The potential complications of a recurrent pterygium include published reports show that the recurrence rate with amniotic
unsightly scarring, restricted ocular motility, ocular surface membrane grafts is approximately twice the rate of recurrence
dryness, and decreased vision. It is therefore important for sur- with conjunctival autografts.1,2 Fibrin glue for conjunctival
geons to choose a surgical technique that safely and effectively autografts seems to yield shorter surgical times and lower recur-
minimizes the risk for recurrence. rences rates than sutured conjunctival autografts.3 Adjunctive
mitomycin C lowers recurrence rates but risks causing severe,
vision-threatening complications such as scleral melts.1,2 Its use
Surgical Options
should be reserved for aggressively recurrent pterygia.
Simple excision leaving bare sclera has largely been abandoned
(or should be abandoned) as a surgical technique due to an
References
unacceptably high recurrence rate. Conjunctival autografts and
amniotic membrane grafts have been used to cover the con- 1. Clearfield E, Muthappan V, Wang X, Kuo IC. Conjunctival
junctival defect following pterygium excision and subsequently autograft for pterygium. Cochrane Database of Systemic Reviews
decrease the recurrence rate. The grafts can be fixated in place 2016, Issue 2. Art. No.:CD011349.
using sutures or fibrin tissue adhesive. Mitomycin C has also 2. Kaufman SC, Jacobs DS, Lee WB, et al. Options and adjuvants
been used as an adjunctive therapy to decrease fibroblast activ- in surgery for pterygium: a report by the American Academy of
ity and thus decrease the rate of pterygium recurrence. Ophthalmology. Ophthalmology 2013; 120(1):201-208.
3. Romano V, Cruciani M, Conti L, Fontana L. Fibrin glue versus
sutures for conjunctival autografting in primary pterygium sur-
gery. Cochrane Database of Systemic Reviews 2016, Issue 12. Art.
No.: CD011308.
26 Section III: Conjunctival Tumors—What’s Old, What’s New? 2017 Subspecialty Day | Cornea
C ase
Discussion
Myofibrosarcoma is a rare mesenchymal tumor that can present
as ocular surface tumor. Final histopathologic diagnosis can be
challenging, and immunohistochemistry is important for evalu-
ation. Myofibrosarcoma should be considered in the clinical dif-
ferential diagnosis of atypical ocular surface lesions and the his-
topathologic differential diagnosis of ocular spindle neoplasms.
2017 Subspecialty Day | Cornea Section IV: Anterior Segment Imaging 27
Is Aberrometry Necessary?
In-Office Aberrometry: Why Do I Care?
Parag A Majmudar MD
I. Basics of Aberrometry IV. Identifying Good Candidates for LASIK vs. Refractive
Lens Exchange
A. Ray tracing aberrometry uses a series of 256 laser
beams through the line of sight through the pupil. If patients have subtle lens changes, it may steer the
The location where the beams contact the retina is discussion toward a more appropriate lens-based pro-
captured by a sensor. In an ideal eye, the location cedure.
for all 256 rays is the fovea. However, lower- and
V. Identifying Candidates for Premium Lens
higher-order aberrations in various parts of the eye
will result in a wavefront error. A. Determining if significant corneal aberrations are
present
B. Is unlike Hartmann-Shack, which measures light
coming back out of the eye (This is not as physi- B. Measuring optical alignment (angle kappa and
ologic a measure as ray tracing.) angle alpha)
II. What Information Can Aberrometry Provide? VI. Toric IOL Check
A. Wavefront map of higher-order aberrations: coma, A. Quickly identifying toric IOL alignment
spherical aberration, trefoil
B. How much to rotate the lens?
B. Root mean square (RMS): Quantification of the
VII. As a Patient Education Tool
aberrations
Help patients visually understand their refractive error
C. Refractive maps
and benefits of correcting astigmatism at the time of
D. Point spread function cataract surgery
E. Snellen letter aberrations: Simulation of how the
letter “E” would look to a patient based on an Selected Readings
estimated mathematical derivation of higher-order 1. Castillo Gomez A, Verdejo del Rey A, Bautista CP, et al. Principles
aberration values and applications of ray-tracing aberrometry (part I). J Emmetro-
F. Internal optics aberration analysis: By subtracting pia. 2012; 3:96-110.
corneal aberrations from the total aberration data, 2. Castillo Gomez A, Verdejo del Rey A, Bautista CP, et al. Principles
it is possible to identify corneal vs. “other” aberra- and applications of ray-tracing aberrometry (part II). J Emmetro-
tions (typically from crystalline or artificial IOLs). pia. 2012; 3:157-165.
III. Troubleshooting the Unhappy Multifocal or Refrac- 3. Wakil JS, Padrick TD, Molebny S. The iTrace combination cor-
tive Surgery Patient neal topography and wavefront system by Tracey technologies. In:
Corneal Topography in the Wavefront Era. Thorofare, NJ: Slack,
A. Identifying the source of vision complaints: Inc.; 2006:177-188.
1. Blur / double vision: coma 4. Molebny VV, Panagopoulou SI, Molebny SV, Wakil YS, Pallikaris
IG. Principles of ray tracing aberrometry. J Refract Surg. 2000;
2. Glare / halo / night myopia: spherical aberration 16:S572-575.
3. Starburst: trefoil 5. Rozema JJ, Dirk EM, Van Dyck PhD, Tassignon MJ. Clinical
comparison of 6 aberrometers: Part I. Technical specifications. J
B. Wavefront maps can identify whether corneal or Cataract Refract Surg. 2005; 31:1114-1127.
“internal” aberrations are responsible.
6. Rozema JJ, Dirk EM, Van Dyck PhD, Tassignon MJ. Clinical
comparison of 6 aberrometers: Part II. Statistical comparison in a
test group. J Cataract Refract Surg. 2006; 32:33-44.
2017 Subspecialty Day | Cornea Section IV: Anterior Segment Imaging 29
Anterior segment OCT (AS-OCT) has become an essential 3. AS-OCT helps detect microperforation of the
diagnostic tool for the anterior segment specialist. It provides an Descemet membrane and double anterior cham-
in vivo optical biopsy of the cornea to guide the diagnosis and ber intraoperatively.
management of anterior segment pathologies.
4. AS-OCT helps avoid residual pathology intra-
I. AS-OCT for Corneal Surgery Planning operatively during DALK procedures.
A. Anterior lamellar keratoplasty: Femtosecond laser– B. Intraoperative OCT in Descemet membrane endo-
assisted lamellar keratoplasty (FALK)1 thelial keratoplasty and Descemet-stripping auto-
mated endothelial keratoplasty surgery (DSAEK):
1. Measure thickness of the corneal pathology
Confirm attachment of the graft intraoperatively.
using AS-OCT. If residual bed is more than
250 µm, then patient is a candidate for suture- III. AS-OCT for the Postoperative Evaluation of Corneal
less FALK. This is based on the literature on Surgeries
LASIK that suggested that around 250 µm of
A. To evaluate detachment of DSAEK grafts: We will
residual corneal bed is enough to prevent ectasia.
show a case with residual Descemet membrane
2. Program femtosecond laser machine to cut at rolled over in the interface, preventing the graft
the depth measured using the AS-OCT. from adhering to the back of the host cornea.
3. Cut both the donor and recipient using the same B. Evaluate visually significant interface opacities
settings.
C. Diagnosis of epithelial ingrowth3
4. Remove the recipient’s pathological corneal tis-
IV. The Future of AS-OCT
sue.
A. Corneal microlayer tomography
5. Replace it with the corneal donor lenticule.
B. OCT angiography of the anterior segment
6. Fit a bandage contact lens over the cornea.
B. Astigmatic keratotomy (AK) and limbal relaxing
References
incisions (LRI): Detect the depth of the cornea at
the location of the AK or LRI to decrease the risk 1. Shousha MA, Yoo SH, Kymionis GD, et al. Long-term results of
of perforation. femtosecond laser-assisted sutureless anterior lamellar kerato-
plasty. Ophthalmology 2011; 118(2):315-323.
C. Intrastromal corneal rings placement
2. Pasricha ND, Shieh C, Carrasco-Zevallos OM, et al. Needle
D. Excision of ocular surface tumors depth and big-bubble success in deep anterior lamellar kerato-
plasty: an ex vivo microscope-integrated OCT study. Cornea
II. Intraoperative OCT to Assist Corneal Surgery 2016; 35(11):1471-1477.
A novel technique that is evolving 3. Suh LH, Shousha MA, Ventura RU, et al. Epithelial ingrowth
after Descemet stripping automated endothelial keratoplasty:
A. DALK 2
description of cases and assessment with anterior segment optical
1. Real-time cross-sectional visualization of the coherence tomography. Cornea 2011; 30(5):528-534.
corneal layers during surgery without compro-
mising the view of the surgeon or the sterility of
the surgical field
2. AS-OCT helps to guide the depth of the needle
tip and air injection in big bubble technique, and
to confirm the absence of fluid and air in the
interface at the conclusion of surgery.
30 Section IV: Anterior Segment Imaging 2017 Subspecialty Day | Cornea
Figure 1.
Figure 2.
32 Section IV: Anterior Segment Imaging 2017 Subspecialty Day | Cornea
ii. Using the Galilei Analyzer (Ziemer Oph- and specificity of 99.59% and 98.19% for
thalmic Systems AG; Port, Switzerland), keratoconus and 91.49% and 93.05% for
the cut-off values for maximum posterior FFKC. For ART-Max, 386 μm and 416 μm
elevation within the central 5-mm diam- were the cut-offs, with sensitivity and speci-
eter obtained by BFTA were 16 μm and ficity of 99.17% and 97.28% for keratoconus
13 μm for keratoconus and mild (forme and 85.11% and 93.05% for subclinical dis-
fruste) keratoconus (FFKC), respectively, ease, respectively.13
with sensitivities of 99% and 82%.25
B. The Pentacam Belin / Ambrósio Enhanced Ectasia
3. The concept of an enhanced elevation has been Display (BAD)
introduced by Belin and implemented on the
1. The BAD is a comprehensive display that com-
Pentacam.13,24 After calculating the standard
bines the standard and enhanced BFS elevation
BFS for the 8-mm corneal zone, a second,
maps of the front and back surfaces, and the
“enhanced” BFS for the same zone, excluding
thickness distribution data. Different tomo-
the 3.5-mm-diameter zone centered at the thin-
graphic parameters are presented as the stan-
nest point, is calculated. The difference map
dard deviation from normality toward disease
from the standard and enhanced BFS will exag-
(d values): anterior and posterior elevation at
gerate any differences (protrusions) within the
the TP (8-mm BFS), change in anterior and pos-
excluded zone. More than 5 μm of difference for
terior elevation of the standard and enhanced
the front elevation and 12 μm difference for the
BFS, thinnest value and location, PPI, ART and
back elevation are considered suspicious.13,24,26
maximal curvature (Kmax). The BAD-D final
Changes in posterior corneal elevation have been
parameter is calculated based on a regression
studied to document long-term stability after
analysis to maximize accuracy for detecting
LASIK, so that using the same BFS for the pre-
ectatic disease.13,24,26,29
operative corneal information, less than 7 µm
on the maximal difference in the central 4.0-mm 2. BAD-D higher than 2.11 was a criterion with
zone was found on stable LASIK cases.27 sensitivity and specificity of 99.59% and 100%
for diagnosing keratoconus, while for detecting
4. Corneal thickness maps enable the characteriza-
mild or subclinical disease, the criteria of higher
tion of the thinnest point (TP) value and its loca-
than 1.22 provided 93.62% sensitivity and
tion, along with thickness distribution.13,24,26
94.56% specificity.13
The TP is a more accurate parameter than
central thickness for screening ectatic corneal a. BAD-D (v3) values turn yellow in the display
diseases,13,24,26,28 as well as for calculating the when higher than 1.6.
PTA and residual stromal bed (RSB).4,26
b. Novel series studies demonstrate lower sen-
5. In the Pentacam, thickness distribution is sitivity for detecting abnormality among the
described as the average of thickness values normal topography eyes from VAE cases.
in concentric annular circles with increasing
i. This determines the need to further
diameters centered on the TP. These values are
improve the artificial intelligence method
presented in the corneal thickness spatial profile
for identifying ectasia susceptibility, and
(CTSP) and the percentage of thickness increase
even the need to further integrate novel
(PTI) graphs, which also contain reference data
data such as from segmental tomography
(mean and 95% confidence intervals) from a
(ie, epithelial thickness data) and corneal
normal population.13,24,26
biomechanics.
The pachymetric progression index (PPI) is cal-
ii. In a retrospective, nonrandomized study
culated for every 1 degree of meridians of the
involving preoperative LASIK data from
cornea, starting from the TP outward.
an international pool comprised of 23
a. This calculation considers the increase in post-LASIK ectasia cases and from 266
thickness, comparing to the TP at each point stable-LASIK cases with over 1 year of
of the cornea, referencing to a normal popu- follow-up, the criteria of BAD-D higher
lation. than 1.29 provided 87% sensitivity and
92.1% specificity.22 Even though the
b. Ambrósio’s relational thickness (ART) val-
BAD-D was the most accurate parameter
ues are calculated as the ratios of the TP and
in predicting ectasia risk, the data suggest
the average of the PPI at all meridians (ART-
room for further improvement.
Ave) and the meridian with maximal PPI
(ART-Max).13,26 See “Thin or thinned, thick C. Other applications
or thickened: should we care?”
1. Planning surface ablation with laser photothera-
www.youtube.com/watch?v=LhmBHYsLtjs
peutic keratectomy eptithelial scrape
c. The cut-off criteria for ART-Ave for clinical
2. Postoperative understanding of outcomes
and mild (FFKC) keratoconus were, respec-
tively, 474 μm and 521 μm, with sensitivity 3. Planning therapeutic corneal procedures
2017 Subspecialty Day | Cornea Section IV: Anterior Segment Imaging 33
IV. Conclusions 14. Reinstein DZ, Silverman RH, Rondeau MJ, Coleman DJ. Epithe-
lial and corneal thickness measurements by high-frequency ultra-
A. Knowledge of corneal tomography and segmental sound digital signal processing. Ophthalmology 1994; 101:140-
tomography with epithelial profile represents a 146.
major advance in the anatomical and optical char-
15. Reinstein DZ, Silverman RH, Trokel SL, Allemann N, Coleman
acterization of the eye.
DJ. High-frequency ultrasound digital signal processing for bio
B. Such understanding is fundamental in enabling metry of the cornea in planning phototherapeutic keratectomy.
better results in therapeutic procedures for irregu- Arch Ophthalmol. 1993; 111:430-431.
lar corneas, including cases that had complications 16. Li Y, Tan O, Brass R, Weiss JL, Huang D. Corneal epithelial
related to corneal refractive surgery. While this thickness mapping by Fourier-domain optical coherence tomo
approach does augment confidence in refractive graphy in normal and keratoconic eyes. Ophthalmology 2012;
procedures, there is also a major impact on corneal 119:2425-2433.
diseases, such as corneal ectasia. 17. Li Y, Chamberlain W, Tan O, Brass R, Weiss JL, Huang D. Sub-
clinical keratoconus detection by pattern analysis of corneal and
epithelial thickness maps with optical coherence tomography. J
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18. Salomao MQ, Hofling-Lima AL, Lopes BT, et al. Role of the cor-
its importance to wavefront technology. Cornea 2001; 20:441-
neal epithelium measurements in keratorefractive surgery. Curr
454.
Opin Ophthalmol. 2017; 28:326-336.
2. Klyce SD. Computer-assisted corneal topography: high-resolution
19. Ambrosio R Jr, Dawson DG, Salomao M, Guerra FP, Caiado AL,
graphic presentation and analysis of keratoscopy. Invest Ophthal-
Belin MW. Corneal ectasia after LASIK despite low preoperative
mol Vis Sci. 1984; 25:1426-1435.
risk: tomographic and biomechanical findings in the unoperated,
3. Binder PS, Lindstrom RL, Stulting RD, et al. Keratoconus and stable, fellow eye. J Refract Surg. 2010; 26:906-911.
corneal ectasia after LASIK. J Refract Surg. 2005; 21:749-752.
20. Buhren J, Schaffeler T, Kohnen T. Preoperative topographic char-
4. Ambrosio R Jr, Randleman JB. Screening for ectasia risk: what acteristics of eyes that developed postoperative LASIK keratecta-
are we screening for and how should we screen for it? J Refract sia. J Refract Surg. 2013; 29:540-549.
Surg. 2013; 29:230-232.
21. Randleman JB, Trattler WB, Stulting RD. Validation of the Ecta-
5. Ambrosio R Jr, Klyce SD, Wilson SE. Corneal topographic and sia Risk Score System for preoperative laser in situ keratomileusis
pachymetric screening of keratorefractive patients. J Refract Surg. screening. Am J Ophthalmol. 2008; 145:813-818.
2003; 19:24-29.
22. Ambrósio Jr R, Ramos I, Lopes B, et al. Assessing ectasia suscep-
6. Ambrosio R Jr, Belin MW. Imaging of the cornea: topography vs tibility prior to LASIK: the role of age and residual stromal bed
tomography. J Refract Surg. 2010; 26:847-849. (RSB) in conjunction to Belin-Ambrósio deviation index (BAD-D).
Rev Bras Oftalmol. 2014; 73:75-80.
7. Cairns G, McGhee CN. Orbscan computerized topography:
attributes, applications, and limitations. J Cataract Refract Surg. 23. Belin MW, Khachikian SS. An introduction to understanding
2005; 31:205-220. elevation-based topography: how elevation data are displayed—a
review. Clin Experiment Ophthalmol. 2009; 37:14-29.
8. Quisling S, Sjoberg S, Zimmerman B, Goins K, Sutphin J. Com-
parison of Pentacam and Orbscan IIz on posterior curvature 24. Belin MW, Ambrosio R. Scheimpflug imaging for keratoconus
topography measurements in keratoconus eyes. Ophthalmology and ectatic disease. Indian J Ophthalmol. 2013; 61:401-406.
2006; 113:1629-1632.
25. Smadja D, Santhiago MR, Mello GR, Krueger RR, Colin J,
9. Wilson SE, Lin DT, Klyce SD. Corneal topography of keratoco- Touboul D. Influence of the reference surface shape for discrimi-
nus. Cornea 1991; 10:2-8. nating between normal corneas, subclinical keratoconus, and
keratoconus. J Refract Surg. 2013; 29:274-281.
10. Maeda N, Klyce SD, Smolek MK, Thompson HW. Automated
keratoconus screening with corneal topography analysis. Invest 26. Ambrosio R Jr, Nogueira LP, Caldas DL, et al. Evaluation of cor-
Ophthalmol Vis Sci. 1994; 35:2749-2757. neal shape and biomechanics before LASIK. Int Ophthalmol Clin.
2011; 51:11-38.
11. Ambrosio R Jr, Caiado AL, Guerra FP, et al. Novel pachymetric
parameters based on corneal tomography for diagnosing kerato- 27. Ciolino JB, Khachikian SS, Cortese MJ, Belin MW. Long-term
conus. J Refract Surg. 2011; 27:753-758. stability of the posterior cornea after laser in situ keratomileusis. J
Cataract Refract Surg. 2007; 33:1366-1370.
12. Ambrosio R Jr, Alonso RS, Luz A, Coca Velarde LG. Corneal-
thickness spatial profile and corneal-volume distribution: tomo- 28. Rabinowitz YS, Li X, Canedo AL, Ambrosio R Jr, Bykhovskaya
graphic indices to detect keratoconus. J Cataract Refract Surg. Y. Optical coherence tomography combined with videokerato
2006; 32:1851-1859. graphy to differentiate mild keratoconus subtypes. J Refract Surg.
2014; 30:80-87.
13. Ambrosio R Jr, Valbon BF, Faria-Correia F, Ramos I, Luz A.
Scheimpflug imaging for laser refractive surgery. Curr Opin Oph- 29. Lopes BT, Ramos IC, Dawson DG, Belin MW, Ambrosio R Jr.
thalmol. 2013; 24:310-320. Detection of ectatic corneal diseases based on Pentacam. Z Med
Phys. 2016; 26:136-142.
34 Section IV: Anterior Segment Imaging 2017 Subspecialty Day | Cornea
Does one need an intraoperative OCT (iOCT)? It depends, DSEK for eyes with significant corneal and anterior segment
and it depends on the type of cases one does. In my experience, abnormalities. These eyes often have problems that make graft
iOCT definitely makes a significant difference for lamellar adherence challenging. Determining whether residual fluid is in
corneal surgery and intracorneal lens sizing. It may also have the graft interface can direct the surgeon to use either milking
potential for minimally invasive glaucoma surgery (MIGS) in maneuvers or drainage incisions. On the other hand, if no inter-
evaluating placement of implants like the XEN. face fluid is present, additional treatment is not needed. With
iOCT helps improve the safety and efficiency of Descemet both DSEK and DMEK, iOCT can help identify areas of scar
membrane endothelial keratoplasty (DMEK) surgery by tissue or synechia that might interfere with graft positioning
allowing evaluation of graft orientation while the graft is only and adherence.
partially uncurled. (Typically with the variety of different In deep anterior lamellar keratoplasty (DALK), a number
marking techniques, the graft has to be unfolded most of the of reports have shown the advantage of iOCT in positioning
way to determine if the endothelium is facing the iris.) iOCT the needle close to the Descemet membrane to improve big
even allows one to determine the orientation in younger, tightly bubble formation. I find the most significant advantage to be in
curled donor grafts when there is no separation between the determining the depth and uniformity of a manual dissection.
two tightly curled scrolls. Even with thickened, edematous, and With iOCT one can evaluate the quality of the dissection plane
hazy corneas, one can not only see the orientation of the graft to make sure the residual stroma is of uniform thickness; this
but also detect subtle problems that might prevent the graft cannot be accomplished with the coaxial view of the operating
from either completely unfolding or being positioned / centered microscope.
in the anterior chamber. Just as the operating microscope allows With intracorneal lens surgery, it can be difficult to deter-
us to see surgery more clearly because of the magnification, mine the exact sizing and vault of the implant. One can improve
iOCT allows us to see another dimension of the tissues: con- the final vault in the second eye by evaluating the vault of the
tours of both the donor and recipient that we cannot discern first eye. iOCT allows us to evaluate the vault in the first eye
with the coaxial view of operating microscopes. so the second eye can be more accurately treated the same day,
In Descemet-stripping endothelial keratoplasty (DSEK) sur- rather than splitting the surgery into two sessions and using in-
gery, iOCT allows us to see if the graft is actually in apposition office OCT to evaluate the vault in the first eye.
to the recipient cornea. In our practice we primarily reserve
2017 Subspecialty Day | Cornea Section IV: Anterior Segment Imaging 35
Perioperative imaging has changed the landscape of anterior 2. An 84-year-old gentleman with Fuchs dystrophy under-
segment surgery in recent years. Optical biometry, Placido- went successful Descemet membrane (DM) endothelial
based and elevation topography, aberrometry, specular and keratoplasty with marked clearing of his cornea and
confocal microscopy, and optical coherence tomography have improvement in his vision. Three months postoperatively
empowered the ophthalmic surgeon to make more accurate he presented with decreased vision and corneal edema
diagnoses and achieve better surgical results than the same in the same eye. He was advised that his graft had failed
surgeon was able to make just a short decade ago. On occasion, and that he needed regrafting. Anterior segment OCT
imaging can change the therapeutic approach so significantly revealed a very shallow DM detachment that was not
that it can save the day! We illustrate 2 such cases: detectable on slitlamp examination. Rebubbling (air des-
cemetopexy) reattached the DM with complete clearing
1. A 72-year-old woman with corneal edema was referred
of the cornea despite a low endothelial cell count.
for endothelial keratoplasty. She had a well-positioned
posterior chamber IOL and a limited view of the poste-
rior pole. OCT of the macula revealed marked cystoid
macular edema (CME). Medical treatment of the CME
improved the vision so significantly that the patient
elected to delay corneal surgery.
36 Section V: Keratoconus, A Steep Learning Curve 2017 Subspecialty Day | Cornea
Figure 3.
Figure 1.
Corneal tomography (the “New View”) offers significant
advantages over older anterior curvature analysis. The phrase
These patients also present for refractive surgery evaluation
“Tried and True” may be more appropriately applied to this
and, while appearing normal on older technologies (anterior
technology.
curvature and central pachymetry), need to be excluded from
refractive surgery due to the high risk of ectatic progres-
sion. One tomographic screening program (Belin / Ambrósio
Enhanced Ectasia Display) demonstrates such a patient. There
are numerous abnormalities in this highly abnormal eye, in spite
of a normal anterior surface (see Figure 2).
2017 Subspecialty Day | Cornea Section V: Keratoconus, A Steep Learning Curve 37
I. Contact Lens Use for Keratoconus / Ectasia Involves IV. New Paradigm for Contact Lens in Keratoconus
“Specialty Contact Lenses.”
A. Not a “contact lens failure” without trial of spe-
A. A “new” field within U.S. optometry cialty lenses
B. Offered by MDs or ODs globally, depending on B. New designs / materials more comfortable, physi-
national scope of practice / credentialing ologic
C. Specialty contact lens is a growth area in the global 1. Si-Hy RGP hybrid
contact lens industry.
2. Si-Hy keratoconus designs
II. Specialty Lenses
3. RGP sclerals / PROSE treatment: Increased
A. RGP corneal lenses, keratoconus designs expertise among specialty fitters
B. Piggyback systems C. Penetrating or lamellar keratoplasty only for axial
opacity limiting vision, assessed in specialty lens
C. Silicone-hydrogel (Si-Hy) lenses, keratoconus
designs D. No regraft for cylinder or recurrence of ectasia
without trial of specialty lens
D. Hybrid lenses
E. Mini scleral lenses
Selected Readings
F. Scleral lenses 1. Abdalla YF, Elsahn AF, Hammersmith KM, Cohen EJ. Synerg-
G. PROSE treatment (prosthetic replacement of the Eyes lenses for keratoconus. Cornea 2010; 29:5-8.
ocular surface ecosystem) 2. Baran I, Bradley JA, Alipour F, Rosenthal P, Le HG, Jacobs DS.
PROSE treatment of corneal ectasia. Cont Lens Anterior Eye.
III. Pearls
2012; 35:222-227.
A. New Si-Hy lenses with keratoconus designs have 3. DeLoss KS, Fatteh NH, Hood CT. Prosthetic replacement of the
extended the use of soft lenses in keratoconus. ocular surface ecosystem (PROSE) scleral device compared to ker-
B. New hybrid materials and designs address past fail- atoplasty for the treatment of corneal ectasia. Am J Ophthalmol.
2014; 158:974-82.
ures from lens fragility and hypoxia.
4. Fernandez Velazquez FJ. Kerasoft IC compared to Rose-K in the
C. Scleral lenses are in the repertoire of an increasing management of corneal ectasias. Cont Lens Anterior Eye. 2012;
number of specialty lens fitters. 35:175-179.
D. Scleral lenses are a useful option in cases of RGP 5. Schornack MM. Scleral lenses: a literature review. Eye Contact
corneal lens failure due to instability or tight lens Lens. 2015; 41(1):3-11
syndrome. 6. Schornack MM, Patel SV. Scleral lenses in the management of
E. The definition of scleral lenses is evolving. “Mini- keratoconus. Eye Contact Lens. 2010; 36(1):39-44.
scleral,” corneoscleral, and intralimbal lenses may 7. Ucakhan OO, Bayraktutar B. KeraSoft 3 contact lenses in corneal
not perform as well as scleral lenses. ectasia. Eye Contact Lens. 2014; 40:390-394.
F. PROSE treatment is a good option for contact lens 8. Van der Worp E, Bornman D, Ferreira DL, Faria-Ribeiro M,
and even scleral lens failures and can accommodate Garcia-Porta N, González-Meijome JM. Modern scleral contact
any cone. lenses: a review. Cont Lens Anterior Eye. 2014; 37(4):240-250.
1. Ashwin PT. Br J Ophthalmol. 2010; 94:965. 10. Shetty R. Br J Ophthalmol. 2014; 98:1033.
2. Caporossi A. Am J Ophthalmol. 2010; 149:585. 11. Sorkhabi R. Int Ophthalmol. 2013; 33:61.
3. Coskunseven E. J Refract Surg. 2009; 25:371. 12. Tabibian D. Eye Vis. 2016; 3:11.
7. Hafezi F. J Cataract Refract Surg. 2007; 33:2035. 2. Kanellopoulous AJ. J Refract Surg. 2009; 25:S812.
8. Hashemi H. Ophthalmology 2013; 120:1515. 3. Kanellopoulos AJ. J Refract Surg. 2011; 5:323.
9. Henriquez MA. Cornea 2011; 30:281. 4. Kymionis GD. Am J Ophthalmol. 2011; 152:748.
10. Hersh PS. J Cataract Refract Surg. 2011; 37:149. 5. Kymionis GD. J Cataract Refract Surg. 2014; 40:1439.
12. Keating A. Sem Ophthalmol. 2010; 25,249. 7. Muller TM. Klin Monbl Augenheilkd. 2017; 234:451.
13. Kymionis GD. Cornea 2014; 33:1071. 8. Rubinfeld R. J Cataract Refract Surg. 2017; 43:131.
14. Poli M. Cornea 2013; 32:583. 9. Seiler TG. J Cataract Refract Surg. 2015; 41:2165.
15. Raiskup F. J Cataract Refract Surg. 2015; 41:41. 10. Tuwairqi WS. J Refract Surg. 2012; 28:341.
6. Panda A. Cornea 2012; 31:1210. 17. Yuksel N. Int Ophthalmol. 2011; 31:513.
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1. Abdelrahman GS. J Cataract Refract Surg. 2013; 39:1164. 4. Cinar Y. Cutan Ocul Toxicol. 2013; 33:218.
3. Caporossi A. J Cataract Refract Surg. 2013; 39:1157. 6. Shetty R. Am J Ophthalmol. 2015; 160:243.
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NOTES
44 Section VI: Inflammatory Conditions of the Anterior Segment 2017 Subspecialty Day | Cornea
I. What Is Dry Eye (DE)? IV. What Can These Tests Tell Us about DE?
A. Symptoms A. Underlying pathophysiology
B. Signs B. Predicting outcome
II. What Are Mechanisms Underlying DE? V. Information / Cost Analysis
A. Inflammation VI. What Can We Expect in the Future?
B. Nerve dysfunction
III. What Point-of-Care Testing Is Available for DE
(Including Cost)?
A. Osmolarity testing (TearLab)
B. MMP9 (Quidel)
C. Immunoglobulin E and lactoferrin (Advanced Tear
Diagnostics)
2017 Subspecialty Day | Cornea Section VI: Inflammatory Conditions of the Anterior Segment 45
Non-Vision Threatening Ocular Allergy (>90% of rate (Zaditor, Alaway), azelastine HCl (Optivar), epi-
cases) nastine HCl (Elestat), bepotastine (Bepreve)
■■ Topical steroids: loteprednol etabonate (Alrex and
■■ Seasonal allergic conjunctivitis (SAC): Caused by air-
Lotemax)
borne pollens from trees, grass, and weeds. Symptoms ■■ Nonsedating oral antihistamines
are episodic and can occur in spring, summer, or fall ■■ Immunotherapy: Allergy shots (subcutaneous immuno-
(depending on exact etiology).
therapy [SCIT])
■■ Perennial allergic conjunctivitis (PAC): Caused by mold, ■■ Nonpharmacologic
dust mites, cockroaches, animal dander (chronic expo- ●● Education is very important.
sure) ●● Allergy testing to figure out the cause of allergy
Vision-Threatening Ocular Allergy (small pollen days. Sunglasses can provide a barrier.
percentage of cases) ●● No eye rubbing because eye rubbing degranulates
The majority of allergy patients have nasal symptoms (aller- animals sleeping in bed (if allergic).
gic rhinitis) in addition to conjunctivitis. Allergy can also affect ●● If dustmite allergy: Hypoallergenic bedding, wash
the mucous membranes in the airway and cause more throat sheets in hot water. Put pillows in dryer on high heat.
itching, as well as asthma. Treatment should be directed to the
site of allergy. Oral nonsedating antihistamines such as cetiri-
46 Section VI: Inflammatory Conditions of the Anterior Segment 2017 Subspecialty Day | Cornea
4. Motility restriction
5. Limbal stem cell deficiency
6. Corneal complications
48 Section VI: Inflammatory Conditions of the Anterior Segment 2017 Subspecialty Day | Cornea
I. Risk Factors 3. Tung CI, Perin AF, Gumus K, Pflugfelder SC. Tear meniscus
dimensions in tear dysfunction and their correlation with clinical
A. High interferon (IFN) activity correlates with parameters. Am J Ophthalmol. 2014; 157(2):301-310.e301.
severity of ocular surface disease.
4. Pflugfelder SC, De Paiva CS, Moore QL, et al. Aqueous tear defi-
B. Intestinal dysbiosis is associated with more severe ciency increases conjunctival interferon-gamma (IFN-gamma)
ocular and systemic disease severity. expression and goblet cell loss. Invest Ophthalmol Vis Sci. 2015;
56(12):7545-7550.
II. Ocular Surface Disease Profile
5. Alex A, Edwards A, Hays JD, et al. Factors predicting the ocular
A. Greatest perturbation of tear function and ocular surface response to desiccating environmental stress. Invest Oph-
surface health among dry eye conditions thalmol Vis Sci. 2013; 54(5):3325-3332.
B. Heightened response to desiccating environmental 6. Moore QL, De Paiva CS, Pflugfelder SC. Effects of dry eye thera-
challenge pies on environmentally induced ocular surface disease. Am J
Ophthalmol. 2015; 160(1):135-142.
C. Severe conjunctival goblet cell loss that may create
7. Galletti JG, Guzman M, Giordano MN. Mucosal immune toler-
a vicious immune cycle with:
ance at the ocular surface in health and disease. Immunology
1. Loss of immune tolerance 2017; 150(4):397-407.
E. Thyroid function testing 3. Fraunfelder FW. Liquid nitrogen cryotherapy of superior limbic
keratoconjunctivitis. Am J Ophthalmol. 2009; 147(2):234-238.
2017 Subspecialty Day | Cornea Financial Disclosure 51
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52 Financial Disclosure 2017 Subspecialty Day | Cornea
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