EyeWorld Asia-Pacific June 2020 Issue

EWAP JUNE 2020 33 REFRACTIVE keratoconus patients. “I think that for years keratoconus patients have been used to hearing, ‘You have keratoconus, but at this point we don’t have anything to offer,’” he said. While it is now possible to stop keratoconus and improve vision, it’s important to assess the patient’s goals, Dr. Rocha stressed. Sometimes the goal is simply to stop progression of keratoconus, while others may want to do away with glasses and contact lenses if possible. In the latter case, it becomes a question of deciding how you are going to rehabilitate the patient’s vision. “I think that the idea is to think outside the box and see where we can get that patient,” Dr. Rocha said. Overall, Dr. Rocha said it’s important to keep an open mind to new techniques, while simultaneously thinking about ̅i Li˜iwÌ Ìœ ̅i «>̈i˜Ì° º think it’s worthwhile when we see that there are different ways of combining treatment to move forward and offer patients a better result than they were expecting,” he concluded. EWAP Reference 1. Rocha G, et al. Combined phototherapeutic keratectomy, intracorneal ring segment implantation, and corneal collagen cross-linking in keratoconus management. Cornea. 2019;38:1233–1238. Editors’ note: Dr. Rocha is professor of ophthalmology, Max Rady College of Medicine University of Manitoba, Winnipeg, Canada, and declared relevant interests with Bausch + Lomb. Cordelia Chan, MD Consultant eye surgeon & partner, Eye Surgeons @ Novena Mount Elizabeth Novena Specialist Centre 38 Irrawaddy Road #09-28, Singapore 329563 drcordeliachan@gmail.com ASIA-PACIFIC PERSPECTIVES B ack in the early 1990s when I was a resident in ophthalmology, keratoconus patients had limited options. /Ài>̓i˜Ì Ü>à Vœ˜w˜i` ̜ }>ÃÃiÃ] Vœ˜Ì>VÌ i˜ÃiÃ] >˜` «i˜iÌÀ>̈˜} ŽiÀ>̜«>ÃÌÞ° Fast forward three decades and the landscape has changed tremendously. Management paradigms have shifted to target not only improvements in functional visual acuity but also cessation of disease progression and simultaneous complete correction of the refractive component of keratoconus. Keratoconus ˆÃ >Ãœ ˆ`i˜Ìˆwi` i>ÀˆiÀ ˆ˜ ̅i `ˆÃi>Ãi ܅iÀi ۈȜ˜ ˆÃ Ài>̈ÛiÞ «ÀiÃiÀÛi` `Õi ̜ ̅i i݈ÃÌi˜Vi œv >`Û>˜Vi` topography systems and the advent of cosmetic refractive surgery, where asymptomatic patients present themselves to be screened for suitability. There have been remarkable improvements in contact lens technology and besides rigid gas permeable (RGP) lenses, other available options include piggyback, hybrid, and scleral lenses. The gamechanger in keratoconus management has to be corneal collagen crosslinking (CXL), a procedure which promises to retard keratoconus progression and afford some extent of refractive correction in suitable patients. A technically straightforward procedure, CXL is not without its issues. Postoperative pain, delayed epithelial healing, risk of ˆ˜viV̈œ˜] >˜` ŽiÀ>̜VÞÌi œÃà ܈̅VœÀ˜i>…>âi] “iÌˆ˜}] >˜` œ«>VˆwV>̈œ˜ ̜}i̅iÀ ܈̅Vœ˜ÌÀ>`ˆV̜ÀÞ Ài«œÀÌà œv ˆÌà ivwV>Vޅ>Ûi «>}Õi` ̅i «ÀœVi`ÕÀi° /…i œÀˆ}ˆ˜> ÀiÃ`i˜ «ÀœÌœVœ…>Å>` “>˜Þ “œ`ˆwV>̈œ˜Ã ̜ >``ÀiÃà ̅i ˆ˜Vœ˜ÃˆÃÌi˜Vˆià œv ̅i ivviV̈Ûi˜iÃà œv ̅i ÌiV…˜ˆµÕi] LÕÌ Ì…iÃi “œ`ˆwV>̈œ˜Ã ̜œ…>Ûi…>` ̅iˆÀ ˆ˜Vœ˜ÃˆÃÌi˜Vˆið œÜiÛiÀ] 8 ˆÃ Ã̈ VÕÀÀi˜ÌÞ ܈`iÞ ÕÃi` ̜ ÌÀi>Ì ŽiÀ>̜Vœ˜Õà >à ˆÌ…>à vՏwi` >˜ ՘“iÌ need in keratoconus management, with its advantages prevailing over the disadvantages. A complete surgical approach in keratoconus management has become increasing appealing with some surgeons combining CXL with adjunctive refractive procedures to retard the ectatic process and enhance functional vision. These “CXL-plus” procedures include CXL with photorefractive keratectomy (PRK), intrastromal corneal ring segments (ICRS), phakic intraocular lenses, conductive keratoplasty, or a combination of these. While results of CXL plus PRK have been encouraging, there are still questions on its long-term effect on the biomechanical stability of the cornea. The downstream effect of CXL-induced stromal changes that cause persistent variations in pachymetric and topographic indices over time make outcomes unpredictable and excimer laser treatment planning tricky. With ICRS, issues with accurate ring placement without established nomograms and decreased predictability of refractive outcomes makes ICRS a less favored procedure. Most of the published studies on these CXL plus procedures are relatively small case series, with Û>Àˆ>Li w˜`ˆ˜}à >“œ˜} `ˆvviÀi˜Ì «ÀœÌœVœÃ° >À}iÀ À>˜`œ“ˆâi` Vœ˜ÌÀœi` ÌÀˆ>Ã ܈̅œ˜}iÀ vœœÜ‡Õ« «iÀˆœ`à are thus required. /œ `>Ìi] ̅iÀi >Ài ˜œ ëiVˆwV }Ո`iˆ˜ià œ˜ ŽiÀ>̜Vœ˜Õà “>˜>}i“i˜Ì] ܈̅ˆ˜`ˆÛˆ`Õ> ÃÕÀ}iœ˜Ã…>ۈ˜} their own treatment algorithms. With such a wide armamentarium of procedures now available to our keratoconus patients, how aggressive should we be? Eye rubbing is an important cause of keratoconus that is often overlooked or inadequately emphasized in clinical practice. Eye rubbing should be addressed or excluded in every keratoconus patient before CXL or any surgical intervention is considered, as cessation of eye rubbing alone has been found to arrest or retard the progression of keratoconus in some patients. We should be open to the “plus” in CXL plus procedures but not be overzealous, as many keratoconus patients with stabilized corneas are able to achieve good v՘V̈œ˜> ۈȜ˜ ܈̅Üi‡wÌÌi` “œ`iÀ˜‡`>Þ , * œÀ ÃViÀ> i˜Ãið iÈ`iÃ] ˜œÌ > ŽiÀ>̜Vœ˜Õà «>̈i˜Ìà `i“>˜` ëiVÌ>Vi œÀ Vœ˜Ì>VÌ i˜Ã ˆ˜`i«i˜`i˜Vi] ܅ˆV…ˆÃ `ˆvwVÕÌ Ìœ >V…ˆiÛi iÛi˜ ܈̅8 «Õà «ÀœVi`ÕÀið As clinicians, it is important to select the optimal treatment options for our patients and individualize them to their needs. For some of these patients, less is the new more. References 1. Subasinghe SK, et al. Current perspectives on corneal collagen crosslinking (CXL). Graefes Arch Clin Exp Ophthalmol . 2018;256:1363-85. 2. Beckman KA, the ASCRS Cornea Clinical Committee, et al. Corneal crosslinking: Current protocols and clinical approach. J Cataract Refract Surg . 2019; 45:1670-9. 3. Zhu AY, et al. Combined protocols for corneal collagen cross-linking with photorefractive surgery for refractive management of keratoconus: update on techniques and review of the literature. Ophthalmol Ther. 2019; 8:S15-31. 4. Sakellaris D, et al. Intracorneal ring segment implantation in the management of keratoconus: an evidence-based approach. Ophthalmol Ther. 2019; 8:S5-14. 5. Gatinel D. Eye rubbing: a sine qua non for keratoconus? Int J Kerat Ect Cor Dis . 2106; 5:6-12 'FKVQTUo PQVG &T %JCP FGENCTGF PQ TGNGXCPV ƂPCPEKCN KPVGTGUVU