Eyeworld

85 EW MEETING REPORTER dystrophy who underwent success- ful DMEK. There was clearing of the cornea and improvement in vision. However, the patient was referred back to Dr. Hannush after 3 months because he developed decreased vi- sion and corneal edema in the same eye. The first thought, Dr. Hannush said, was that the graft had failed. However, after further inspection with anterior segment OCT, it was revealed that the patient had a shal- low Descemet's membrane (DM) de- tachment that was not clear on slit lamp exam. Dr. Hannush was able to rebubble the patient and reattach the DM with complete clearing of the cornea, despite low endothelial cell count. He concluded by stressing that perioperative imaging has empow- ered the anterior segment surgeon to make more accurate diagnoses and achieve better surgical results than in the past. Editors' note: Dr. Hannush has no financial interests related to his presentation. Retinal imaging Jay Duker, MD, Boston, provided an update on the current status of swept-source OCT (SS-OCT), which he noted is expensive due to the high speed and frequency of the lasers. SS-OCT reflections are depth encoded and detected with photo- detectors, then are decoded with Fourier transform. Swept-source im- ages are taken at longer wavelengths compared to spectral-domain OCT. The clinical advantages of SS-OCT include a wider scanning range, the ability to image vitreous and the choroid simultaneously, and the ability to better penetrate the choroid, lens opacity, and pigment. SS-OCT, Dr. Duker said, features an increased field of view and wide- field imaging with better resolution than spectral domain. Despite these advantages, Dr. Duker said there are some significant disadvantages, in- cluding the increased cost, less axial resolution, worse signal-to-noise ratio, and worse motion artifact. In his presentation, Srinivas Sadda, MD, Los Angeles, said there corneas transplanted each day. But where do they come from? Ocular donation is a complicated process, Dr. Macsai said, and eye banks can help with this. She cited a study from 2006 looking at pre-cut tissue, which found no significant differ- ence in the quality of tissue or pa- tient outcomes. "Pre-cut tissue saves time and money," she said. It can also help reduce a surgeon's stress in the OR, as well as tissue waste. Another lesson learned from eye banks is that the S stamp is valuable. "It has revolutionized the way we do corneal transplants," Dr. Macsai said. Though there is slight damage to en- dothelial cells, Dr. Macsai thinks it's worth it to have the stamp, which is placed on the tissue by the eye bank. She spoke about surgeon misperceptions addressed in the Cornea Donor Study. The study found that preoperative ECD is not predictive of graft failure caused by endothelial decompensation at 5 years following PKP. Donor age up to 75 years old did not impact PKP out- comes at 5 years, and graft rejection was not associated with donor age. Additionally, Dr. Macsai said that death to preservation or to surgery is not associated with changes in ECD over time. Editors' note: Dr. Macsai has no finan- cial interests related to her presentation. How imaging can "save the day" In a section at Cornea Day focused on anterior segment imaging, Sadeer Hannush, MD, Philadel- phia, shared several instances where imaging saved the day when he was treating patients. His first case was a 72-year-old woman with corneal edema who was referred for en- dothelial keratoplasty. She had a well-positioned PCIOL and limited view of the posterior pole. When Dr. Hannush used OCT, it was revealed that this patient also had cystoid macular edema. When the macular edema was treated medically, she improved significantly and decided not to pursue surgical intervention on her cornea. His second case was that of an 84-year-old man with Fuchs' OCT scans should be performed at baseline and serially. Editors' note: Dr. Weinreb has no financial interests related to his presentation. "Corneal infections: Old bugs, new drugs" The first section of Cornea Day high- lighted infections. Denise de Freit- as, MD, São Paulo, Brazil, presented "Acanthamoeba Keratitis: Embracing the Challenge." This is a challenging infection for several reasons, she said. First of all, it's a parasite, and it comes in two forms. Dr. de Freitas noted that the form that physicians need to worry about are dormant cysts because these can be resistant to almost all antimicrobial drugs. Another challenge is a delay in diagnosis. It's important to think of this possible infection in all contact lens wearers. The sooner it can be di- agnosed, the better. When diagnosis is delayed, the infection can pene- trate more deeply into the corneal stroma, and successful therapy can become exceedingly difficult. But with an early diagnosis and treat- ment, there is a good prognosis, Dr. de Freitas said. In relation to contact lenses, the prevalence is higher in soft lenses than rigid lenses. Risk fac- tors include poor lens hygiene and exposure to potentially contaminat- ed solutions. Clinical findings may include a long history, which usually starts with contact lens intolerance. The patient may or may not experi- ence pain. When treating Acanthamoeba keratitis, Dr. de Freitas said the goal of treatment is rapid eradication of viable organisms and eventual suppression of the inflammatory response. Editors' note: Dr. de Freitas has no financial interests related to her presentation. "Keratoplasty: Are we doing the right thing?" In a section at Cornea Day focused on keratoplasty, Marian Macsai, MD, Glenview, Illinois, discussed how corneal surgery starts in the eye bank. In the U.S., there are 209 Dr. Novack said. Other future thera- peutic possibilities include ripasudil (Glanatec, Kowa Company, Nagoya, Japan), which was approved in Ja- pan in 2014, and gene therapy. Joel Schuman, MD, New York, addressed preclinical agents and therapeutic possibilities, including SiRNAs, neuroprotective agents, optic nerve regeneration, and gene therapy. Lisa Gamell, MD, Tampa, Flori- da, presented on vitamins and herbs that may hold promise for glauco- ma prevention. Although retinal specialists have the AREDS formula to recommend, glaucoma has yet to find that "magic mixture," she said. The one area of interest to many patients is the potential IOP-lower- ing power of medical marijuana, Dr. Gamell said. Medical marijuana is currently legal in 30 states. Although it could potentially lower IOP, it would require a very high dosage and has side effects such as systemic hypotension. For this reason, AAO does not support the role of medical marijuana use for glaucoma patients, Dr. Gamell said. However, cannabi- noids show some potential promise for glaucoma treatment. Editors' note: Dr. Novack has finan- cial interests with various ophthalmic companies. Dr. Schuman has financial interests with Aerie Pharmaceuticals, Alcon (Fort Worth, Texas), and other ophthalmic companies. Dr. Gamell has no financial interests related to her presentation. Pearls for glaucoma progression detection To best detect glaucoma progres- sion, use visual field testing and OCT scans, recommended Robert Weinreb, MD, San Diego. "Both are essential for detecting progres- sion throughout the glaucoma continuum," he said. Dr. Weinreb advised the use of both 24-2 and 10-2 visual field tests performed at baseline and then semiannually, but he also recommended confirming the visual field test results. "Not all patients who look like they have glaucoma have it," he said. Baseline optic disc photos should be obtained for comparison with the clinical examination, and disc and macula December 2017 continued on page 86

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