Download A Review of Global Consensus on Keratoconus and Ectatic

2/8/2017
Disclosure
The Battle of the Bulge…
Its All About the Backside
• No Financial Interest
• Not the opinion of the VCE, DoD, VA or any
other US Government Agency
Andrew S. Morgenstern, OD FAAO
Bethesda, Maryland
Disclosure
•
•
•
•
•
•
•
Alcon
Allergan
Bruder Heathcare
Ocusoft
Oculus
TLC Laser Eye
Thank you to my colleague Clark Chang, OD
Video Courtesy Mike Tullo
Advanced KC Treatment Strategies
“Classic” Manifestations
• Progressive apical thinning
with inferior conical
protrusion
– Non-vascularized?
– Non-inflammatory?
• Bilateral but Asymmetric
– True Unilateral KC?
• Irregular Cylinder & HOA
– Vertical Coma
– Spherical Aberrations
Advanced KC Treatment Strategies
“Classic” Manifestations
• Onset ~ 1st - 2nd decade of life
and slows down ~ 4th decade
– Stabilization trend ≠ absolute
• Incidence ≥ 1/2000?
• Multifactorial causes
Rabinowitz et. al
– Genetic?
– Trauma?
– IOP?
• LVC implications?
– FFKC
– Topo WNL but Family Hx
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0
1
Topo
Pattern
WNL/SBT
ABT
RSB
(Stromal
Bed)
≥ 300µm
280 - 299µm
260 279µm
240 –
259µm
Age
≥ 30
26 – 29
22 - 25
18 - 21
CT
≥ 510µm
481 510µm
451 480µm
< 450µm
MRSE
≤ -8D
≤ -12D
≤ 14D
> 14D
≤ 10D
2
3
4
Advanced KC Treatment Strategies
Multifactorial Etiologies
Inferior
Abnormal
Steepening/S ie, FFKC
RA
• Mechanical trauma in predisposed
individuals
– IOP Spikes
– Increased surface temperature
< 240µm
• Inflammatory mediators
• IL-1/IL-6, MMPs, TNF-α
• Proteolytic enzymes
– Contact lens trauma?
– Sleeping posture?
– keratocyte apoptosis
Reduced biomechanics!
1. Randleman JB, Trattler WB, Stulting RD. Validation of the Ectasia Risk Score System for
preoperative laser in situ keratomileusis screening. Am J Ophthalmol. 2008 May;145(5):813-8.
Advanced KC Treatment Strategies
Advanced KC Treatment Strategies
Challenges In Conventional Mx
Challenges In Conventional Mx: Refractive
Traditional Challenges in KC Mx
Biomechanical
Weakening
Irregular
Optics
Retarded
┼
Progression
═
Advanced
Aberrated
Wavefront
Marsack, JD
 Increased HOA (5.5x vs. control)
 vertical coma, trefoil, tetrafoil, and 20 astigmatism1,2
1.
2.
Advanced KC Treatment Strategies
Challenges In Conventional Mx: QOL
Pantanelli S et al. Characterizing the wavefront aberration with keratoconus or penetrating keratoplasty using a high-dynamic range of wavefront
sensor. Ophthalmology. 2007;114:2013-2021
Kosaki R et al. Magnitude and orientation of zernike terms in patients with Keratoconus. Invest Ophthalmol Vis Sci. 2007;48:3062-3068
Advanced KC Treatment Strategies
Expanding Management Paradigm
Growing Accumulations of Stress and Development
hrs/wk when absenteeism and presenteeism
“PITA”Americans
Syndromewith
Duelow
to:vision1
reviewed inof
working
1) Patient Monitoring Approach – Refractive Correction
Visual Frustration
 Corneal diseases ranked 5th major eye diseases
Physical Frustration
—Indirect health care cost estimated at $2.14 billion for
2
Psychological
Frustration
Medicare beneficiaries in 2003
3) Functional Approach – Stabilization + Ref. Correction
 12.9
 Misperceived
2) Prophylaxis Approach – Stabilization
± progression & age
as small public health impact
Early Detection & Interdisciplinary Co-Management
AMD 3 (90)
vs. AMD
4 (71)
Are Keys tovs.
Optimizing
Patient
Outcome!!
—CLEK Study (73)
1.
2.
Jacobson G, Frick K, Massof R. Impact of Low Vision and Chronic Ophthalmic Conditions on Absenteeism and Lost Work Productivity
2005;22:abstract no. 4117. Available at http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=103623580.html (accessed on 12/02/2011)
Javitt JC, Zhou Z, Willke RJ. Association Between Vision Loss and Higher Medical Care Cost in Medicare Beneficiaries. Ophthalmology
2007;114:238-245
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Advanced KC Treatment Strategies
Advanced KC Treatment Strategies
Anatomical/Optical Signs: Examples
Topography: Hotspot Recognition!
Munson’s Sign/Rizzuti’s sign
Fleischer Ring/Hydrops/Corneal scar
 Scissor Reflex/Oil droplet Reflex
 “Warped” Mires on keratometry/photokeratoscopy


Lower Specificity
if Solely Using
Color Pattern Recognition Via
Anterior
S/P Decentered
SunRiseCorneal Topographical
HSV Corneal Scar
LTK
Profiles
Emerging KC
Advanced KC Treatment Strategies
Pachymetry/Tomography
 Ultrasound
Pachymetry (5262 Eyes)
—Avg. CT
= 544 ± 34 um
—Suspect if < 476 um
—CCT is Least reliable indicator
–
–
Global Delphi Panel
KC with normal CCT
 Optical
Pachymetry
—CT
Distribution and Elevation
—Epithelial masking of anterior curvatures
–
Color Pattern Recognitions!!
Posterior Profiles and HOAs (ie, V. Coma)
Advanced KC Treatment Strategies
Pachymetry/Tomography
Pachymetry/Tomography
Image Courtesy of Barry Eiden, OD, FAAO
Advanced KC Treatment Strategies
Image Courtesy of Barry Eiden, OD, FAAO
–
Video Courtesy Mike Tullo
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Advanced KC Treatment Strategies
Advanced KC Treatment Strategies
Pachymetry/Tomography
Corneal Biomechanics
Image Courtesy of Barry Eiden, OD, FAAO
• Dynamic Bidirectional Applanation
Advanced KC Treatment Strategies
Advanced KC Treatment Strategies
Corneal Biomechanics
Wavefront Aberrometry
• Dynamic Bidirectional Applanation
Zernike Chart
Podium Presentations
1st
( 1, -1)
( 1, 1)
2nd
( 2, -2)
( 2, 0)
( 2, 2)
3rd
( 3, -3)
( 3, -1)
( 3, 1)
( 3, 3)
4th
( 4, -4)
Normal Thin cornea
Keratoconus
Image Courtesy of Renato Ambrosio, MD, PhD
( 4, -2)
( 4, 0)
( 4, 2)
( 4, 4)
Higher order aberrations make up approximately 17% of
the total aberrations of normal eyes
Advanced KC Treatment Strategies
Advanced KC Treatment Strategies
High Frequency Ultrasound: Artemis
Expanding Management Paradigm
1) Patient Monitoring Approach – Refractive Correction
2) Prophylaxis Approach – Stabilization
3) Functional Approach – Stabilization + Ref. Correction
Reinstein DZ, Archer TJ, Gobbe M, Silverman RH, Coleman DJ. Epithelial thickness in
normal Cornea: three dimensional display with Artemis very high frequency digital
ultrasound. J Refract Surg 2008;24:571-581
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Advanced KC Treatment Strategies
glycolaldehyde
ribose
glucose
methylglyoxal
aldehyde sugars (14 days)
glyceraldehyde
0.1 %/10 min
436 nm/30 min
365 nm/30 min
0.075 %/20 min
glutaraldehyde
90
80
70
60
50
40
30
20
10
0
254 nm/20 min
– Theo Seiler
– Eberhard Spoerl
– Gregory Wollensak
UV-irradiation
with riboflavin
Increase in Stiffness ( %)
• UV + Riboflavin (vitamin B2): reported at U of
Dresden; many other studies ongoing since 1994
1st
0.075 %/10 min
CXL/Corneal Cross-linking
Spoerl and Seiler, J Refract Surg 1999;15:711.
Advanced KC Treatment Strategies
Advanced KC Treatment Strategies
CXL: Riboflavin Absorption Spectrum
CXL: UVA 365/370nm
5
365-370 nm
4
3
2
1
0
300
350
400
450
500
550
wavelength (nm)
Advanced KC Treatment Strategies
CXL: Different Devices
•
•
•
•
•
•
Avedro - USA
CXLUSA - USA
Peshke
IROC Innocross
Sooft
Vega X-Link
A Review of
Global Consensus on Keratoconus
and Ectatic Diseases
Cornea
April 2015
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Purpose of the Project
• Desire to reach consensus
– Keratoconus
– Ectatic diseases
Design and Organization
• Focus on
– Definition
– Concepts
– Clinical Manangement
– Surgical Treatments
Conclusions
Selection of Expert Panel
• Resulted in the diagnosis and management of
keratoconus and other ectatic diseases via
worldwide insight
• Conclusion resulted in
• Ophthalmologists with experience in the
management of keratoconus and ectatic diseases
• Authorship of scientific publications in highimpact medical journals
• Wide recognition by the specialized medical
community
• Willing to comply with the initial question
rounds, face-to-face meeting, and project
timelines
– Definitions
– Statements
– Recommendations
Selection
Flowchart of the Project
• Worldwide geographic distribution
• Represent 4 Ophthalmological Cornea socities
– Asia Cornea Society (Asia)
– Cornea Society (USA and international)
– EuCornea (Europe)
– PanCornea (Latin America, USA and Cananda)
• Each society had 4 experts plus coordinators
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Mandatory Findings to Diagnose
Keratoconus
Definition and Diagnosis
• Abnormal POSTERIOR Ectasia
• Abnormal Corneal Thickness Distribution
• Clinical Non-inflammatory corneal thinning
• Values and reference points vary based on
device used for screening
Ectatic Disease List
•
•
•
•
Keratoconus
Pellucid Marginal Degeneration (PMD)
Keratoglobus
Post Refractive Surgery Ectasia
Non-Ectatic Corneal Diseases
• Terrien Marginal Degeneration
• Dellen
• Inflammatory Melts
Best way to distinguish
Keratoconus from PMD
Initial Consensus Statements
• Keratoglobus and Keratoconus are different
clinical entities
• True unilateral keratoconus DOES NOT EXIST
• Thinning, location and pattern are aspects
that distinguish Keratoconus, PMD and
Keratoglobus
•
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Full corneal thickness map
Slit lamp exam
Anterior curvature map
Anterior tomographic elevation map
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Least Reliable
Indicator or Determinant
Consensus on Tests to Diagnose Early or
Sub-Clinical Keratoconus
• Tomography (Scheimpflug or OCT)*
• Central Pachymetry
Posterior corneal elevation abnormalities must
be present to diagnose mild or sub-clinical
keratoconus
This is because Keratoconus can be present in a
cornea of normal thickness
*Best and Most Widely Available tests
Definition of Ectasia Progression
• Consistent change in at least 2 of the 3
following parameters
– Steepening of the anterior corneal surface
– Steepening of the posterior corneal surface
– Thinning and/or an increase in the rate of corneal
thickness change from the periphery to the
thinnest point
• Changes need to be consistent over time and
above normal variability
Ectasia Progression
• A change in both UCVA and BSCVA is NOT
required to document progression
• Testing for progression should be SHORTER for
younger patients
• The same measurement platform should be
used in sequential examinations
Summary of Agreements Reached in
the Definition/Diagnosis Panel
Ectasia Risk Factors
• Down Syndrome
• Relatives of affected individuals/patients
– Especially in young
• Ocular allergy and systemic atopy
• Ethnic factors (Asian and Arabian)
• Mechanical factors
•
•
•
•
– Eye rubbing and Floppy eyelid syndrome
• Connective tissue disorders
•
– Marfan syndrome
• Ehlers-Danlos syndrome
• Lebers congenital amaurosis
•
•
•
The following findings are mandatory to diagnose keratoconus
– Abnormal posterior elevation
– Abnormal corneal thickness distribution
– Clinical noninflammatory corneal thinning
Keratoconus and PMD are different clinical presentations of the same disease
The aspect that distinguishes keratoconus, PMD, and keratoglobus is “thinning location and pattern”
Keratoconus and PMD are best differentiated by a combination of
– Full tomographic corneal thickness map
– Slit-lamp examination
– Anterior curvature map
– Anterior tomographic elevation map
As opposed to “thinning disorders” the following are classified under “ectatic diseases”
– Keratoconus
– PMD
– Keratoglobus
– Postrefractive surgery progressive corneal ectasia
Keratoglobus and keratoconus are different clinical entities
True unilateral keratoconus does not exist
The best current and widely available diagnostic test to diagnose early keratoconus is tomography
(Scheimpflug or optical coherence tomography)
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Summary of Agreements Reached in
the Definition/Diagnosis Panel
•
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•
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•
•
Currently, there is no clinically adequate classification system for keratoconus
Posterior corneal elevation abnormalities must be present to diagnose early or
subclinical keratoconus
Secondary induced ectasia may be caused by a pure mechanical process (and can
be unilateral)
Central pachymetry is the least reliable indicator (determinant) for diagnosing
keratoconus
The pathophysiology of keratoconus is likely to include the following components
– Genetic disorder
– Biochemical disorder
– Biomechanical disorder
– Environmental disorder
Placido-based topography analyzes the central anterior corneal surface, whereas
tomography (Scheimpflug and/or optical coherence tomography) analyzes the
anterior and posterior cornea and produces a near full corneal thickness map
Keratoconus can be present in a cornea of normal central thickness
Summary of Agreements Reached in
the Definition/Diagnosis Panel
•
•
•
Ectasia progression is defined by a consistent change in at least 2 of the following parameters
where the magnitude of the change is above the normal noise of the testing system
– Progressive steepening of the anterior corneal surface
– Progressive steepening of the posterior corneal surface
– Progressive thinning and/or an increase in the rate of corneal thickness change from the
periphery to the thinnest point
The changes need to be consistent over time and above the normal | variability (ie, noise) of
the measurement system (this will vary by system). Although progression is often
accompanied by a decrease in BSCVA, a change in both uncorrected visual acuity and BSCVA
is not required to document progression
Risk factors for keratoconus:
– Down syndrome, relatives of affected patients especially if they are young,
– Ocular allergy and systemic atopy
– Ethnic factors (Asian and Arabian),
– Mechanical factors, eg, eye rubbing, floppy eyelid syndrome,
– Connective tissue disorders (Marfan syndrome),
– Ehlers–Danlos syndrome and Leber congenital amaurosis
Most Important Goals in
Non Surgical Management
Non Surgical Management
Non Surgical Management of Ectasia
• Verbal Guidance to the patient to not rub
one’s eyes
• Use of topical antiallergenic medication in
patients with allergy
• Use of topical antiallergenic medications in
patients with atopy or history of eye rubbing
• Use of topical lubricants
• Halting disease progression
• Visual rehabilitation
Dry Eye and Keratoconus
• There is no direct relationship between dry
eye and keratoconus
• Use of eye drops without preservatives is
preferable in keratoconic patients
– PF agents reduce irritation and epithelial trauma
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Refraction
• Subjective refraction should be attempted in
all patients with ectasia
• Aberrometry my help determine the
refraction early in the disease process
• PAL’s are not contraindicated by rarely
successful
Contact Lenses
• Contact lenses do not halt or slow the
progression of corneal ectasias
• Cosmetic contact lenses should be
discouraged due to difficulty in contact lens
fitting and THE INCREASED RISK OF
COMPLICATIONS FROM A POORLY FIT
CONTACT LENS
“Rigid Contact Lenses”
Special Situations
• Should be used in cases of unsatisfactory vision
with glasses or SCL’s
• Gas-permeable are preferred and should be tried
initially in patients with keratoconus
• If failed in RGP’s then attempt
• Careful evaluation in cases of Down syndrome
• Pregnancy can contribute to the acceleration
of ectasia progression
• In cases of acute hydrops non surgical or less
invasive surgical management such as
intracameral gas should be attempted before
pregnancy
–
–
–
–
–
Hybrid
Toric or Bitoric
Specialty Keratoconic soft or rigid lens
Piggy-back
Scleral lenses
Summary of Agreements Reached in
the Non Surgical Management Panel
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•
•
The 2 most important goals of management are halting disease progression and
visual rehabilitation. Verbal guidance should be given to patients regarding the
importance of not rubbing one’s eyes, use of topical antiallergic medication in
patients with allergy, and use of topical lubricants (in the case of ocular irritation)
to decrease the impulse to eye rub
In cases of allergy or if there is any allergic component, patients should be treated
with topical antiallergic medication and lubricants. Topical multiple-action
antiallergic medications (ie, antihistamines, mast cell stabilizer, antiinflammatory)
should be used in patients with keratoconus with atopy or history of eye rubbing
There is no direct relationship between keratoconus and dry eye
Preservative-free agents are preferred as they are associated with less irritation
and epithelial trauma compared with agents with preservatives
Subjective refraction should be attempted in all patients with corneal ectasia.
Aberrometry may help to determine the optical correction in early disease
Progressive-type glasses are not contraindicated in eyes with keratoconus or other
ectasias, but they are rarely successful
Contact and scleral lenses are extremely important for visual rehabilitation
in patients with keratoconus and other corneal ectasias
Summary of Agreements Reached in
the Non Surgical Management Panel
• Contact lens use does not slow or halt progression of corneal ectasias
• Rigid contact lenses should be used in cases of unsatisfactory vision with
glasses or conventional soft contact lenses. Among the rigid contact
lenses, gas-permeable lenses are preferred and should be tried initially in
patients with keratoconus. In a patient with keratoconus who has failed
conventional corneal gas-permeable lenses, alternative contact lens
options would be: hybrid lens (rigid center, soft skirt); toric, bitoric, and
keratoconus design soft contact lens; keratoconus design corneal rigid gaspermeable contact lens; piggy-back; corneoscleral, miniscleral, and
semiscleral contact lens; and scleral lens
• A careful evaluation for keratoconus is strongly recommended in patients
with Down syndrome and should be considered in patients with known
risk factors for developing keratoconus (Table 2)
• Pregnancy could contribute to acceleration of the progression of ectasia
• In acute hydrops, nonsurgical management should be attempted before
keratoplasty
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Surgical Management
Surgical Management
• Surgery should be considered when patients
were not fully satisfied with non surgical
treatments
– “Satisfied best-corrected”
CXL
CXL
• Available and performed by 83.3% of panelists
• Extremely important for keratoconus with
progression
• Very important for post-refractive
keratoectasia (does not say progressive)
• Important for treatment of keratoconus with a
perceived risk of progression (not confirmed)
• No consensus for sub-clinical keratoconus
– Other 16.7% would use it if available
• Variety of techniques
• Collagen Cross Linking is not a correct term
• Corneal Cross Linking is a correct term
CXL
• Consensus on No age restrictions
– Should be used in eyes with demonstrated
progression
• No consensus on age limit for treatment in
keratoconic eye without evidence of progression
• Rarely indicated in patients over 40
• No consensus best UCVA that limits CXL
treatment
Penetrating Surgery
•
•
•
•
Anterior lamellar keratoplasty (ALK)
Deep anterior lamellar keratoplasty (DALK)
Penetrating keratoplasty (PK)
Intra corneal ring segments (ICRS)
– i.e. Treat if better than 20/30?
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Superficial Keratectomy
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•
•
•
Photo therapeutic keratoplasty (PTK)
Photo refractive keratoplasty (PRK)
Conductive keratoplasty (CK)
Incisional keratoplasty (IK)
Microwave corneal remodeling
• Clear lens extraction with IOL (sperical or
toric) were uncommonly used by the panel
Surgical Considerations
• DALK
– Most important patient-related factor is CL
intolerance
• PK
–
–
–
–
Most important factor is corneal scarring
Post hydrop scarring
CL intolerance
Low corneal pachymetry (below 200microns)
• High risk for hydrops
– Previous failed corneal surgery
Corneal Transplant
• Any form offered to 21%-60% eligible
keratoconic patients
• In patients with no prior hydrops
– Either ALK or DALK performed in more than 60%
of patients
• In patients with prior hydrops
– ALK or DALK performed in 0% to 20% of patients
PK
• Over half the panel have performed
femtosecond laser-assisted PK for keratoconus
– Of those who perform femto PK, only perform it
on 1%-20% of their cases
ALK Techniques
• No prior hydrops
– Over 51% would perform DALK big bubble
• Microkeratome ALK is never performed
• Other ALK is performed less than 25%
– Manual layer by layer predescemetic DALK
(pdDALK) with viscodissection
– pdDALK with Melles technique
– Femtosecond laser assissted DALK
Most Important Surgical Techniques
for Keratoconus
• dDLAK
• PK
• ICRS
• Majority of panelists currently perform a non
laser technique
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Most Important Surgical Technique for
Post Op Rigid Lens Fit
Keratoconus Treatment
• dDALK
• PK
Summary of Agreements Reached in
the Surgical Management Panel
•
•
•
•
•
•
Young (eg, 15-year-old) patient with stable KCN with satisfactory vision with glasses
– Prescribe glasses only or in combination with contact lenses or CXL
Young (eg, 15-year-old) patient with progressive KCN with satisfactory vision with glasses
– Perform CXL and prescribe glasses 6 contact lenses
Older (eg, 55-year-old) patient with stable KCN with satisfactory vision with glasses
– Prescribe glasses only or with contact lenses
Older (eg, 55-year-old) patient with progressive KCN with satisfactory vision with glasses?
– Perform corneal cross-linking only or with prescription of glasses/ contact lenses
Patient with stable KCN with unsatisfactory vision with glasses but satisfactory vision with
rigid contact lenses and tolerates them well? This patient has a spherical equivalent of
moderate myopia [eg, 5 diopters (D)]
– Prescribe contact lenses (including scleral lenses)
Patient with stable KCN with unsatisfactory vision with glasses but good vision with rigid
contact lenses, and tolerates them well? This patient has a spherical equivalent of high
myopia (eg, 15 D)
– Prescribe contact lenses (including scleral lenses)
Documenting Ectasia Progression
• Requires 2 of the following:
– Steepening of the anterior surface
– Steepening of the posterior surface
– Thinning or changes in the pachymetric rate of change
• Magnitude of changes is unknown
YOUNGER PATIENTS SHOULD BE EXAMINED FOR
CHANGE AT SHORTER INTERVALS AS ECTATIC
CHANGE CAN PROGRESS RAPIDLY IN THIS GROUP
Summary of Agreements Reached in
the Surgical Management Panel
•
•
•
•
Patient with stable KCN with unsatisfactory vision with glasses and contact
and
scleral lenses, or who does not tolerate contact or scleral lenses?
This patient has a
spherical equivalent of moderate myopia (eg, 25 D)
– Perform dDALK. Consider ICRS in eyes with adequate corneal thickness and minimal to
no scarring
Patient with stable KCN with unsatisfactory vision with glasses and contact and scleral lenses,
or who does not tolerate contact or scleral lenses? This patient has a spherical equivalent of
high myopia (eg, 15 D)
– Perform dDALK
Patient with stable severe KCN with unsatisfactory vision with glasses and contact and scleral
lenses? This patient has moderate anterior corneal scarring but no evidence of previous
corneal hydrops
– Perform dDALK
Patient with stable severe KCN with unsatisfactory vision with glasses and contact and scleral
lenses? This patient has moderate anterior and deep corneal scarring with evidence ofof
previous corneal hydrops
– PK alone or attempt pdDALK
Importance of Tomography
• Anterior and posterior views
• Significant importance of the posterior cornea
as an early indicator of ectatic change
• Posterior corneal surface and alteration in the
corneal thickness progression are necessary to
diagnose keratoconus
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Differentiate KC form PMD
• Items needed to differentiate:
– Anterior and posterior tomography
– Corneal thickness map
– Slit lamp exam
– Anterior surface measurements
Pathophysiology of Ectasias
•
•
•
•
•
Multifactorial
Genetic
Biochemical
Biomechanical
Environmental
KC and PMD Summary
• Different clinical presentations of the same
basic disease process
• Ectatic diseases:
– Keratoconus
– PMD
– Post refractive surgery ectasia
– Keratoglobus
Summary of CXL
All assuming good candidates
• Anyone with progressive ectasia should
undergo CXL no matter what age level or
vision
• OK to proceed with CXL even if patients were
happy with their vision
Questions
• What is the new estimate or incidence of Keratoconus?
• Why weren’t Yaron Rabinowitz, MD Stephen Klyce, MD
and Steven Wilson, MD included in the panel?
• Why is there no information on contact lens fitting,
materials, design and follow-up?
• Why no Optometrists if they deal with a significant part
of the non surgical and post operative patient?
• How is there is no direct relationship between dry eye
and keratoconus?
• Contact lenses are just wrong…
Questions
• Why no information on placido disc technology?
• Why no discussion about biomechanical
properties of the cornea?
• Why no information or recommendation of epion or epi-off
• If keratoconus is bilateral, should you treat a
20/20 eye non-keratoconic eye to prevent the
progression?
• Is prophylactic treatment recommended?
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Review of
The Association Between
Sociodemographic Factors,
Common Systemic Diseases , and
Keratoconus
Ophthalmology 2015
Andrew S. Morgenstern, OD FAAO
Executive Board Member
International Academy of Keratoconus
Purpose
• Determine if an association exists between
– Common systemic diseases
– Sociodemographic factors
– Keratoconus
Largest Keratoconus Study
EVER
32,000 patients
Maria Woodward, MD
Taylor Blachley, MS
Joshua Stein, MD MS
Design and Participants
• Retrospective
longitudinal cohort
study
• 16,053 Keratoconic
patients
• 16, 053 nonKeratoconic patients
Among a large, diverse group of insured individuals
in the United States
Results:
Odds of being diagnosed with
Keratoconus
• Compared to Whites - No Diabetes Mellitus (DM)
– 57% higher in Blacks
– 43% higher in Latinos
– 39% lower in Asians
– 20% lower in uncomplicated DM
– 52% lower in DM with end organ damage
– 35% lower in collagen vascular disease
Other Factors Increased Odds
• Sleep Apnea
• Asthma
• Down Syndrome
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Factors Not Associated
•
•
•
•
Allergic Rhinitis
Mitral Valve Prolapse
Aortic Aneurysm
Depression
Conclusions
• When caring for the keratoconic patient,
clinicians should
– Inquire about breathing or sleeping
– Refer for sleep apnea or asthma evaluation
• Patients with Diabetic Mellitus have a
potentially lower risk of Keratoconus due to
glycosylation
16