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EW SHOW DAILY 28 ASCRS Symposia Tuesday, April 21, 2015 by Vanessa Caceres EyeWorld Contributing Writer that same study, there was one case of a corneal ulcer and one case of infectious keratitis. There have also been reports in the literature of Acanthamoeba keratitis, primary or reactivation of herpes keratitis, corneal haze, and corneal scarring. Although there were early concerns about endothelial damage, the Avedro trial did not report this. Dr. Hersh concluded that CXL is gener- ally safe but that ophthalmologists must carefully monitor healing and advise patients of the typical time course for healing. Other presentations during the session focused on CXL trials, presented by John Vukich, MD, Madison, Wis., new technologies for riboflavin formulation or delivery, with George O. Waring IV, MD, Charleston, S.C., ancillary refractive treatments, with A. John Kanellopoulos, MD, Athens, Greece, and a regulatory perspective with Maureen O'Connell, North Reading, Mass. EW Editors' note: Dr. Gomes has finan- cial interests with Alcon (Fort Worth, Texas), Allergan (Irvine, Calif.), Bausch + Lomb (Bridgewater, N.J.), and other ophthalmic companies. Dr. Hersh has financial interests with Avedro. Dr. Rootman has financial interests with Abbott Medical Optics (AMO, Abbott Park, Ill.). Dr. Stulting has financial interests with AMO, Alcon, Allergan, and other ophthalmic companies. T he therapeutic promises and questions behind cor- neal collagen crosslinking (CXL) were the focus of Monday morning's sympo- sium "Update on Corneal Collagen Crosslinking," sponsored by the ASCRS Cornea Clinical Committee and ASCRS Refractive Surgery Clini- cal Committee. Although CXL is well known as a treatment for keratoconus, Jose A.P. Gomes, MD, Sao Paolo, Brazil, shared other indications for the procedure, including with corneal edema, infectious keratitis, and for use with PRK and post-radial kera- totomy. For corneal edema, studies show that CXL appears safe and therapeu- tic but that the effect is shorter term. There is also the occasional side effect of crystalline keratopathy, Dr. Gomes said. To treat Acanthamoeba keratitis, CXL has had some mixed results with in vitro models, but clinical work has shown good results, he added. Some panelists focused on future advances to the delivery of CXL, which would include changes to the delivery of ultraviolet (UV) light, said David Rootman, MD, Toronto. This could involve varia- tions in irradiance, time, pulse, and topography-guided CXL, he said. "In the future, we may get better at control of the reaction and a safer, faster treatment," he said. There's an ongoing debate for epithelium-on (epi-on) versus epi-off treatment with CXL, said Doyle Stulting, MD, Atlanta. A previous study has shown a 300-fold differ- ence in concentration of riboflavin with epi-off; additionally, riboflavin- saturated epithelium could block UV light absorption into the stroma, Dr. Stulting said. However, several of the complications associated with CXL link back to removal of the epithelium, such as sterile infiltrates and perforation. For these reasons, attempting epi-on CXL could lower some of the procedure's risks and lead to future improvements in protocol, Dr. Stulting said. He is involved with an epi-on study with 113 patients. With 6 months of data, there have been no complica- tions, and there has been significant visual improvement. "Epi-on doesn't produce CXL as strong as epi-off, but there are lower risks, and the possi- bility of repeat treatment may make epi-on the preferred approach," Dr. Stulting said. Complications are always a concern with any new procedure, and Peter Hersh, MD, Teaneck, N.J., addressed the most common ones associated with CXL. In Avedro's (Waltham, Mass.) trial, the most common adverse event was expect- ed sequelae related to debridement of the cornea, Dr. Hersh said. In Taking a big-picture look at corneal collagen crosslinking by Lauren Lipuma EyeWorld Staff Writer to see if there was some consensus on this issue. The various surgery centers offered a range of recom- mendations. Among the military centers surveyed, the average patient time off was 5.8 days for PRK and 4.3 days for LASIK. On average, patients returned to field duty about a month after surgery for both pro- cedures. PRK patients had to wait on average 85 days after surgery to be deployed, however, compared to just 39 days for LASIK patients. Risks and complications Karin E. Thomas, MD, Bethesda, Md., presented a history of LASIK S peakers at Monday's "Mil- itary Refractive Surgery" symposium highlighted the current safety issues, risks, and complications associated with performing refrac- tive surgery on the U.S. Armed Forces. Elizabeth M. Hofmeister, MD, San Diego, outlined the current procedures that are authorized for individuals in military service. LASIK and PRK are both ap- proved for entry into military service, but implantable collamer lenses (ICLs) are not. "That has become a major tripping point for many appli- cants along the way," she said. ICLs are approved, however, for active duty members of the Army and Navy. Historically, PRK has been the procedure of choice for military members, but the number of LASIK procedures performed continues to rise. Dr. Hofmeister believes that there will be equal numbers of each surgery performed in the next few years. Addressing safety concerns How quickly can service members return to duty after refractive sur- gery? In the military, no standard- ized guidelines exist that address this question, said Gary L. Legault, MD, El Paso, Texas. While it is common for civilian patients to return to work within a few days of having PRK or LASIK, the nature of military life demands a longer waiting period. Night vision, dry eyes, and the possibilities of missing drops or follow-up appoint- ments are a few of the issues that military surgeons have to consider in determining when patients can safely return to active duty, Dr. Legault said. Dr. Legault surveyed all of the U.S. military refractive surgery centers and 3 civilian surgery centers Updates in military refractive surgery Dr. Gomes addresses attendees during Monday's crosslinking symposium.

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