EyeWorld India December 2017 Issue

by Rich Daly EyeWorld Contributing Writer Patient behaviors to watch for when providing crosslinking treatments S ome patient behaviors can affect the success of crosslinking to strength- en the cornea and halt progressive keratoconus. Young keratoconus patients seen by Edward Holland, MD , professor of ophthalmology, Uni- versity of Cincinnati, fall into two groups: those with severe allergic eye disease and those for whom rubbing is habitual. Among allergy sufferers, the eye rubbing is secondary to their underlying problem. “Before we perform any proce- dure such as crosslinking or kera- toplasty, we want to aggressively manage their allergic eye disease,” Dr. Holland said. Among other patients with no clinical findings of allergic eye disease and no history of any atopic findings, such as asthma or eczema, sometimes the family will say that the patient has been a chronic eye rubber and it is just a habit. “Maybe that patient was an allergy patient at a younger age and learned how to eye rub and it has become habitual,” Dr. Holland said. “Invariably patients say they don’t rub their eyes, then we ask the family members and they say the patient rubs their eyes all day long.” Alan Carlson, MD , professor, Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina, also screens all such patients for eye rub- bing and the possibility that they could be applying pressure to their eyes during sleep. “Fortunately, the word is get- ting out with regard to the role of eye rubbing accelerating progres- sion of ectasia,” Dr. Carlson said. “I want to make sure that the crosslinking procedure is not simply making the cornea more resistant to ongoing eye rubbing.” Patients can help break the eye rubbing cycle by wearing a shield at night and using additional lubrica- tion during the day to lubricate the surface and reduce lid wiper epithe- liopathy, Dr. Carlson noted. Dr. Holland recruits the family members to get an accurate assess- ment of whether the patient has stopped the eye rubbing or not. He hasn’t seen a case where a chronic eye rubber caused a recurrence of ectasia post-crosslinking, but theo- retically they could. “I managed a teenage girl with early and progressing keratoconus. She was a confirmed eye rubber by family members. We convinced her to stop rubbing her eyes, and over the next 12 months her keratoco- nus regressed and her topography normalized,” Dr. Holland said. Dr. Carlson also addresses blepharitis, dry eye, and the ocular surface to make sure that postop healing will tolerate a bandage contact lens for several days and progress without complications. Sleep position Another group of patients who can have not only ectasia but other types of nocturnal trauma are those patients who sleep face down. They are often sleep apnea patients, Dr. Holland noted. “They can induce floppy eyelid syndrome, chronic conjunctivitis, and this trauma can induce changes in the cornea leading to ectasia,” Dr. Holland said. “We’re starting to see the diagnosis of sleep apnea in younger patients, especially in younger obese patients. It’s not common but should be in the differential diagnosis of a young keratoconus patient.” Dr. Carlson has observed and reported the apparent subset of patients with keratoconus who have findings outside of the cornea, showing a propensity for weight gain, obstructive sleep apnea, flop- py eyelid, and mitral valve prolapse. “It’s suggesting that keratoco- nus patients may not only have a floppy cornea but also a floppy belly, floppy soft palate, floppy eyelid, and a floppy mitral valve,” Dr. Carlson said. “I think it is worth screening for this by a review of systems.” Contact lenses Dr. Holland noted that contact lens- es can be associated with ectasia, with patients who have a long-term December 2017 50 EWAP SECONDARY FEATURE Behavioral impacts on crosslinking AT A GLANCE • Prevent patient behaviors from adversely impacting crosslinking treatment by aggressively managing allergic eye disease. • Ask family members if the patient is a chronic eye rubber. • Address patients who sleep face down, often sleep apnea patients.