Keratoconus Lasers, Lenses & Boomerangs (the journey, missing links, and management & treatment options) Moderator: Jan P G Bergmanson, OD, PhD

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1 2014 AAO CCLRT Section Symposium Keratoconus Lasers, Lenses & Boomerangs (the journey, missing links, and management & treatment options) Moderator: Jan P G Bergmanson, OD, PhD Recurrent Keratoconus: Does it Happen and, if so, How? Jan Bergmanson, OD, PhD Professor, University of Houston College of Optometry, Houston TX Keratoconus has been known as a corneal pathology for soon 150 years but we still do not understand its etiology nor do we know where exactly it starts. As a consequence, there are a number of theories on the background and origin of this disease. Management options for the keratoconic patient remain contact lenses and surgery with the recent addition of UVA in conjunction with Riboflavin administration. Recent clinical and basic reasearch at Texas Eye Research and Technology Center (TERTC) has given us new insights regarding the precise focus and extent of this corneal pathology. We have also begun to understand the events leading up to the formation of ectasia, which may have a similar mechanism in postrefractive surgery patients developing this condition. The objective of this presentation is to share new information about keratoconus and discuss the clinical implication of new knowledge. Our histopathological research has demonstrated clearly that the pathological changes have an anterior focus with an involvement of both the epithelium and the anterior stromal tissue. This explains why staining is so common in patients with this disease but also indicates that we need to avoid heavy contact lens bearing over the cone surface. Since both our histopathological and clinical research has demonstrated that keratoconus is not a disease limited to the area of the cone but rather is a pancorneal disease, the scleral contact lens, which is fitted to vault the entire cornea, start making a great deal of clinical sense. Keratoconus patients fitted with such lenses are generally very pleased with the comfort they offer. Research at TERTC has shown that corneal stromal lamellae breaks up into smaller units lamellar splitting and when this event is combined with corneal thinning, as in keratoconus and postrefractive surgery, ectasia develops. However, an alternative hypothesis for the mechanism of corneal ectasia has been proposed and is the known as the slippage theory,

Jan Bergmanson, OD, PhD Professor, University of Houston College of Optometry, Houston TX Keratoconus has been known as a corneal pathology for soon 150 years but we still do not understand its

2 where lamellae slide over each other to create a thinner cornea over the cone. A discussion on the validity of these two explanations to corneal ectasia, splitting versus slippage, will be provided. We have observed in some of our transplant patients that over time they appear to develop keratoconus again. Patients with keratoconus, who need transplant surgery, should be informed of the risk that the disease may return. An interesting question here is where does the disease come from the host or donor tissue? Today we call this complication recurrent keratoconus but, if the pathology never was completely surgically removed, it may find its way to the donor tissue, in which case a better term may be reemergence.

We have observed in some of our transplant patients that over time they appear to develop keratoconus again.

3 The Keratoconus Journey from Diagnosis to Surgery & Beyond Susan J Gromacki, OD, MS, FAAO, Washington Eye Physicians & Surgeons, Chevy Chase, MD Diagnosis & Prognosis the Patient Conversation To Fit or to Refer? Contact Lens Management When it s time for surgery When to treat? Which procedure? Which surgeon? Counseling on outcomes Referrals & Comanagement strategy

4 Contact Lens Options for the Keratoconic Patient Patrick Caroline, FAAO, Associate Professor, Pacific University College of Optometry 1. Effect of Contact Lenses in Keratoconus 1. Do contact lenses stop or slow the progression of keratoconus? 2. Do contact lenses cause keratoconus? 2. Puberty Onset 1. Begins in youth or early adolescence approx. age Usually bilateral with one eye affected worse than the other. 3. Following the onset, there is a progression for 7 or 8 years, then the condition often remains stationary. 4. Acute relapses in middle age, 3540, are not uncommon. 3. Late Onset Keratoconus 1. Usually begins in late 20 s or early 30 s 2. Both eyes can be affected the same 3. The incidence of progression reduces greatly with the age of onset 4. Keratoplasty 1. Indications for Keratoplasty for Keratoconus 2. When the patient can no longer be fitted with contact lenses. 3. When contact lenses no longer provide adequate visual acuity due to corneal scarring. 4. Patients who require sharp bilateral visual acuity for their profession. 5. Fitting Early Keratoconus 1. Spherical GP lenses 2. Aspheric GP lenses 3 Reverse geometry lens designs 4. Scleral lens designs 6. OverRefractionUse large spherical steps i.e. +/ 1.00 D 1. If O/R > 4.00 D then transpose power to ocular surface. 2. If VA doesn t improve try sph/cyl O/R 3. Front surface toric 4. Over spectacles

3. Following the onset, there is a progression for 7 or 8 years, then the condition often remains stationary. 4. Acute relapses in middle age, 3540, are not uncommon. 3. Late Onset Keratoconus 1.

5 7. Soft Lenses for Keratoconus 1. Piggyback lenses designs 2. Soft torics in early KC 3. Custom special soft lens designs 4. Hybird lensdesigns

6 Corneal Crosslinking What every OD Needs to Know William Tullo, OD, FAAO, VP Clinical Services, TLC Laser Eye Centers, Princeton, NJ Corneal Crosslinking for Keratoconus Background Mechanisms Current International Protocols & Results Epithelium on techniques Epithelium off techniques Current US clinical trials Protocols Perioperative management & Vision Rehabilitation Techniques Primary ectasia Secondary ectasia Comorbidity issues (Dry eye, herpetic eye disease, allergy)

Epithelium on techniques Epithelium off techniques Current US clinical trials Protocols Perioperative management &

Corneal Collagen Cross-Linking (CXL) With Riboflavin

Dr. Paul J. Dubord, MD, FRCSC Clinical Professor Department of Ophthalmology and Visual Sciences University of British Columbia Patient Information Guide Corneal Collagen Cross-Linking (CXL) With Riboflavin