Eyeworld

66 | EYEWORLD | JULY 2023 C ORNEA What would you do with these irregular cornea cases? by Liz Hillman Editorial Co-Director About the physicians Kenneth Beckman, MD Comprehensive EyeCare of Central Ohio Westerville, Ohio Ramy Riad Fikry, MD, PhD Cairo University Cairo, Egypt Sumit "Sam" Garg, MD Professor of Ophthalmology Gavin Herbert Eye Institute University of California, Irvine Irvine, California Karolinne Rocha, MD, PhD Associate Professor of Ophthalmology Medical University of South Carolina Charleston, South Carolina Audrey Talley Rostov, MD Northwest Eye Surgeons Seattle, Washington Marcony Santhiago, MD, PhD Professor of Ophthalmology University of Sao Paulo Sao Paulo, Brazil Neda Shamie, MD Maloney-Shamie Vision Institute Los Angeles, California Nir Sorkin, MD Tel Aviv University Tel Aviv, Israel William Trattler, MD Center for Excellence in Eye Care Miami, Florida I n a symposium at the 2023 ASCRS Annual Meeting, six cases with irregular corneas were presented and the panel was chal- lenged to answer what would they do. Here's an overview of those cases. Case 1: Young patient for LASIK eval with borderline topo irregularity William Trattler, MD, presented this case, featuring a 30-year-old male seeking refractive surgery whose Pentacam (Oculus) imaging showed inferior steepening. His corneas had thicknesses of 540 and 550 microns, and he was a mild myope (OD: –3.75+0.25x032, OS: –3.5 sphere) who corrected to 20/20. Dr. Trattler also presented that the patient had Belin/ Ambrosio Enhanced Ectasia Display (BAD) scores of 1.44 and 1.26. Dr. Trattler said that even though there is inferior steeping, the BAD scores are in the normal range. From there, Dr. Trattler presented the patient's epithelial thickness maps, which showed epithelial hyperplasia, confirmed by a second map from a second device that measures epithelial thickness. "This patient has steepen- ing not due to an abnormal stromal shape, but due to epithelial hyperplasia," Dr. Trattler said, noting that research by Dan Reinstein, MD, has shown that corneal refractive surgery is safe in these cases. Neda Shamie, MD, said she would want to optimize the ocular surface and make sure the patient was out of contact lenses long enough to confirm that it wasn't transient epithelial hyperplasia and after that would be comfortable with a corneal-based procedure. Sumit "Sam" Garg, MD, suggested doing genetic testing for keratoconus might be helpful. Case 2: Young patient for LASIK evaluation with high score on genetic testing but normal topography Nir Sorkin, MD, shared this case of a 25-year- old female with no family history of keratoconus who was interested in refractive surgery. Her manifest refraction was –3.25/–0.5x180 correct- ing to 20/20 in the right eye and 3.5/–0.5x180 correcting to 20/20 in the left. Her slit lamp exam was unremarkable and Pentacam images, BAD score, pachymetry, and epithelial maps were normal. However, genetic testing showed she was at high risk for keratoconus. "She's the ideal LASIK candidate, but she's had genetic testing, high scoring," Dr. Sorkin said. Dr. Trattler said that, while he's a fan of ge- netic testing, he thinks topography and tomog- raphy are more important preoperative tests in determining candidacy for laser vision correc- tion. "I would offer laser vision correction but would tell the patient that we're going to follow you every year with topography, and if we see findings that are suspicious for ectasia, we'll do crosslinking," he said, noting that an ICL could also be considered. Kenneth Beckman, MD, noted the scale on the topography. He said if the scale was a half a diopter it could show irregularities on the topography. Marcony Santhiago, MD, PhD, said that the genetic test could be a false positive. Case 3: Patient with post- refractive ectasia (unstable) for cataract evaluation Neda Shamie, MD, shared the case of a 56-year- old referred for cataract consultation who had prior LASIK that she was happy with until a few years ago when she began to need glasses again. The patient's manifest refraction was –0.75–3.25x003, correcting to 20/30, in her right eye and –0.75–2.25x007, correcting to 20/40, in her left. "This patient has cataracts, but when a pa- tient has LASIK and you see a lot of astigmatism in their refractive error, that's a red flag," Dr. Shamie said, bringing up that her topography showed ectasia. In counseling a patient like this, Dr. Beck- man said he'd want to see old refraction and old topographies, if possible, to confirm stability. It would help address if you're doing the cornea or the lens first, he said. Dr. Shamie said they had previous data that showed progression. She said the plan was to crosslink first, then wait to allow stabilization to obtain measurements for cataract surgery.

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