Eyeworld

Cornea Society News – published quarterly by the Cornea Society 4 Asia Cornea Society Meeting wrap up T he Asia Cornea Society (ACS) 5th Biennial Scientific Meeting was held in December in Seoul, South Korea, with presentations cov- ering a variety of cornea-related topics throughout the meeting. Diagnosis and treatment in cornea The Asia Cornea Foundation Lecture was given by Choun-Ki Joo, MD, PhD, Seoul, South Korea, on the topic of "De- velopment of Diagnosis and Treatment in the Corneal Field." In his lecture, Dr. Joo highlighted the change in corneal research over the years, stressing the tremendous devel- opments in diagnosis and treatment. In terms of diagnosis, he discussed biolog- ical character, optical anatomy, biome- chanics, and tear film. Dr. Joo spoke about the timeline of different treatment options in refrac- tive surgery and keratoplasty. The first theoretical work on the potential of refractive surgery was done in 1896, he said, with the first attempt at performing surgery occurring in 1930. Refractive surgery can be broken down into flap procedures, surface procedures, corneal incision procedures, and presbyopia surgery. With keratoplasty, different cate- gories include full thickness, anterior lamellar, posterior lamellar, other kerato- plasty, and computerized. Dr. Joo also discussed the future in cornea, stressing that he thinks diagno- sis and treatment should be integrated. Options in corneal imaging Carol Karp, MD, Miami, spoke about how high-resolution OCT has changed her ocular surface oncology practice. In diagnosis of ocular surface lesions, the gold standard is histopathology, she said. But it would be nice to have a way to find out what's going on before doing a biopsy, Dr. Karp said, and high-reso- lution OCT is a great way to do this. It helps to show the tear film, epithelium, Bowman's layer, stroma, features of the endothelium, and Descemet's mem- brane. Dr. Karp first started to realize the benefit of this technology in her work in 2009. She demonstrated the features of ocular surface squamous neoplasia (OSSN) on an OCT. In reading an OCT, you first find the normal epithelium, then find the inferior edge of the ep- ithelium, assess the main lesion, and determine if there is epithelial or subep- ithelial. For OSSN, you will see normal epithelium, then an abrupt transition from normal to abnormal, and then a thickened hyper-reflective epithelium, she said. In summary, Dr. Karp said that high-resolution OCT is an exciting new technology for ocular surface imaging. It has a high degree of correlation with histopathology, and is an "optical biop- sy," providing an excellent adjunct to clinical acumen. Dr. Karp said that it has revolutionized her practice. Plenary "puts the pieces together" In "Putting the Pieces Together: Ap- proaches in the Investigation and Man- agement of Atypical Corneal Infections," Elmer Tu, MD, Chicago, took the opportunity of giving the first Plenary Lecture of the Asia Cornea Society 5th Biennial Scientific Meeting to take a breather from big data and highlight the value of what he called "small" and "very small data." "We'll go the opposite way from big data," Dr. Tu said. Rather than following the trend toward big data forward, he began by looking into the past. England in the 1800s, Dr. Tu said, was "somewhat of a miserable experi- ence." For centuries, he said, there had been no real improvement in terms of life expectancy, with most people dying in their 30s and 40s, "much like a may- fly after mating." This was in no small part due to various European pandemics, such as the bubonic plague and cholera. Com- pounding the abyss of the period's prim- itive level of technology, hygiene, and abbreviated life spans, there was no real way of stopping these pandemics other than by isolating subjects to prevent infecting others. At the time, the prevailing theory for transmission of disease was the mias- matic theory—diseases such as chol- era, it was believed, were transmitted through exposure to "bad air," typically emanating from foul or rotting organic matter. Diseases were thus believed to be transmitted through breathing rather than direct contact or ingestion. This theory, Dr. Tu said, had been held throughout history, and as an inter- vention in the case of cholera epidemics in London, the city began directing human waste away from homes and into the river Thames to keep "bad air" out of the city. Enter John Snow—who, as it turns out, knew something. A skeptic of the miasmatic theory, Snow had previously written on his theory of the origin of cholera outbreaks in 1849. He identified a particular water company supplying South London that he associated with more than 50% of deaths in all of London. Following the Soho cholera out- break in August 1854, the Reverend Henry Whitehead, miasmatic theorist and self-styled "mythbuster" of his age, met John Snow through a local commis- sion to investigate cholera. He immedi- ately set out to disprove Snow's theory. However, after interviewing local residents, Reverend Whitehead mapped the subjects around a single water source—and ultimately came to believe Snow. He used small data to get to the bottom of why cholera outbreaks were occurring. This led to the eventual demise of the miasmatic theory and the eventual acceptance of germ theory. The case of the Broad Street tap, Dr. Tu said, is an example of how to approach other human diseases—really, he said, this was "the birth of epidemiol- ogy." More than just statistics, epidemi- ology brings together experts from mul- tiple disciplines to collaborate in a small, well-designed study asking appropriate questions based on a best understanding of a disease. Fast forward to the present: Turns out, Dr. Tu said, atypical corneal in- fections are "quite amenable" to this approach. His particular experience, he said, has been with Acanthamoeba keratitis—a traditionally rare disease with a reported incidence of two cases per million con- tact lens wearers per year; easily trace- able using special diagnostic modalities requiring specialized, compound medica- tions; and primarily a disease of the eye.

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