Eyeworld

83 November 2017 EW MEETING REPORTER treatment alone to that combined with crosslinking in deep fungal keratitis showed no benefit in the crosslinking group, and this group also saw more perforations than the non-crosslinking group. There are numerous studies, Dr. Larkin said, showing efficacy of an- tibacterial and antifungal treatments as a medical cure in the majority of cases. There is a need for non-medi- cal adjunctive treatment for infec- tive keratitis, Dr. Larkin said, but he doesn't think there is enough evidence showing efficacy of PACK crosslinking just yet. But he also doesn't think research on it should be abandoned. There is a need for more complete data on a wider range of microorganisms, alterna- tive enhancers, optimization of irradiation patterns, and efficacy in vivo, especially against deep corneal infiltrates. Dilemmas in glaucoma diagnosis Diagnosis of glaucoma can be a chal- lenge due to differing definitions of the disease and pitfalls associated with diagnostic tools and imaging, said Anja Tuulonen, MD, Tampere, Finland, in the first session of the European Society of Cataract & Refractive Surgeons (ESCRS) Glaucoma Day. When glaucoma is misdiag- nosed—either missed completely or diagnosed as a false positive—it not only has an impact on the individ- ual patient but can have larger im- plications for the healthcare system. Misdiagnosis of glaucoma leads to suboptimal use of resources. Fotis Topouzis, MD, Thessalon- iki, Greece, said population-based studies suggest at least half of all glaucoma goes undiagnosed. The Thessaloniki Eye Study found a sim- ilar percentage, and primary open more than a month of infection) with deteriorating disease but with controlled scleritis is to perform keratoplasty after 8–10 months of medical therapy or if they have a mature cataract. There is no evi- dence, he said, showing a benefit of keratoplasty over medical therapy before this timeframe. Medical cures are seen in 50–60% of AK patients in 10–12 months, and only a quarter of pa- tients who get better with treatment needed more than 8 months of medical therapy, Dr. Dart said. Therapeutic keratoplasty, Dr. Dart noted, carries a risk for second- ary glaucoma, loss of clarity, failure to reepithelialize, corneal melt, irreg- ular astigmatism, and more. Based on research, Dr. Dart said a poor visual outcome is significantly more likely in patients with therapeutic keratoplasty. Crosslinking for keratitis was debated by Farhad Hafezi, MD, Zu- rich, Switzerland, and Frank Larkin, MD, London, U.K. Dr. Hafezi argued in favor of crosslinking for bacte- rial and fungal keratitis for several reasons: (1) increasing antimicrobial resistance; (2) crosslinking's effect on steric hindrance makes the tissue more resistant to damage provoked by digestion and thus reduces scar- ring; (3) reduced number of medical follow-ups needed, reducing the cost burden; (4) it is independent of doctor experience; (5) it helps reduce microbial load; and (6) it kills bacteria and fungi simultaneously. Dr. Larkin, however, showed conflicting data in the published literature on the efficacy of photo- activated chromophore for keratitis (PACK) crosslinking. "The real prob- lem is in patients with deep kera- titis," Dr. Larkin said, mentioning one study that showed no benefit of PACK crosslinking combined with medical treatment compared to medical treatment alone. An- other study comparing medical the mainstay, but patients should be monitored closely for side effects and put on a lower dose as soon as possible. Prednisolone/dexametha- sone should be used in VKC/AKC, especially when corneal lesions are present. Dr. Nubile discussed other therapies for allergic eye disease, including mast cell stabilizers, H1 antihistamines, NSAIDs, and immu- nomodulators. Surgical interventions could include excision of papillae, though that's rare, Dr. Dua said, and amni- otic membrane could be useful for some ulcers in VKC and AKC. Controversies in corneal treatment Treating Acanthamoeba keratitis (AK) with early keratoplasty, using crosslinking to combat keratitis, combining crosslinking and topog- raphy-guided PRK, ultra-thin DMEK vs. DMEK, and keratoprosthesis vs. cell therapy were all debated during the EuCornea Congress. Berthold Seitz, MD, Erlangen, Germany, advocated for penetrating keratoplasty (PKP) for AK that's re- sistant after 3–4 months of medical treatment, while John Dart, MD, London, U.K., shared evidence that suggests that a longer medical treat- ment period is effective. There are several problems with long-standing disease, Dr. Seitz said in his argument in favor of earlier surgical treatment. In a study of 23 patients who underwent PKP, those who had the procedure earlier in the infection had clear transplants and no persistent epithelial defects, while those who had the infection longer before having PKP fared sig- nificantly worse, Dr. Seitz said. Graft survival in the group with a shorter disease duration was 90% compared to 48.8% in the group with longer disease duration. In his presentation, Dr. Dart said his recommendation for patients with late diagnosis (diagnosis after Seasonal allergic conjunctivitis is an immediate hypersensitivity re- action with symptoms that include swelling, chemosis, and redness. It is also associated with itching, redness, and a watery discharge. Similarly, perennial allergic conjunctivitis, like seasonal, is a hypersensitivity reaction but to a perennial allergen, such as a dust mite. Its signs and symptoms are similar to seasonal allergic conjunctivitis. These do not affect the cornea and the vision is not compromised, Dr. Dua said. Vernal keratoconjunc- tivitis (VKC) and atopic keratocon- junctivitis (AKC), however, will affect the cornea and could compro- mise vision. "In some parts of the world, it's a severe blinding disease," Dr. Dua said, noting its complex pathogenesis. Cases of VKC will present with giant papillae that are quiet when the disease is inactive but that pro- duce mucus when active. Micro- erosions or macroerosions could be present on the corneal endothelium; corneal plaque (mucus material with cellular debris stuck to the cornea) could be seen, as well as limbal inflammation. AKC is usually seen in patients who also have eczema of the skin and lashes. It can cause corneal ectasia, atopic cataract, and retinal detachment. These patients could have a short tarsal plate, posterior blepharitis, corneal plaque, and neovascularization. Giant papillary conjunctivitis, Dr. Dua said, is benign and never affects the cornea, but it can present with limbal inflammation. VKC and AKC, Dr. Dua reit- erated, are the only two allergic eye conditions where the cornea is involved and are sight-threatening and "therefore need your attention." When it comes to treatment of these conditions, Mario Nubile, MD, Chieti, Italy, said steroids are continued on page 84

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