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OSD, keratitis, ocular injury....better be equipped with the cornea essentials
The Cornea Essentials Toolkit by Brooke Herron
Not only is the cornea the eye’s first line of defense — providing a structural barrier against infection — it also plays a key role in vision. Damage to the cornea can occur from injury, infection and disorders, or as a result of ocular surface disease, with side effects ranging from blurred vision to severe pain.
Therefore, experts from around the world shared their insights on treating ocular surface disease, keratitis and more, during the Cornea Essentials symposium on the second day of the American
Society of Cataract and Refractive Surgery Virtual Annual Meeting (ASCRS
2020). In addition, she said: “Chronic comorbidities of the ocular surface — dry eye disease, blepharitis and limbal stem cell deficiency — all of these should be assessed for because they compound the entire picture.”
New medical treatment in neurotrophic keratitis
Regarding treatment, the first step is to add lubrication and remove any medications that contain preservatives, which can provide extra toxicity to the ocular surface. Then, start antimicrobials to prevent a secondary bacterial infection. Finally, Dr. Farid recommends checking for inflammation: “If I notice inflammation, I have a relatively low threshold for putting these patients on some topical steroids short-term.”
The hallmark of neurotrophic keratitis is decreased (or completely absent) sensation in the cornea — and it has multiple etiologies, the most common being herpetic corneal disease, said Dr. Marjan Farid. “There’s really a long list of etiologies that can lead to this damage to the cornea,” she explained. There is also a new drug on the block, which is showing positive results for treating neurotrophic keratitis: Oxervate (cenegermin-bkbj) ophthalmic solution 0.002% (20 mcg/mL), a product of Dompé farmaceutici SpA (Milan, Italy). Approved by the United States Food and Drug Administration (U.S. FDA) in 2018, cenegermin − a recombinant human nerve growth factor − which is applied 6 times per day for an 8-week course, is structurally identical to the nerve growth factor naturally produced by the eyes.*
Dr. Farid said that recent clinical results for patients receiving cenegermin are exciting: In one U.S. clinical trial, 72% of patients had complete corneal healing at 8 weeks; meanwhile a European study showed similar results, with 80% of patients’ corneas showing complete healing. “Interestingly, the patients who had 80% healing remained healed at about a year out and we don’t really see this with any other interventions that we do,” she said, adding that it also has a good safety profile.
Ocular surface disease (OSD) can result in unexpected cataract surgery outcomes — like a refractive surprise. And unfortunately, OSD is very common in patients presenting for cataract surgery evaluation, said Dr. Preeya K. Gupta.
In one preoperative cataract evaluation, the patient, a 65-year-old woman, was found to have some meibomian gland disease (MGD), decreased tear break-up time (TBUT), some corneal staining, abnormal osmolarity and matrix metalloproteinase-9 (MMP-9) levels. She also had some irregular astigmatism, with high expectations for her visual outcomes, said Dr. Gupta.
“In these situations, where the patient has significant visual demands, and when there’s astigmatism to manage, I really feel very strongly about hitting the pause button and focusing on the ocular surface disease first and then repeating the biometry and topography to see how accurate our measurements are,” explained Dr. Gupta.
It’s important to explain to the patient that they had two disease processes going on as well: cataracts and ocular surface conditions, she continued. “It was only recently that we started to recognize that dry eye disease is severely underdiagnosed preoperatively and can have significant impacts on refractive outcomes.”
So, what happened with this particular patient? After treating the OSD, Dr. Gupta said most importantly, there was a reduction in the patient’s measured astigmatism: “The toric IOL power changed to a T3 from a T5, so clearly we would have had a refractive surprise had we not addressed the ocular surface disease.”
Knock It Out of the Park
with Refractive Cataract Surgery by Sam McCommon
Day two of the American Society
of Cataract and Refractive Surgery Virtual Annual Meeting
(ASCRS 2020) featured a symposium on refractive cataract surgery — with a baseball theme. If the goal of any surgery is success, then the analogy of hitting a homerun aligns perfectly with a surgeon’s goals. Analyzing just how to get that run scored was the topic of discussion.
Show up at the game: Why perform refractive cataract surgery?
Dr. Daniel H. Chang knocked it out of the park with his introductory presentation, which was perhaps the most eyeopening of the bunch. He asked a simple question: If the goal of medicine is to first do no harm, how do you prevent harm? Why perform this surgery in the first place? What’s wrong with bifocal glasses?
He turned his attention to something that many don’t think of when they think of ophthalmology: falling. Specifically, in this case, he discussed seniors falling.
Bifocal glasses nearly double the risk of falls in elderly patients, with one in three falls being attributable to the glasses. There were 29 million falls among elderly patients in the United States in
2014, leading to 2.8 million ER visits, 800,000 hospitalizations — and 27,000 deaths.
The cost was enormous: Falls accounted for $31 billion in medical costs in 2014. With bifocals causing nearly of falls, that’s roughly $10 billion in damage. This combined with the human suffering indicates a clear reason to choose IOLs: Eye cataract surgery has been shown to reduce senior fall rate by.
Step up to the plate: Preoperative preparations
Selecting which patients are right for treatments is as crucial as performing the treatments themselves. Dr. Jessica Ciralsky highlighted discussing optical compromise with patients to manage expectations. When would they be okay with wearing glasses? What’s their lifestyle? She also discussed which patients to avoid, especially those with unrealistic expectations.
Dr. Steven Dell suggested not offering a patient a ‘menu’ of treatments with prices — instead, introduce premium options as the only choice. If the patient can’t afford or doesn’t want premium options, then further discussions can be had. He recommended marketing outcomes and not technologies.
Finally, when preparing for surgery, Dr. Sarah Nels recommended a minimum measurement set of biometry, topography and tomography, and noted that surgeons shouldn’t neglect the macula. She pointed out that using topography can help reduce the risk of surprises like irregular astigmatism.
Swing for the fences
Dr. John A. Vukich featured a technique he learned from Dr. Chang: using Purkinje images to correctly center a toric lens. He pointed out that surgeons don’t necessarily want to center the lens on the pupil. They can use layers of Purkinje images to correctly center the lens, especially if the patient is having trouble fixating due to anesthesia.
Running the bases: Postoperative management
Dr. Kathryn Hatch and Dr. John Cason both addressed a key part of postoperative management: dealing with unhappy patients. It may sound oddly simple, but listening to the patient is one of the most important steps in this process. You need to understand their lifestyle and specifically what they’re unhappy about before proceeding. There are plenty of options to improve a surgery postoperatively if the patients’ needs are understood.
Bring it on home: Investing in better outcomes
Finally, Dr. William Wiley discussed the role of technology and investments in exceeding patient outcomes. While doctors must be doctors, they also have to be businessmen sometimes.
He pointed out that staying on the cutting edge of technology can create a culture of excellence that leads both doctors and patients to confidence. At the same time, choosing equipment wisely — like using equipment that has multiple functions — can be a wise choice.
For the next six months, however, he recommended that doctors focus on personal protective equipment (PPE) and safety to make patients feel comfortable. He said that, for now, safety trumps everything else and should be the priority in the near future.
