Eyeworld

MAY 2019 | EYEWORLD | 55 C Allergan) off label. In drop form, this does not have the side effects of the oral version. Dr. Udell noted that NSAIDs are approved for ocular allergies. While these reduce prosta- glandin reactions, there are better medication options to consider. He views this class of med- ications as helpful as a possible adjunct to other allergy medications. Still, there is room for more agents in the arena. Even with everything available, ophthal- mologists don't yet have the perfect drug, Dr. Udell noted. What patients ultimately want is something that acts quickly and lasts for a long time, a criterion he uses when evaluating any allergy medication. response, that gives me a sense that they may not respond to other agents." If such a patient seems desperate, he may give them a steroid to quiet things down and transition them to other agents. In some cases, sensitivity to the BAK preservative can be an issue. Dr. Udell has found that switching patients to a compound- ed, low-dose, preservative-free steroid such as dexamethasone can make it possible to use at a safer 1/10th concentration with excellent outcomes. "We have hundreds of these patients on preservative-free steroids where nothing else works," he said. Dr. de Luise pointed out that for some it may be possible to use Restasis (cyclosporine, whether longitudinally this has any impact on the long-term graft failure." Investigators also found that the leading indication for full thickness procedures con- tinues to be a failed graft, Dr. Gupta reported. Still, partial thickness procedures, which had accounted for about two-thirds of those in the initial study, in a short period of time were up to 85%. She said this could be attributed to im- proved visual outcomes, reduced astigmatism, and possibly fewer suture complications com- pared to penetrating keratoplasty. Dr. Gupta also credits surgeons' growing experience with DMEK, which was new to many in 2013, with practitioners at the time facing a learning curve with the rapid growth of the procedure. DSAEK's popularity held in bullous keratopathy cases. "This has been shown to have less endothelial cell loss post-transplant," Dr. Gupta said, adding that while such bullous keratopathy cases are still mainly treated by DSAEK, DMEK is gaining ground. Results showed that the most common cause for corneal transplant was Fuchs' dystro- phy, which accounted for 42% of the trans- plants performed, with graft failure at 17%, and bullous keratopathy and keratoconus both at 15%. In Dr. Gupta's view, corneal transplantation has changed a lot. "Compared to a decade ago, there has been a huge shift," she said. "In just the last 5 years, partial thickness has dominated compared to PKP, and although DSAEK was the procedure of choice for our most common pathologies, it's now DMEK at the University of Toronto." While many surgeons already favor this, there is opportunity for further growth, she pointed out. Use of precut donor tissue may be one such avenue. "If you remove the time that it takes for DMEK, in terms of OR time when you're preparing corneal tissue and it's ready to go, that's a huge improvement and will help to increase adoption." Going forward, Dr. Gupta thinks more studies are needed to help determine whether new complications or changing impact on graft survival are going to emerge as a result of doing more DMEK. "I think another study similar to this in a few years will help give us some of the longitudinal data to understand whether the observed patterns have changed the outcomes," she said. continued from page 53 Tips for palliative approaches Not all patients need to take an eye drop or pill, Dr. de Luise said. Some can get relief by taking these steps: •Keep windows closed in an area where there are a lot of allergens. •Use cold compresses to reduce the hista- mine response. •Clean air ducts. •Purchase a new cold-mist humidifi- er every couple of years because these can accumulate dust, mold, and mites.

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