EyeWorld India March 2014 Issue

45 EWAP CORNEA March 2014 Views from Asia-Pacific LIM Li, MBBS, FRCS(Ed), MMed(Ophth), FAMS Head (Clinical Service and Education) and Senior Consultant, Corneal & External Eye Disease Service Singapore National Eye Centre 11 Third Hospital Ave., Singapore 168751 Tel. no. +65-62277255 lim.li@snec.com.sg D r. Raiskup provides a comprehensive account of the postoperative management of corneal crosslinking patients. Appropriate postoperative management of corneal crosslinking patients is essential for a successful outcome. At the Singapore National Eye Centre, corneal crosslinking is performed after deepithelization of the cornea. Hence, management of the epithelial defect to ensure rapid healing and epithelial closure is crucial to the success of the procedure. Restoration of the corneal epithelium improves patient comfort and visual acuity and prevents complications such as infection and corneal melting. We use a postoperative regime similar to that of refractive surface ablations. At the end of surgery, a bandage soft contact lens (silicone hydrogel) is inserted to enhance epithelial healing and reduce postoperative pain. We prescribe preservative-free topical fluoroquinolones and topical steroids until the epithelium has fully healed and the bandage lens has been removed. Frequent application of preservative-free lubricants is also encouraged. After the epithelium has healed, the patient is continued on steroid eyedrops for a month to reduce corneal haze and to prevent corneal scar formation. Counseling of the patient should include information on the safety and efficacy of the procedure as well as potential side effects that might occur. In particular, the patient needs to be aware that the postoperative recovery period of a few days is usually associated with pain, tearing, and photophobia. Analgesics such as nonsteroidal anti-inflammatory drugs are usually sufficient for pain relief. Corneal crosslinking is generally safe, and sight-threatening complications such as infective keratitis are rare and occur in the immediate postoperative period prior to epithelial closure. Corneal haze after crosslinking is a common occurrence and this usually resolves over time and with topical steroid treatment. Occasionally, it could persist but usually does not affect the visual acuity. Long-term vision rehabilitation after crosslinking depends on the severity of the keratoconus. In mild keratoconus cases, spectacle correction is usually sufficient to achieve functional vision. In moderate to severe cases, rigid lens wear is usually required. Surgical modalities of vision correction include topography-guided surface ablations and intrastromal corneal ring insertions. In summary, good postoperative care and management of corneal crosslinking patients include appropriate patient counseling, pain management, a careful attention to corneal epithelial healing, an awareness of the potential complications of crosslinking and long-term vision rehabilitation. Editors’ note: Dr. Lim has no financial interests related to her comments. Colin CHAN, MD Associate Professor, Vision Eye Institute and University of New South Wales Level 3 270 Victoria Avenue Chatswood NSW AUSTRALIA Tel. no. +612 94249999 Fax no. +612 94249944 colin.chan@vgaustralia.com S ince I began crosslinking in 2005, I have watched it go from a controversial investigational treatment to the current accepted standard treatment for progressive keratoconus. It is one of the truly revolutionary treatments of the past few decades. Dr. Raiskup’s article highlights a number of key points based on his own extensive experience. I completely agree that careful management of the ocular surface and promoting reepithelialization is crucial in the outcome and preventing complications such as infection. My colleagues and I have not had an infection in our institution since we began crosslinking in 2005. Besides the points raised by Dr. Raiskup, we believe that careful aseptic technique in a day surgery theater setting will also reduce the risk of infection. Dr. Raiskup also explains the importance of patient counseling. I would again agree with the importance of adequate chair time both with the patient and often the parents, as many patients are teenagers or young adults. Parents are very anxious about having their child undergo a still relatively new procedure and I always repeatedly emphasize a few key points: 1. That the risk of corneal transplant is greater without crosslinking and that the younger a patient, the more likely this is to happen as these patients deteriorate more rapidly; 2. That vision is unlikely to improve noticeably from the procedure and may be worse for up to 6–12 months afterwards as the cornea recovers; 3. That a significant degree of postoperative pain especially in the first 6–8 hours is normal due to the inflammatory response of the cornea. Careful counseling around expectations makes the patient’s postoperative experience more acceptable and improves satisfaction. In terms of managing the postoperative discomfort and aiding reepithelialization, we also use a bandage contact lens, topical antibiotics and oral analgesics similar to Dr. Raiskup. However, we find that commencement of a topical steroid immediately postoperatively greatly reduces the postoperative pain and does not appear to delay epithelialization especially in a younger population. I will typically use dexamethasone q.i.d. for the first day and then switch to fluoromethalone q.i.d. for 3 weeks. In conclusion, my personal experience of crosslinking is that it is a safe and remarkably effective procedure. Careful counseling and postoperative management is necessary to manage expectations and achieve the best outcomes. Editors’ note: Dr. Chan has no financial interests related to his comments .