Eyeworld

EW CORNEA 64 May 2017 ate to severe level of inflammation from their dry eyes, as evidenced clinically or via a positive Inflam- madry test, then I will be more likely to do a short course of Lotemax [loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb, Bridgewater, New Jersey] concurrent- ly while starting either Restasis or Xiidra," Dr. Starr said, adding that this helps to break the inflammatory cycle as quickly as possible. "What I really like about the Lotemax gel (loteprednol etabonate gel, Bausch + Lomb), the new formulation, is that it's an emulsion. It doesn't need to be shaken, and due to its mucoad- hesive properties it is gentle on the eye and very well tolerated, and in the short duration used for DED/ OSD it is very safe, avoiding the serious potential steroid side effects encountered with longer-term use," he said. Likewise, Dr. Farid also includes steroids in patient regimens for flare-ups. She also prefers the Lotemax gel because of the vehicle which she finds sits on the eye and penetrates it a bit better. However, in some cases, she will perhaps reach for FML instead in these cases. Alrex, she finds, tends to be really mild, although in some cases she has used this in kids. One new steroid under Don't forget continued from page 61 development that she is looking forward to hopefully adding to the armamentarium is loteprednol in a nanoparticle (Kala Pharmaceu- ticals, Waltham, Massachusetts). "It's supposed to have a little better penetration into the ocular surface and then less side effect profile," Dr. Farid said. Overall, Dr. Starr views the new options today as a boon for combatting dry eye disease. "It does make the discussion and clinical decision-making a little bit more complex, but it's also very exciting to have more options to choose from and patients ultimately benefit greatly. It's an exciting new era in ocular surface and dry eye disease, with even more treatment and diagnostic options coming down the pipeline," he concluded. EW Editors' note: Dr. Farid has financial interests with Allergan, Kala, RPS, Shire, and Tear Science (Morrisville, North Carolina). Dr. Starr has financial affiliations with Allergan, Bausch + Lomb, RPS, Shire, and TearLab (San Diego). Contact information Farid: mfarid@uci.edu Starr: cestarr@med.cornell.edu graft by 0.5 mm in elderly patients because the equipment he uses for cutting typically gives him postop K-readings in the vicinity of 42 to 43. For patients with keratoconus or using tissue from a younger donor, Dr. Van Meter may oversize the donor by only 0.25 mm. For emer- gency patients that require a large scleral graft for corneal perforation, he may oversize by 1 mm. In most non-keratoconus cases, Dr. Verdier routinely sizes the donor tissue trephine 0.25 mm larger than the host trephine. "If the corneal horizontal white- to-white [WTW] measurement is 12.0, I use an 8.0 mm for the host and 8.25 mm trephine for the graft; if WTW is 11.5, I use a 7.50 mm or 7.75 mm host trephine; and if WTW is 12.5, I use an 8.25 mm or 8.5 mm host trephine," Dr. Verdier said. For keratoconus eyes, Dr. Verd- ier uses the same size trephine for both host and donor to flatten the cornea and reduce myopia. "In keratoconus, most cones are inferiorly displaced, and the donor graft should be sized and positioned to fully encompass the area of cone involvement," Dr. Verdier said. Smaller vs. larger grafts Larger grafts, especially greater than 8.5 mm diameter, have an increased risk of rejection as the graft–host junction moves closer to the limbus, Dr. Verdier said. However, Dr. Van Meter noted that with current im- munotherapy drops there is less of a problem with rejection than in the past. Smaller grafts tend to induce more corneal astigmatism near the visual axis than larger grafts, Dr. Van Meter said, while larger grafts may also require a few more sutures for wound closure than smaller grafts. Larger grafts provide more endo- thelial cells, Dr. Verdier said, which may be an advantage in eyes with Fuchs' dystrophy or other endothe- lial disease. Postop management A typical PK postop management plan will use topical corticosteroid drops 4 times a day for several months and then taper by one drop every 2 months, Dr. Van Meter said. Surgeons should watch for postop problems, such as slow epithelial resurfacing of the graft, poor wound healing, loose or broken sutures, elevated IOP, and high astigmatism. Dr. Van Meter closes a penetrat- ing keratoplasty wound with eight interrupted sutures and a 16-bite continuous suture. He will start removing one or more of his eight interrupted sutures 4–6 weeks post- op for astigmatism control and leave the continuous suture to stabilize the wound. Dr. Verdier typically prescribes prednisolone acetate 1% 4 times per day for the first several months postop. He then tapers by one drop per month down to once per day, and after one year switches to flu- orometholone once per day for long-term anti-rejection mainte- nance, especially if the patient is not phakic. Intraocular pressure should be measured at every visit. Steroid responders comprise up to one-third of patients and are switched to fluo- rometholone or loteprednol. "For high-risk patients I will sometimes use Restasis [cyclospo- rine ophthalmic emulsion 0.05%, Allergan, Dublin, Ireland] up to four times per day," Dr. Verdier said. "Tacrolimus is available in derma- tologic ointment form [Protopic, Astellas, Toyama, Japan] and can be considered as an effective off-label use for treatment of severe or poorly controlled rejection." Three-week postop PK patient who had a history of keratoconus Source (all): David D. Verdier, MD Dr. Van Meter keeps many graft patients on Restasis, but was unaware of any research suggesting that Restasis increases the longevity penetrating grafts. Additionally, he noted that topical compounded tac- rolimus is an effective anti-rejection medicine, but complications around compounding have made it less convenient to use than traditional commercially available drops. Postop residual refractive error management for Dr. Verdier includes spectacles for modest degrees of astigmatism, while gas permeable contact lenses may provide better vision in cases of significant irregular corneal astigmatism, high refractive error, or anisometropia. Recent ad- vances in scleral contact lenses may provide better comfort and vision. Dr. Verdier avoids contact lenses in PK eyes until all sutures are re- moved and has treated high degrees of corneal astigmatism with relaxing incisions in the graft–host junction, which are performed at the slit lamp. If PK patients have unacceptable astigmatism after all sutures have been removed and the patient is un- able to wear rigid gas permeable lens, Dr. Van Meter considers a wound revision or relaxing incision. If that fails, he considers a re-graft. "Remember, the reason the pa- tient had the keratoplasty in the first place is because they could not see well," Dr. Van Meter said. "If they cannot achieve good vision with glasses or a contact lens, then some modification of the cornea shape is necessary. If all else fails, the patient may benefit from a new cornea." EW Editors' note: Drs. Verdier and Van Meter have no financial interests related to their comments. Contact information Verdier: daverdier@aol.com Van Meter: wsvanmeter@aol.com Getting beyond continued from page 62

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