Eyeworld Daily News

EW SHOW DAILY 8 Tuesday, April 29, 2014 ASCRS Symposia Pardon the disagreement by Rich Daly EyeWorld Contributing Writer S harp conflicts in the treatment of several conditions emerged among participants in the annual symposium "Pardon the Ophthalmology: Hot Topics in Cornea and External Disease." Based on the ESPN show Pardon the Interruption, the symposium featured some of the same sharp elbows that lent fame to its fast- paced, confrontational name-sake show. In one of the cases reviewed in the quick-take format, panelists preferred different treatment options for a patient with limbal stem cell deficiency from chronic contact lens wear, who showed classic late fluorescein staining. Thomas John, MD, Oak Brook, Ill., and Neda Shamie, MD, Beverly Hills, Calif., said they would use amniotic membrane and scrap off the epithelium. "We've seen in a lot of patients with even 30% normal limbus that they can epithelialize the surface," Dr. Shamie said. But Edward Holland, MD, Cincinnati, one of the symposium "With ReSure you have to have a reasonably dry surface to apply it, otherwise it can become diluted and not work for you," Dr. Hovanesian said. Richard Davidson, MD, Aurora, Colo., suggested using the sealant at the beginning of such a case to try to prevent complications by strengthening the peripheral cornea where the RK incisions may open. The panelists mentioned concerns that their colleagues are missing many occurrences of anterior basement membrane degen- eration (ABMD), such as was present in a cataract patient who presented with normal Ks. Dr. Hovanesian, who noted ABMD is present in up to 5% of the general population, underscored the importance of recognizing the often-asymptomatic condition before biometry is performed. "If you see staining that is irregular on the surface of the eye— either pooling or negative staining or significant map lines in the central visual axis—you know it's going to be affecting your refractive outcome and your visual outcome of the case," Dr. Hovanesian said. "So you have to address it before surgery." Panelists worried that ophthal- mologists may overlook or even ignore ABMD, although 92% of the physicians attending the symposium correctly identified it from the presenting symptoms. Christopher Starr, MD, New York, said his residents and fellows often miss the condition. "A lot of times you have to lift up that upper lid because it's more common in the superior cornea," Dr. Starr said. EW Editors' note: Dr. John has financial interests with Allergan and other ophthalmic companies. Dr. Shamie has financial interests with Bausch + Lomb, Allergan, and Nicox. Dr. Holland has financial interests with Abbott Medical Optics and other ophthalmic compa- nies. Dr. Mah has financial interests with Alcon and other ophthalmic com- panies. Dr. Hovanesian has financial interests with 800 Doctors and other ophthalmic companies. Dr. Davidson has financial interests with Alcon and Carl Zeiss Meditec. Dr. Starr has financial interests with Allergan and other ophthalmic companies. moderators, warned the more aggressive treatment favored by other panelists may not benefit such a patient. "The number of clock hours affected here are extensive and if you have this many clock hours it is a total limbal deficiency and it's not going to do well," Dr. Holland said. Their preferred approach differed sharply from much of the audience, which generally favored optimizing the ocular surface (49%) or using a living related conjunctival allograft or KLAL (27%). Another division arose when the panel discussed approaches to cataract surgery in a post-radial keratotomy (RK) patient. Francis Mah, MD, La Jolla, Calif., suggested the use of ReSure (Ocular Therapeu- tix, Bedford, Mass.), a gel sealant, in such patients. The study on which the FDA based its approval of the sealant found the gel was superior to sutures in preventing wound leaks among patients who had demonstrated leaks. However, John Hovanesian, MD, Laguna Hills, Calif., warned that ReSure may need to be com- bined with sutures in such a patient. Drs. Starr, Mah, and Hovanesian were panelists at the "Pardon the Ophthalmology: Hot Topics in Cornea and External Disease" symposium.

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