Eyeworld

Cornea Society News – published quarterly by the Cornea Society 3 also important factors to consider. "You can keep the pupil dilated after phaco," Dr. Walter said, adding that the surgeon can easily plan for topical anesthesia for a combined procedure. Dr. Daluvoy argued that "less is more," sharing her reasons for separate procedures. A staged procedure means less surgery time, less risk of IOL in- stability, less risk of DSEK/DMEK graft complications, less special positioning, and less risk of rejection. Maybe you just need cataract surgery, Dr. Daluvoy said, adding that it's possible to perform an "endotheli- al friendly" cataract surgery. With no EK needed, this would mean no risk of rebubbling and no risk of rejection. When you perform cataract surgery first, she said there are a number of advantages. Intraoperatively, you can perform the cataract in a normal fash- ion. The CCC sizing and capsular tears are less of an issue, and the IOL com- plex/AC is more stable. Postoperatively, Dr. Daluvoy said that there is no special positioning required and no risk of graft detachment. The patient may be happy with the vision as well. Some patients may only need an EK procedure. Intraoperatively, there is less pupil management required and less likelihood of leaky paracentesis inci- sions. Postoperatively, there is lower risk of graft dislocation and low risk for sub- sequent CE. A clear cornea and known refractive error can help ensure more ac- curate IOL choices. Accommodation can be preserved and there may be better quality of vision, Dr. Daluvoy said. Corneal crosslinking (CXL) was the topic of another session at Cornea Day. The incorporation of CXL into a prac- tice requires some careful consideration of several factors, including education, Sam Garg, MD, Tustin, California, told attendees. Surgeons should remind pa- tients that CXL is not refractive surgery and that they will maintain their current visual status after the procedure. Patients should also know that there likely will be initial steepening followed by flatten- ing and that 1% to 2% of those having CXL can experience complications. The ideal CXL candidate is young, able to lay still, has a clear visual axis, and can see well in glasses, Dr. Garg said. Patients who are not good candidates usually are older and have scarring and very thin corneas. There are also practice management concerns with CXL, according to Nicole Fram, MD, Los Angeles. For example, you'll want to educate your staff about what CXL is, who is a candidate, and what financial considerations are in- volved. "The financial [aspect] is huge," Dr. Fram said. Consider where you will perform CXL; two typical locations would be a laser suite or a short procedure room. Make sure to train at least two techni- cians on how to work with CXL proce- dures, in case one technician is sick and unavailable. Block out 90 minutes for each CXL case, and always work with a sterile technique. This is important be- cause there is a risk for bacterial keratitis, she said. Some novel uses of CXL going forward include for infection, pellucid marginal degeneration, LASIK Xtra, and for pseudophakic bullous keratopathy, said Kristiana Neff, MD, Ladson, South Carolina. Other uses that researchers are beginning to explore include small in- cision lenticule extraction (SMILE, Carl Zeiss Meditec, Jena, Germany), leaking blebs, and scleral CXL for myopia. The use of CXL in these novel capacities requires more long-term study in larger cohorts, Dr. Neff said. As part of a series of presentations focusing on dry eye disease, Deborah Jacobs, MD, Boston, addressed the pain syndrome that occurs in some patients, even if they have few clinical symptoms of dry eye. Dr. Jacobs discussed the difference between nociceptive and neu- ropathic pain, noting that patients with neuropathic pain and dry eye may be perceived as "crazy" because they have minimal symptoms. Research is ongoing for the best diagnostic criteria for dry eye as a pain syndrome, Dr. Jacobs said. The use of biologicals to treat dry eye will continue to grow in the future, said Bennie Jeng, MD, Baltimore. He discussed autologous serum for dry eye and how far it has evolved in the past decade. However, "it's not a magic bul- let," he said. Per the U.S. Food and Drug Administration's definition of biologi- cals, there are other treatments that fall into this category, including allogeneic serum and amniotic membrane. CN Editors' note: Dr. Walter has financial in- terests with SightLife (Seattle). Dr. Fram has financial interests with Alcon (Fort Worth, Texas), Johnson + Johnson Vision (Santa Ana, California), and other ophthalmic companies. Dr. Garg has financial interests with Alcon, Allergan (Dublin, Ireland), and other ophthalmic companies. Dr. Jeng has financial interests with Alcon, Avedro (Waltham, Massachusetts), and other oph- thalmic companies. Dr. Neff has financial interests with Sun Ophthalmics (Princeton, New Jersey). Drs. Jacobs, Cortina, and Daluvoy has no financial interests related to their comments. Dr. Neff discusses new uses of CXL. continued from page 1

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