EyeWorld Asia-Pacific March 2020 Issue

40 EWAP MARCH 2020 CORNEA W hen considering cataract surgery in patients with keratoconus, there may be certain factors to take into account before developing a surgical plan. Experts discussed treatment options for these patients, steps to take before surgery, how they decide on a plan of action, and appropriate lens options. What are the treatment options for keratoconus and particular considerations for patients with a cataract? The first priority is to identify whether keratoconus is present, William Trattler, MD, said. “Patients who come in with loss of vision from cataracts may also have keratoconus. The only way to find out is to perform topography,” he said. “It’s pretty shocking that some patients who we diagnose with keratoconus have no idea that they have this condition, even though they have been seeing their own doctor for years.” Dr. Trattler added that keratoconus is often identified when patients come in for a LASIK screening and are having their very first topography of their life. He added that topography is being performed more commonly than it was as decade ago, but it’s still not done by every doctor on every patient at least once. Since there are no signs on the slit lamp exam unless the patient has advanced keratoconus, the only way to identify keratoconus is with topography. Hopefully more screening topography will be performed, as this will enable patients with keratoconus to be diagnosed at an earlier stage before vision loss has occurred. After identifying that a patient with cataracts also has keratoconus, Dr. Trattler said the next step is to consider the treatment options. “If someone has a significant cataract along with keratoconus, you have to decide how to tackle these two conditions, and there’s no required order,” he said. For example, Dr. Trattler said that if someone has a visually significant cataract, you could choose to perform cataract surgery first, which would significantly improve vision. Then glasses, soft contacts, or a scleral lens may be used postoperatively, depending on the level of keratoconus, to further improve the vision. The other option, he said, is to treat keratoconus first. Crosslinking will strengthen the cornea and typically will help improve the corneal shape over time. “The problem is that the change in shape will develop over months to years rather than in weeks,” he said. So, while crosslinking is an effective treatment for patients with keratoconus, the improvement in corneal shape is slow. “It is helpful, especially in patients who have documented progression of keratoconus despite their advanced age,” Dr. Trattler said. Another option that is favored by a subset of surgeons, he said, is to use Intacs (Addition Technology) to reshape the cornea, which can help in some cases, but it varies on a case-by- case basis. And a third option is topography-guided PRK with Contoura (Alcon), which Dr. Trattler said is now available in the U.S. This technology will reshape the cornea to a more normal, less irregular shape, he said, adding that he’s looking forward to seeing more data on its effectiveness in keratoconus. Anthony Aldave, MD, noted that when he is treating a keratoconus patient with significant irregular astigmatism, his plan of action is to refer for a rigid gas permeable or scleral lens or to perform a corneal transplant. In keratoconus patients who will need cataract AT A GLANCE • Making a diagnosis of keratoconus and ensuring the ocular surface is optimized are important first steps when treating patients with both keratoconus and cataracts. • Experts said that multifocal lenses may not be the best options for patients with keratoconus, but monofocal or toric lenses could be used. • Options for treatment of keratoconus include crosslinking, Intacs, and topography-guided PRK. Often the treatment plan may need to be decided on a case-by-case basis for these patients who also have a cataract that needs to be addressed. Handling patients with keratoconus who need cataract surgery by Ellen Stodola EyeWorld Editorial Co-Director Contact information Aldave: aldave@jsei.ucla.edu Beckman: kenbeckman22@aol.com Trattler: wtrattler@gmail.com This article originally appeared in the November 2019 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Advanced keratoconus: No obvious axis to place a toric IOL. Advanced keratoconus: Axis for placement of toric IOL can be identified. Source (all): William Trattler, MD