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EW SHOW DAILY 34 ASCRS Symposia Tuesday, May 9, 2017 Preoperatively, Dr. Chan does a 10% povidone-iodine lid scrub to address the possibility for infection. In terms of healing and haze, it's important to optimize the ocular surface prior to treatment. In terms of pain, Dr. Chan recommended sublingual lorazepam. Intraoperatively, she said that infection is not too much of a con- cern. In terms of delayed healing, you can protect the limbus. Dr. Chan recommended that 0.02% mitomycin-C for 30 to 60 seconds be used for haze in some cases. For pain, ensure greater than 400 mi- cron pachymetry readings through- out the procedure. Use hypotonic riboflavin if needed. Postoperatively, Dr. Chan said to use fluoroquinolone QID for about 7 days to address the possibility of infection. Preservative-free tears can be used for delayed healing, while topical dexamethasone can address haze. For pain, a topical NSAID, acetaminophen and oxycodone, and bandage contact lenses can help, Dr. Chan said. Dr. Chan spoke about the dis- cussion to have with patients about risks. She said to tell them there is a 1% chance of delayed epithelial healing, a 1% chance of decreased BCVA, a 1% chance of IOP elevation, and a theoretical risk for infectious keratitis. Dr. Chan noted that haze is common after crosslinking, and it typically disappears within 6 to 12 months and is not visually signifi- cant. In conclusion, she said that crosslinking is a minimally invasive procedure that is safe and associated with few complications. Adverse events can occur with crosslinking. Crosslinking surgeons need to be comfortable managing potential complications. An epithelial-off technique requires a healing process, while the epithelial-on technique may confer less risk, but randomized controlled trials are needed. EW Editors' note: Dr. Waring has financial interests related to his comments. The other speakers have no financial inter- ests related to their comments. by Ellen Stodola EyeWorld Senior Staff Writer If you go by labeling, make sure the preoperative central pachyme- try is greater than 400 microns so that during treatment it doesn't drop below that, he said. Addition- ally, avoid use in centrally scarred corneas where opacity limits visual potential. Dr. Manche said to set the expectation that crosslinking is not a refractive procedure, and let the patient know they will still require glasses and contacts. Regular eye exams are still needed to monitor keratoconus. Dr. Manche said to educate patients regarding the time course of the postoperative healing process. Steepening Kmax is observed at 1 month postoperatively, followed by flattening. Postoperatively, Dr. Manche said a bandage contact lens would be used to promote healing and im- prove patient comfort. Additionally, topical antibiotics may be used until the epithelial defect is healed, and topical steroids used for 2 weeks. Dr. Manche said to use non-preserved topical medications and lubrication in cases of delayed epithelial closure. He also said to remove the bandage contact lens when the epithelial defect is healed. Some possible adverse events like anterior stromal haze, delay in corneal epithelial closure, superficial punctate keratitis, ocular irritation, dry eye, photophobia, and ocular pain could occur. In conclusion, he said physi- cians need to select appropriate can- didates for crosslinking. It's also im- portant to carefully monitor corneal pachymetry during treatment to ensure that the cornea does not thin to less than 400 microns. The most common complications are anterior stromal haze and delayed epithelial closure, and careful postoperative observation for complications is essential to successful outcomes. Clara Chan, MD, Toronto, Canada, discussed prevention and management of complications. She highlighted pearls to prevent com- mon crosslinking complications, the risks that you should tell patients about, and complication manage- ment after crosslinking. referring doctors, educate staff, pur- chase the appropriate diagnostic and surgical instruments, identify tech- nicians and space, and make sure the finances work for your practice. George Waring IV, MD, Charleston, South Carolina, high- lighted the role of diagnostics in crosslinking. The incidence of kera- toconus is reported around 1/2,000, but most agree that's grossly un- derreported. There is significant morbidity associated with keratoco- nus, and we're learning more about this with advanced diagnostics, he added. Dr. Waring said that he does not propose to wait for progression. He discussed a number of imaging considerations in crosslinking. He highlighted technologies to look at shape, structure, strength, and function. Edward Manche, MD, Palo Alto, California, shared information on intraoperative and postoperative management of eyes undergoing crosslinking. A Monday morning sympo- sium focusing on cross- linking was co-sponsored by the ASCRS Cornea Clinical Committee and the Refractive Surgery Clinical Committee. The symposium offered practical pearls for starting a corneal collagen crosslinking practice. The session was moderated by Terry Kim, MD, Durham, North Carolina, and John Vukich, MD, Madison, Wisconsin. David Vroman, MD, Charles- ton, South Carolina, highlighted some of the nuts and bolts of start- ing a crosslinking practice. Some of the top things to consider, he said, are patient base, indications and consent, equipment, space, staff, flow, the procedure, and finances. He also discussed patient selection in the procedure, the me- chanics of the space needed for the procedure, risk management, and reimbursement topics. In summary, he said to dedicate time to educate Symposium offers information on crosslinking and how to start a crosslinking practice Dr. Waring discusses the role of diagnostics in crosslinking.

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