EyeWorld India December 2017 Issue

Corneal crosslinking – from page 41 December 2017 42 EWAP SECONDARY FEATURE that preservative-free drops were preferable. The use of contact lenses for aesthetic purposes was contraindicated due to the increased difficulty in contact lens fitting and complications arising from poorly fitting lenses. Rigid contacts were recommended in cases of unsatisfactory vision with glasses. CXL is indicated in the treat- ment of keratoconus with docu- mented clinical progression, as well as for eyes with keratoconus that have previously received other forms of corneal surgery. Although the panel did not reach a consensus regarding the use of CXL in subclinical keratoconus, they did agree that as long as there is evidence of progression, there should be no age restriction for CXL in keratoconic eyes. The wide geographic distri- bution of the panelists and the fact that some surgical options were more readily available in some countries than others made achieving a consensus for the best surgical option difficult. Next to CXL, anterior lamellar keratoplas- ty (ALK), specifically descemetic deep ALK, largely indicated by contact lens intolerance, and penetrating keratoplasty (PK), mostly done in eyes with signifi- cant corneal scarring, were the most frequent surgical modalities used in the surgical treatment of keratoconus. 5 According to Christopher J. Rapuano, MD , Wills Eye Hospi- tal, Philadelphia, who was a glob- al consensus panel member, CXL has moved the timing of treat- ment intervention to much earlier in the disease process. “We do not delay therapeutic treatments until there is significant loss of vision anymore, which is what makes early diagnosis so much more important and our work to establish a consensus very rel- evant. In terms of the surgery, the worldwide standard for CXL is the original Dresden protocol involv- ing 30 minutes of UV treatment with the epithelium off. There are many variations on crosslinking done both in the U.S. and around the world. One of the biggest variations is keeping the epithe- lium on or removing it prior to riboflavin application. There are proponents for each. Epi-on is more comfortable and has less risk. Currently, however, the only procedure approved by the FDA is the epi-off protocol. The majority of the literature around the world demonstrates that epi-off seems to work better than epi-on. Another variation in CXL causing much debate revolves around duration and intensity,” Dr. Rapuano said. Fast and furious or low and slow The aim of using different proto- cols is to optimize control of the CXL process and improve predict- ability for the best clinical out- comes. The FDA approved CXL us- ing the Avedro system (Waltham, Massachusetts) with the Dresden protocol, which involves a 9-mm epithelium removal and irradia- tion of 3 mW/cm 2 at a dose of 5.4 J/cm 2 using 0.1% riboflavin every 1–2 minutes for 30 minutes. Irra- diation is performed once 400 µm is met or exceeded on ultrasound pachymetry, and is performed for 30 minutes. Dr. Rapuano performs CXL in his practice according to the Dresden protocol. He thinks that while accelerated CXL has its advantages, it may be wise to stick to the standard protocol for the time being. His unpublished results, however, on higher in- tensity CXL treatments revealed good short-term outcomes. “In my experience with faster/higher intensity treatments, the protocols Slit lamp photograph of an eye immediately after epithelium-off CXL. There is a band- age soft contact lens in place. Mild diffuse post-CXL corneal haze and the yellow of the ribo avin can still be seen. Source (all): Christopher J. Rapuano, MD Diamatrix Ltd. Page: 51 www.diamatrix.com Feather Safety Razor Page: 21 www.feather.co.jp Johnson & Johnson Vision Page: 5, 71 www.abbottmedicaloptics.com Oculus Optikgeräte Page: 47 www.oculus.de Ziemer Page: 72 www.ziemergroup.com World Ophthalmology Congress Page: 56 www.woc2018.org ASCRS Page : 7, 22 , 49 www.ascrs.org APACRS Page: 2, 18, 36 , 37, 38, 40, 64 , 67 , 68 www.apacrs.org EyeWorld Page: 10, 11, 26, 32 , 44, 53 www.eyeworld.org Cornea Society Page: 58 , 60 www.corneasociety.org Index to Advertisers