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EW SHOW DAILY 26 ASCRS Symposia by Ellen Stodola EyeWorld Senior Staff Writer Dr. Farid said in conclusion that crosslinking does work. In terms of whether it will change vision and correction need, she said it can im- prove it, but the goal is stability. She pointed out that there is currently only one FDA approved method, however, she mentioned ongoing studies looking at accelerated and epi-on, combined topography-guid- ed PRK and CXL, and intracorneal ring segments and CXL. Audrey Talley Rostov, MD, Seattle, discussed treating older patients with crosslinking and how old is too old. She showed a breakdown of demographics of patients she has treated. In 803 eyes of 638 patients from April 2012 to April 2018, 130 (36.1%) of her patients were 40 or older. She also noted that 124 pa- tients (19.4%) were between 40 and 49, and 106 patients (16.6%) were over 50. Dr. Talley Rostov shared rea- sons for treating older patients with crosslinking: to prevent progression, A Monday morning sym- posium covered "Cross- linking Essentials" and was moderated by Francis Mah, MD, La Jolla, California, and John Vukich, MD, Madison, Wisconsin. William Trattler, MD, Miami, discussed if there is a minimum age for crosslinking (CXL), sharing cases of CXL in children. Making the diagnosis of keratoconus as early as possible is the goal, he said. Patients of any age can be treated, and in Dr. Trattler's experience, patients age 8 and older can do very well with CXL. Our understanding is that the development of early keratoconus in children is a sign of progression, he said. It's important to educate all children on the importance of avoiding eye rubbing, and to treat underlying ocular allergies and/or ocular surface disease. Dr. Trattler described several of his cases of young patients and noted the challenge of deciding whether or not to treat the patient. In one case, a 14-year-old male had never worn glasses and reported that his vision was not as good as in the past. However, the slit lamp exam was normal, and Dr. Trattler had to decide if it would be appropriate to perform topography on the patient. The problem is that chang- es in children could be a sign of early keratoconus, Dr. Trattler said. He showed several other cases to demonstrate how quickly these young patients might progress. So how can one diagnose keratoconus and monitor progres- sion? Dr. Trattler said that screening patients with corneal imaging is critical to diagnosing keratoconus. The slit lamp exams will be normal until long after there are changes in the corneal shape, he said, adding that difference maps allow clinicians to compare changes over time. Also during the session, Mar- jan Farid, MD, Irvine, California, discussed current and long-term results of crosslinking, and she not- ed common questions that patients ask her about crosslinking: Does CXL work? Will it change my vision and correction need? What is the best method? What are the risks and potential complications? She noted haze is a potential complication that is seen in 50–90% of patients, but Dr. Farid said most issues of haze resolve by 1 year. She also noted that according to a study, haze was reported to permanently affect vision in 8.6% of cases. Other potential complications are sterile infiltrates or infection. Dr. Farid said there is no adverse effect on endo- thelial cell density Dr. Farid stressed the impor- tance of patient education. Set the expectation that crosslinking is not refractive surgery. The goal is to sta- bilize and maintain vision. It's also important to educate the patient on the time course of the postoper- ative healing process. On average, steepening of Kmax is observed at 1 month postoperatively, which is followed by flattening through 12 months, Dr. Farid said. She stressed that it's important patients know that glasses and/or contact lenses will still be needed. to obtain decreased/flattening of K readings to allow better contact lens fit or glasses, it can improve irregular astigmatism, and it can help obtain more consistent K readings. Crosslinking can be performed before or after cataract surgery, she said, noting considerations for cata- ract surgery, which included patient expectations, topography, density of the cataract, consideration of a toric IOL, usually cataract surgery is per- formed first, and younger patients may have CXL first. "The main thing here is patient expectations," she said. "You really need to involve your patient in the decision and educate them on what crosslinking can or cannot do." EW Editors' note: Dr. Trattler has financial interests with CXLO (Chevy Chase, Maryland), CXLUSA (Chevy Chase, Maryland), Oculus (Arlington, Wash- ington), and Avedro (Waltham, Massa- chusetts). Drs. Farid and Talley Rostov have no financial interests related to their comments. Tuesday, April 17, 2018 Crosslinking essentials highlighted in symposium Dr. Farid shares questions she gets asked by patients about crosslinking.

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