Eyeworld

EW MEETING REPORTER 94 February 2011 a patient off prostaglandins and then waits 4-8 weeks to see how the pressure rises. "I take the highest pressure served during that period and use it as a baseline IOP," he said. At 3 months, he determines the ef- fect of the laser and then rechal- lenges the patient "with the assumption that if I did the proce- dure correctly, there should be a pressure-lowering effect." In the first 24 patients, the baseline was 16.57. When the prostaglandins were with- drawn, it went up to 21.73. "Then I lasered the patients, and at 3 months, without analogs, … the ef- fect of the laser was almost always a little bit lower than the effect of the prostaglandin." Dr. Alvarado said that SLT is 100% predictable. "SLT provides stability over a 24-hour pe- riod, compared to medication. That is a distinct advantage. Therefore, laser trabeculoplasty may be used as a primary therapy because it's safe, efficacious, and gets rid of the com- pliance issues." Editors' note: Dr. Wiggs is a NEIGH- BOR collaborator. Dr. Singh has finan- cial interests with Alcon, Allergan, and Santen (Napa, Calif.). Dr. Huang has a financial interest in OCT technology with OptoVue (Fremont, Calif.) and Carl Zeiss Meditec. Dr. Francis has a fi- nancial interest with Humedica (Boston). On Thursday, January 20, Hawai- ian Eye 2011 focused on manage- ment of the ocular surface. Endothelial keratoplasty: What's new and what's coming Newer endothelial keratoplasty pro- cedures offer rapid visual recovery and minimal refractive surprises be- cause of smaller incisions and, de- spite being more complicated to perform, are the rising stars of grafts, according to a speaker here. "De- scemet's membrane endothelial ker- atoplasty (DMEK) is going to be the standard of care if we want good vi- sion," said Francis W. Price Jr., M.D., Price Vision Group, Indi- anapolis, and president of the board, Corneal Research Foundation of America, Indianapolis. Endothelial keratoplasty has become the stan- dard of care in the United States, ac- counting for more than 40% of all grafts in the country. "We just reported our 5-year sur- vival rates and we found that our Fuchs' patients have a 95% survival with these grafts; pseudophakic/ aphakic bullous keratopathy is 76%. Probably what's more interesting is that in Fuchs' patients, the most common reason we regraft is be- cause of poor vision—not 20/40 or better," Dr. Price said. PBK/ABK grafts fail in eyes that have a glau- coma filter or tube, Dr. Price re- ported. Despite Descemet's stripping endothelial keratoplasty's (DSEK) success rate, surgeons are moving on to other procedures, including DMEK and Descemet's membrane automated endothelial keratoplasty. "It's all about vision," Dr. Price said. "We don't get as many 20/20 results as I think we should, especially in comparison to cataract surgery." Also, DSEK surgery's 5-mm incisions sometimes cause astigmatism, and transplanting the stroma can cause a hyperopic shift and macro/micro folds in the tissue. Although DMEK and DMAEK procedures, which in- volve tricky manipulation of ex- tremely thin donor tissue, are harder to perform, they offer more rapid vi- sual recovery and few refractive sur- prises, Dr. Price said. New transplant devices Henry D. Perry, M.D., clinical asso- ciate professor of ophthalmology, Weill School of Medicine, Cornell University, New York, touted the benefits of the Neusidl Corneal In- serter (NCI, Fischer Surgical, Impe- rial, Mo.) for DSEK. Currently, surgeons fold the donor tissue and use forceps for insertion and another forceps to grab the tissue. The NCI folds the donor tissue without over- lap, and endothelial cells rarely come into direct contact. No vis- coelastic is required during the sur- gery, and the tissue is protected dur- ing insertion through the incision, which, according to Dr. Perry, should be 5.2 mm. The NCI plat- form unfolds the donor tissue in the anterior chamber without extra ma- nipulation. The irrigation portion of the device deepens the anterior chamber to prevent tissue trauma. "The cornea looks very good," he said, after showing a video of the technique. "These are the first pa- tients I've seen the next day with 20/50 or 20/60 vision. Overall I think this is probably the best unit at this time, but there are problems." Among the problems are that the tis- sue sometimes sticks once it's inside the eye and the $150 per-unit cost. Beyond PK for keratoconus patients The Boston Ocular Surface Prosthesis (Boston Foundation for Sight, Need- ham, Mass.), which is becoming available around the country, is an updated option for keratoconic pa- tients, according to Michael B. Raiz- man, M.D., Ophthalmic Consultants of Boston Inc. "This is a very important inno- vation, in my view," he said. "I would say my rate of penetrating keratoplasty has dropped more than 50% from this single innovation." Corneal collagen crosslinking, which is not yet FDA approved in the U.S., and thermal keratoplasty are two other procedures that are helping surgeons decrease their re- liance on PK, Dr. Raizman said. The procedure not only flattens the cornea, but also improves vision, he said, adding that FDA trials will be revived in the next few months and completed within a year. "Of course, we hope the FDA approval will follow. A lot of our patients will benefit," Dr. Raizman said. "There are a lot of centers in the U.S. doing this off-label right now. I think this will become a pretty common proce- dure for managing our patients with kerataconus." Thermokeratoplasty, which provides better application of the heat in a more controlled man- Reporting live from the 2011 Hawaiian Eye Meeting, Maui, Hawaii by Jena Passut Editors' note: This Meeting Reporter contains original reporting by the EyeWorld news team continued from P. 93 continued on page 96

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