Eyeworld

EW FEATURE 82 Update on crosslinking • September 2017 AT A GLANCE • Prevent patient behaviors from adversely impacting crosslinking treatment by aggressively managing allergic eye disease. • Ask family members if the patient is a chronic eye rubber. • Address patients who sleep face down, often sleep apnea patients. by Rich Daly EyeWorld Contributing Writer Patient behaviors to watch for when providing crosslinking treatments S ome patient behaviors can affect the success of cross- linking to strengthen the cornea and halt progres- sive keratoconus. Young keratoconus patients seen by Edward Holland, MD, professor of ophthalmology, Uni- versity of Cincinnati, fall into two groups: those with severe allergic eye disease and those for whom rubbing is habitual. Among allergy sufferers, the eye rubbing is secondary to their under- lying problem. "Before we perform any proce- dure such as crosslinking or kera- toplasty, we want to aggressively to see the diagnosis of sleep apnea in younger patients, especially in younger obese patients. It's not common but should be in the differ- ential diagnosis of a young keratoco- nus patient." Dr. Carlson has observed and reported the apparent subset of patients with keratoconus who have findings outside of the cornea, showing a propensity for weight gain, obstructive sleep apnea, floppy eyelid, and mitral valve prolapse. "It's suggesting that keratoconus patients may not only have a floppy cornea but also a floppy belly, floppy soft palate, floppy eyelid, and a flop- py mitral valve," Dr. Carlson said. "I think it is worth screening for this by a review of systems." Contact lenses Dr. Holland noted that contact lenses can be associated with ectasia, with patients who have a long-term history of rigid contact lens wear es- pecially wearing relatively flat lenses over the years. "If someone was crosslinked and went back to the contacts, that could be a potential issue," Dr. Holland said. "I have seen it in patients with a history of long-term rigid lens wear who come in with a later onset of keratoconus. Typically, that cone is different than the ones we see in a young adolescent—it's manage their allergic eye disease," Dr. Holland said. Among other patients with no clinical findings of allergic eye disease and no history of any atopic findings, such as asthma or eczema, sometimes the family will say that the patient has been a chronic eye rubber and it is just a habit. "Maybe that patient was an allergy patient at a younger age and learned how to eye rub and it has become habitual," Dr. Holland said. "Invariably patients say they don't rub their eyes, then we ask the fami- ly members and they say the patient rubs their eyes all day long." Alan Carlson, MD, professor, Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, also screens all such patients for eye rubbing and the possibility that they could be applying pressure to their eyes during sleep. "Fortunately, the word is getting out with regard to the role of eye rubbing accelerating progression of ectasia," Dr. Carlson said. "I want to make sure that the crosslinking procedure is not simply making the cornea more resistant to ongoing eye rubbing." Patients can help break the eye rubbing cycle by wearing a shield at night and using additional lubrica- tion during the day to lubricate the surface and reduce lid wiper epitheli- opathy, Dr. Carlson noted. Dr. Holland recruits the family members to get an accurate assess- ment of whether the patient has stopped the eye rubbing or not. He hasn't seen a case where a chronic eye rubber caused a recurrence of ectasia post-crosslinking, but theo- retically they could. "I managed a teenage girl with early and progressing keratoconus. She was a confirmed eye rubber by family members. We convinced her to stop rubbing her eyes, and over the next 12 months her keratoconus regressed and her topography nor- malized," Dr. Holland said. Dr. Carlson also addresses bleph- aritis, dry eye, and the ocular surface to make sure that postop healing will tolerate a bandage contact lens for several days and progress with- out complications. Sleep position Another group of patients who can have not only ectasia but other types of nocturnal trauma are those patients who sleep face down. They are often sleep apnea patients, Dr. Holland noted. "They can induce floppy eyelid syndrome, chronic conjunctivitis, and this trauma can induce changes in the cornea leading to ectasia," Dr. Holland said. "We're starting Behavioral impacts on crosslinking Monthly Pulse Update on crosslinking Regarding FDA-approved crosslinking in the U.S., do you: As far as crosslinking for keratoconus or ectasia, what do you coach your patients regarding behavioral concerns? EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so readers can see how they compare to our survey. If you would like to join the physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put "EW Pulse" in the subject line. Use crosslinking for progressive keratoconus Use crosslinking for progressive ectasia after LASIK Use current approved protocol of epi-off followed by 30 minutes of topical riboflavin followed by 30 minutes of 30 mW ultraviolet energy delivery All of the above That patient behaviors and habits can negatively affect the success of crosslinking to strengthen the cornea None of the above That eye rubbing accelerates the progression of keratoconus and should be considered for allergic eye disease evaluation That sleep patterns that induce pressure on the eye can speed the progression of keratoconus All of the above None of the above

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