Eyeworld

EW FEATURE 84 Laser vision correction • February 2018 AT A GLANCE • Divide evaluations of patients presenting with irregular corneas between refractive and therapeutic. • In a routine exam, patient com- plaints, including worsening vision, should be a major alert. • CXL treatment is most effective at halting progression, so if performed early enough the resulting vision loss can be reduced. by Rich Daly EyeWorld Contributing Writer available on the Pentacam (Oculus, Wetzlar, Germany), has been useful. Exam keys In a routine eye exam or a refractive consultation, surgeons should look for risk factors for ectasia—high posterior float, pachymetric pro- gression, or otherwise suspicious appearance for ectatic disease—as constituting a cornea that should be crosslinked, according to David Hardten, MD, director of refractive surgery, Minnesota Eye Consultants, and adjunct professor of ophthal- mology, University of Minnesota, Minneapolis. Dr. Randleman agreed that the detection of progressive corneal ectasia indicates a need for CXL. "Crosslinking is highly effective at halting progression, but its results are a bit unpredictable in terms of an overall flattening effect or regulariza- tion, so I do not recommend using CXL for non-progressive corneas or for patients without clear corneal ectasias," Dr. Randleman said. segments, and CXL have benefits for corneal ectasia and keratoconus, as well as other causes of irregular corneas. "The paradox is that if the patient does not need surgery, we should avoid or consider it very carefully," Dr. Ambrósio said. "But when the patient needs surgery, we should do the procedure as soon as possible." Although quality of vision is important, refractive independence should not be a priority, he said. Also important is the balance be- tween the eyes, as many cases have significant anisometropia. The second reason to indicate surgery is related to corneal stability, Dr. Ambrósio said. "If there is progression, we should proceed with crosslinking even if the patient retains good corrected vision," Dr. Ambrósio said. "But the need for corneal imaging for documentation and guiding clin- ical decisions is a must." Dr. Ambrósio said the Belin ABCD Progression Display, which is Renato Ambrósio Jr., MD, PhD, adjunct professor of ophthal- mology, Federal University of the State of Rio de Janeiro (UNIRIO), also first distinguishes between re- fractive and therapeutic patients. "Treating diseased corneas is a whole different world from enabling patients to be less dependent on spectacles and contact lenses," 1 Dr. Ambrósio said. Both patients and surgeons need to be educated about the fundamental differences between elective treatments with a refractive purpose and those for the visual re- habilitation of patients with corneal disease, he said. "For the latter, the education of patients and their families is fundamental to the success of your intervention, as it enables patients to manage their disease better, and it also helps them maintain realistic expectations of what treatment can achieve," Dr. Ambrósio said. Recent developments in refractive technologies including custom ablations, intracorneal ring Surgeons address the complex issue of when to treat—or not treat— patients with suspicious corneas A mong the important con- siderations for surgeons confronted with irregular corneas are whether and when to treat them. "This is currently a highly controversial topic," said J. Bradley Randleman, MD, professor, De- partment of Ophthalmology, Keck School of Medicine, University of Southern California (USC), and director of cornea, external disease and refractive surgery, USC Roski Eye Institute, Los Angeles. Dr. Randleman divides such patients between those who have known ectatic disorders, who are being considered for therapeutic ablations to improve their corne- al regularity, and those who are presenting for refractive surgery evaluation and are seeking or being offered refractive correction. "For patients with ectatic cor- neas, the cornerstone of treatment involves corneal crosslinking (CXL) first with future considerations about therapeutic ablations," Dr. Randleman said. "For patients with irregular corneas but without a clear ectasia diagnosis, some have advo- cated for using surface ablation in these patients, but there are also cas- es in the literature of these patients developing ectasia after surgery, and I do not currently offer treatment to these individuals." Instead, he follows the latter group of patients for any evidence of progression. Considerations for irregular cornea treatments continued on page 86 Eye undergoing CXL Source: James Randleman, MD

• Blank Page
• Blank Page (1)