FEATURE EWAP DECEMBER 2023 21 channel to reshape the cornea. If the patient’s disease is too severe or if they have too much scarring, a corneal transplant (hopefully lamellar) is an option, he said. If the patient is eligible for cataract surgery, there are lens-based options that could improve their vision (again after crosslinking and stabilization). Dr. Greenstein said he has had success with reshaping the cornea (with CTAK or topography-guided PRK) prior to cataract surgery. He sees a role for monofocal and toric lenses and blended vision and monovision options. Drs. Greenstein and Williamson mentioned the utility of an adjustable IOL, like the Light Adjustable Lens (LAL, RxSight), due to the ability to fine tune vision postop. They all mentioned the utility of the IC-8 Apthera IOL (Bausch + Lomb). Dr. Greenstein and Dr. Williamson advised caution when it comes to multifocal lenses with these patients, though Dr. Williamson said some patients might be eligible for Eyhance (Johnson & Johnson Vision) or Vivity (Alcon). Dr. Williamson said he thinks the LAL in both eyes or the IC-8 Apthera in the non-dominant eye and LAL in the dominant eye are good for patients who have 2–2.5 D of cylinder. If there is more cylinder, like 3–4 D of irregular cylinder, Dr. Williamson said he might use bilateral IC-8 Apthera off - label. “It can clean up coma and some of the higher order aberrations that you typically see in those post-refractive ectasia patients,” he said. In addition to selective choice, Dr. Williamson said factors for achieving on-target cataract surgery still apply. These include making sure you have a good informed consent that “gives you plenty of runway to achieve a reasonable result,” using the right tools (accurate measurements with multiple devices confirming degree and power of astigmatism, updated formulas), and appropriate lens offerings. Monitoring for progression is especially important for patients with keratoconus or post-refractive ectasia. Dr. Trattler said while crosslinking is highly effective at strengthening the cornea, a small percentage of patients can still progress. Known risk factors for progression include continued eye rubbing and advanced ectasia. “The good news is that most patients with ectasia will not progress after a single crosslinking procedure. However, patients need to be seen every year after crosslinking to ensure that their corneal shape is stable or improving,” he said. “In our experience, when progression is identified after a previous crosslinking procedure, a second crosslinking procedure is quite effective at preventing further progression.” Dr. Greenstein presented 10-year results of crosslinking with patients who had topography - altering surgery (PRK or Intacs) compared to those who didn’t at the 2023 ASCRS Annual Meeting. Overall, there was stability 10 years after crosslinking (76.7% of eyes were stable) with no significant differences in eyes that had subsequent topography - altering surgery. However, eyes with keratoconus that received crosslinking were less likely to progress later compared to eyes that had crosslinking for post-refractive surgery ectasia; 86.7% of eyes with keratoconus that had crosslinking remained stable at 10 years postop compared to 66.6% of eyes that had crosslinking for post - refractive ectasia. “This is why it’s important to tell those patients: 1) They need crosslinking done to stabilize their cornea now, and 2) they need to be monitored for the rest of their lives to make sure they don’t need repeat crosslinking down the road,” Dr. Greenstein said. EWAP Reference 1. Al-Mohaimeed MM. Combined corneal CXL and photorefractive keratectomy for treatment of keratoconus: a review. Int J Ophthalmol. 2019;12:1929 –1938. Editors’ note: Dr. Greenstein is Medical Director, Cornea and Laser Eye Institute, Teaneck, New Jersey, and has interests with CorneaGen and Glaukos. Dr. Trattler practices at the Center for Excellence in Eye Care, Miami, Florida, and has interests with CXLO, Glaukos, and Oculus. Dr. Williamson practices at Williamson Eye Center, Baton Rouge, Louisiana, and has interests with Glaukos. Axial topography maps before and 1 year after topography-guided PRK in a patient with ectasia after LASIK. Preop uncorrected Snellen visual acuity and best spectacle corrected Snellen visual acuity was 20/200 and 20/50, respectively. Postop, uncorrected Snellen visual acuity was 20/25 with no additional improvement in best spectacle corrected visual acuity at 1 year. Source (all): Steven Greenstein, MD
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