Eyeworld Daily News

EW SHOW DAILY 38 ASCRS Symposia by Lauren Lipuma EyeWorld Contributing Writer intuition, we take what we think, then we consolidate that into: 'If this was me, what would I want?'" He thinks it makes sense to do crosslinking prior to cataract surgery if the patient has ectasia that is progressing; if the patient has advanced keratoconus with unstable biometry; if the patient is younger; if you're coupling the crosslinking with another staged procedure like intracorneal ring segments; or if you have a planned refractive outcome with a toric lens. "If a patient had reasonably symmetric astigmatism and did not get better with a gas permeable lens, that's the only way I would consider a toric lens in these patients," he said. In Dr. Berdahl's practice, he's performed crosslinking on 11 eyes prior to cataract surgery since 2016, at an average interval of 6 months preoperatively. He now uses cross- linking as part of his preoperative planning for managing the two diseases. Consider treating a kera- toconus patient similar to a patient with dry eye or significant epithelial basement membrane dystrophy (EBMD), he said. EW Editors' note: Dr. Berdahl and Dr. Beckman have financial interests with Avedro (Waltham, Massachusetts). their lives and cataract-age keratoco- nus patients are typically stable, but these assumptions may not be true, Dr. Berdahl said. Crosslinking can provide a benefit to cataract patients because cataracts tend to occur earlier and more often in keratoconus patients, keratoconus can progress through- out adulthood, and crosslinking stabilizes corneal topography and flattens the cornea, which improves biometry measurements, he said. If you're going to crosslink a patient before surgery, your goals should be to stabilize the corneal topography prior to ocular biom- etry, improve the accuracy of IOL calculations, and reduce the risk of progression after surgery. Performing crosslinking prior to cataract surgery may give the surgeon a better and more stable cornea to work with. A lot of kerato- conus patients already wear a scleral contact lens or a rigid gas permeable lens that may affect their biometry, Dr. Berdahl said. When making the decision to perform crosslinking on a cataract patient, Dr. Berdahl recommends asking yourself: What if this was my eye? "As doctors, we try to take the evidence, but the evidence doesn't always apply," he said. "We take our "Don't get lulled into a sense of security with consecutive readings that are stable," he said. "These pa- tients need to be followed for life." You want to catch keratoconus in patients early, but crosslinking can give patients significant corneal flattening even if they're stable, so they can still benefit from crosslink- ing if they're older, Dr. Beckman said. If patients are in their 30s and 40s, they are probably still progress- ing, and it's perfectly reasonable to treat them with crosslinking if they want it because you may have saved them from having to get a corneal graft, he said. Even patients in their 50s can benefit from crosslinking, he added. "If they're optically clear and not scarred, there's no harm in do- ing it," Dr. Beckman said. Crosslinking in cataract patients: Yay or nay? What happens when a patient has keratoconus and needs a cataract ex- traction? Ophthalmologists should at least think through crosslinking as part of their algorithm prior to taking out cataracts, said John Berdahl, MD, Sioux Falls, South Dakota. Historically, doctors have as- sumed cataract patients have been naturally crosslinked throughout H ow do you define progres- sion in keratoconus? How do you treat it? When does it make sense to perform crosslinking in a keratoconus patient before cataract surgery? Cornea specialists addressed these and other questions in yester- day's "Cornea Essentials" sympo- sium. The purpose of the session was to run through a variety of common cornea scenarios ophthalmologists see on a regular basis and discuss some of the questions that come up when treating these patients because there's not always a right or wrong answer, said Francis Mah, MD, La Jolla, California, who moderated the session. Kenneth Beckman, MD, Co- lumbus, Ohio, started the conver- sation by discussing three existing challenges in keratoconus manage- ment: diagnosing it, determining if the disease is getting worse, and deciding whether to treat it with crosslinking. The key to diagnosing keratoco- nus is to use the patient's topogra- phy and tomography, Dr. Beckman said. But be aware that keratoconus progression is often not linear; it could be episodic, where a patient's cornea is stable for years but then quickly steepens, he said. Monday, April 16, 2018 Pearls for managing keratoconus Cornea specialists discuss how to manage a variety of cornea scenarios ophthalmologists see on a regular basis.

• Cover