Eyeworld

Reporting from the 5th Asia Cornea Society Biennial Scientific Meeting, December 9–11, 2016, Seoul, South Korea Sponsored by EW MEETING REPORTER 94 Asia—almost 10 times that in devel- oped countries," said N. Venkatesh Prajna, MD, Madurai, India. The region also has a disproportionately higher incidence of fungal keratitis, such that Dr. Prajna said that fungi have replaced bacteria as the most common organism causing suppura- tive keratitis. At a symposium on corneal infection/inflammations, Dr. Prajna discussed the results of a study on the "Efficacy of Oral Voriconazole in Severe Fungal Keratitis." Establishing the background for the recently completed study, Dr. Prajna said that to date, research in antifungals is not in proportion with the magnitude of the disease. Mean- while, he and his colleagues chose voriconazole as the topical treat- ment for fungal infections most pre- ferred by cornea specialists surveyed, as well as for being the agent shown more effective in in vitro studies. Dr. Prajna described the Mycotic Ulcer Treatment Trial (MUTT) 1— comparing topical natamycin versus voriconazole in the treatment of filamentous fungal keratitis—and II—comparing oral voriconazole with placebo in addition to topical voriconazole in the treatment of severe fungal keratitis. The MUTT trials were multicenter trials involv- ing eye centers in India and Nepal. In MUTT 1, natamycin treat- ment was associated with signifi- cantly better clinical and microbio- logical outcomes than voriconazole treatment for smear-positive fila- mentous fungal keratitis. Meanwhile, MUTT II found significant adverse events in the oral voriconazole group—elevated AST or ALT levels (8.4%), hallucination and dizziness (8.5%), and nausea and vomiting (8.4%). Interestingly—and eerily—Dr. Prajna said that patients in the group, regardless of culture or place of origin—all hallucinated having conversations with dead relatives. Following the results of MUTT II, Dr. Prajna and his colleagues con- cluded that there was no benefit in adding oral voriconazole to topical antifungal agents for severe fungal keratitis. EW his "minimalist approach for OSD management." If there is presumed complete limbal stem cell deficiency (LSCD), he said he will only perform surgery if the patient is bilaterally blind or there is a tectonic/therapeu- tic need. "I think less is more," Dr. Tan said. If one eye is seeing well, don't do surgery or consider a con- servative management and perform a limited limbal segmental autograft from the good eye. If there is poor vision in both eyes, only operate on one eye, Dr. Tan said, adding that you should perform surgery for tec- tonic or therapeutic indications. It's also important to avoid damaging remaining limbus or stem cells and to avoid replacing healthy endothe- lium. DALK not only improves vi- sion but restores a normal Bowman's membrane surface, Dr. Tan said, which may potentially stabilize the ocular surface and improve epitheli- al healing. Dr. Tan then described his surgi- cal approach for DALK in OSD. His first step is to optimize ocular surface management prior to surgery, and he recommended preservative-free medications, reducing ocular surface inflammation, and correcting lid abnormalities and blepharitis. Avoid damaging the limbus and peripheral corneal epithelium during the DALK procedure, Dr. Tan said. He also recommended performing a smaller diameter DALK and a pre-descemetic DALK. Using blunt instruments and preparing to dilate the pupil if an air tamponade is needed were other tips he suggested. Dr. Tan said to use a bandage contact lens, as well as preservative-free medications in all cases, and consider lid closure. In conclusion, Dr. Tan said that surgical management of ocular surface disease remains a clinical challenge, and he again stressed that a minimalist approach is advised. Consider just DALK for cases of partial limbal deficiency because it's repeatable and safer than PK. Dr. Tan added that surgeons may want to consider DALK even for focal corne- al perforations. Infectious keratitis in Asia "Infectious keratitis is a big public health problem in many parts of with overseas transportation—for a total ECD loss of 5.68%—and anoth- er study on 40 donor corneas during international shipment underwent 2.3% ECD loss, Dr. Macsai said that the dislocation and rejection rates were comparable with corneas that stayed local before transplantation. It is true, however, that Elmer Tu, MD, has published a study showing that fungal contaminants can be amplified in storage media by more than 100 times by rou- tine warming cycles as compared to a single warming cycle, and Dr. Macsai wondered whether antifun- gal should be added to the storage media. In her lecture, Dr. Macsai also discussed the Notify Project and the Eye Bank Technical Advisory Group. The Notify Project is a global project "born to promote the use of Vigilance & Surveillance (V&S) in the provision and clinical applica- tion of medical products of human origin and to maximize at a global level the benefits to be realized through effective V&S." It aims "to create a compendium of cases of adverse reactions/events for donors and recipients of organs, tissues or cells, noting how they were detect- ed, confirmed and documented and to develop guidance based on the information collected." Meanwhile, the Eye Bank Tech- nical Advisory Group, consisting of representatives from EBAA and other eye banking associations around the world, was formed to standardize terminology and establish the ISBT 128 coding system, which provides globally unique identification num- bers, standardized terminology, and a standardized means of coding in- formation for accurate and efficient electronic transfer. All that in mind, by offering the tightest controls for cornea processing, Dr. Macsai said that the eye bank is where modern cornea surgery begins. Anterior lamellar keratoplasty discussed in symposium In a symposium on anterior lamel- lar keratoplasty, Donald Tan, MD, Singapore, shared his presentation on DALK for ocular surface disease and perforations. He first shared January 2017

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