Eyeworld

R by Liz Hillman Editorial Co-Director About the physicians Brandon Ayres, MD Cornea Service Wills Eye Hospital Philadelphia, Pennsylvania Kenneth Beckman, MD Director of Corneal Surgery Comprehensive Eyecare of Central Ohio Westerville, Ohio Michael W. Belin, MD Professor of Ophthalmology and Vision Science University of Arizona College of Medicine Chief Medical Officer Epion Therapeutics Tucson, Arizona Roy Rubinfeld, MD Clinical Professor Georgetown University Medical Center Medical Director, ReVision Washington, D.C., and Rockville, Maryland William Trattler, MD Director of Cornea Center for Excellence in Eye Care Miami, Florida EVOLVING WINTER 2024 | EYEWORLD | 47 C rosslinking to stop progression of keratoconus and post-surgical ectasia has undergone an evolution both in the U.S., where it was first approved in 2016, and outside the U.S., where it has been in use significantly longer. With new techniques in (or having recently completed) Phase 3 clinical trials to potentially move crosslinking to the next stage in the U.S., EyeWorld spoke with specialists to take a look back at where keratoconus monitoring and treatment was, where it is now, and what could be coming in the future. Then: transplants Prior to crosslinking becoming available in the U.S., there was no treatment for keratoconus patients until they needed corneal transplants. "Documenting progression was important back then but for different reasons. Back in the day, there was nothing in the U.S. approved to stop progression," said Kenneth Beckman, MD. "There were things to give you better vision in the moment, such as intrastromal cornea rings. Prior to crosslinking, patients basically lived with glasses and contacts until they needed a transplant. For as long as you could keep them functioning in a contact, you didn't do the trans- plant. … That was the previous strategy." The tools to diagnose and monitor were not as sophisticated as they are now. Dr. Beck- man said all that was available was topography (which was not as good as today's technology), clinical signs (such as thinning or the Munson's sign), or significant refractive changes. Roy Rubinfeld, MD, said keratoconus man- agement was "pretty primitive" back then. "You would hope they wouldn't get worse, and hope is not a medical plan," he said. Now: epithelium off In 2016, the FDA approved the Avedro cross- linking system—a combination of riboflavin loading on the cornea from which the epitheli- um had been removed followed by continuous UV light exposure for 30 minutes—for treat- ment of documented progressive keratoconus. Glaukos acquired Avedro in 2019. iLink—Pho- trexa Viscous (riboflavin 5'-phosphate in 20% dextran ophthalmic solution) and Photrexa (riboflavin 5'-phosphate ophthalmic solution) for use with the KXL System—remains the only FDA-approved crosslinking system in the U.S. Since this became available, alongside sig- nificantly improved diagnostics, many changes have occurred in keratoconus management. New corneal imaging systems (topography and tomography), Dr. Beckman said, have allowed earlier and more accurate diagnosis of kerato- conus, which is important to identify and treat early to stop progression and prevent subse- quent, irreversible vision loss. Dr. Beckman also said epithelial mapping has been helpful in differentiating thickened epithelium from a steep cornea. Tracking progression of keratoconus has now become critical, as documented progres- sion is indicated for use with the currently approved crosslinking system. Dr. Beckman said it's also important to consider risk for progression. If you're seeing a young patient who already has a significant cone, waiting to document progression could result in increased Crosslinking: then, now, and next up continued on page 48 Severe keratoconus with scarring Source: Kenneth Beckman, MD

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