Eyeworld

EW FEATURE 68 Refractive corrections • March 2019 Obtaining continued from page 66 A suspect for keratoconus because high irregular astigmatism is truncated. The thickness maps suggest keratoconus, but this is probably a very central cone, which tricks the device's artificial intelligence. Belin/Ambrosio Enhanced Ectasia display, which is used to detect earlier keratoconic changes, shows the patient is relatively normal. Anterior segment OCT thickness maps look normal, but the epithelial thickness map shows the epithelium has remodeled in order to hide the extremely central cone. Source (all): John Kanellopoulos, MD Age detection Although about 60% of keratoconus patients are male, all patients should be screened, Dr. Trattler said. That is especially true if they experience changes in refraction. It can be difficult to test very young patients with topography and and follow these patients closely, every 3 months, and recommend crosslinking with our Athens proto- col, which appears to be the most effective and the most productive way to correct these eyes, even if the ablation is minimal," Dr. Kanello- poulos said. Patients who refract even to 20/25 but who are unable to drive comfortably and do their daily chores are candidates for treatment. Moving to crosslinking For Dr. Belin, moving to performing to crosslinking varies on the age of the patient and the severity of the disease. "The younger the patient, typi- cally the more aggressive the disease is, and there is a good argument to crosslink children when a definitive diagnosis is made," Dr. Belin said. "On the other hand, in adults, we often monitor for disease progres- sion." Monitoring requires tomo- graphic evaluation, as many patients show progression despite appearing to have a stable anterior surface or Kmax, Dr. Belin said. As a general rule, Dr. Kanello- poulos crosslinks diagnosed patients younger than 20 years old, even without documented progression. If the keratoconus is mild—stage 2 and under—he explores a refractive transepithelial or epithelium-on crosslinking with the advanced KXL System (Avedro, Waltham, Massachusetts) offering customized pattern ability. If there is documented progres- sion, Dr. Kanellopoulos crosslinks as soon as possible. A crucial point is to establish a parallel strategy to avoid eye rubbing, he said. EW Editors' note: Dr. Belin has financial interests with Oculus, Avedro, and CXL Ophthalmics (Sherborn, Massachu- setts). Dr. Ambrósio has financial in- terests with Oculus, Alcon (Fort Worth, Texas), Carl Zeiss Meditec (Jena, Ger- many), Mediphacos (Belo Horizonte, Brazil), and Essilor (Charenton-le-Pont, France). Dr. Kanellopoulos has finan- cial interests with AJKMD Events, Alcon, Avedro, ISP Surgical (Bangkok, Thailand), Tula Medical (Doylestown, Pennsylvania), and Carl Zeiss Meditec. Dr. Trattler has financial interests with ArcScan (Golden, Colorado), Avedro, Oculus, and CXL Ophthalmics. Contact information Ambrósio: dr.renatoambrosio@gmail.com Belin: MWBelin@aol.com Kanellopoulos: ajkmd@mac.com Trattler: wtrattler@gmail.com tomography, and the youngest Dr. Trattler is able to reliably test range from 7 to 9 years old. Dr. Ambrósio urged screening patients beginning at 4 or 5 years old, depending on the cooperation of the child. Improved treatments have changed the paradigm in keratoco- nus screening, Dr. Kanellopoulos said. The advent of corneal cross- linking, which can halt progression of the disease and even reverse some of its manifestations, has made screening patients pivotal to prevent young adults or teenagers suffer- ing from severe visual debilitation related to keratoconus. The ideal screening age is 16 or 17 years old, especially for males, but Dr. Kanel- lopoulos images the cornea of every patient evaluated in the office for any reason. Dr. Kanellopoulos also pursues scans for relatives of known patients with keratoconus. Additionally, it is important to educate optometrists and ophthal- mologists on the need for screening. Dr. Ambrósio agreed on the need for enhanced corneal imaging technologies, especially for high-risk patients such as children who rub their eyes and family members of keratoconus patients. "The clinician should do what is available, but ideally, every child should have corneal imaging tests done, and these should be stored in a database for future reference com- parison," Dr. Ambrósio said. Patient education Post-diagnosis, the first step in patient education for Dr. Trattler is to address eye rubbing, which is a known risk factor. "I have them do what they can to avoid eye rubbing, although that's difficult because eye rubbing is a habit that can be hard for some patients to modify or eliminate," Dr. Trattler said. Dr. Ambrósio also agreed with the importance of educating pa- tients not to rub the eye so as not to cause nocturnal eye pressure. Dr. Trattler also talks to patients with keratoconus about the impor- tance of the crosslinking procedure to strengthen the cornea to prevent progression of their condition. Dr. Kanellopoulos' post-diag- nosis approach is tailored to the patient's age, the residual cornea thickness at the thinnest part of the cornea, and the level of patient functioning. For instance, among patients 15 to 25 years old, Dr. Kanellopou- los focuses on not letting them slip through and progress rapidly. But he examines patients older than 35 years old every 1 or 2 years or more if their symptoms change. "Under the same token, if the cornea thickness is less than 450 microns, I am much more aggressive

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