doc5 or 6 - Pennsylvania Optometric Association
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5 or 6 - Pennsylvania Optometric Association
10/13/15 • Financial Disclosures 10 Things Every OD Should Know About the Cornea • BioD • Maculogix Ohio Vision Founda?on 2015 William R. Marcolini, OD, FAAO OMNI Eye Services-‐New Jersey 4 How many layers of the cornea are there? 5 or 6 5 # 10 Did you know? There is a new layer of the cornea 6 A NEW CORNEAL LAYER—DUA’S LAYER 7 8 1 10/13/15 Dua’s Layer • Harminder Dua from the University of No^ngham, UK • 15 microns thick • Between STROMA and Descemet’s 9 Could this be useful in Glaucoma? • Professor Dua suggests this is relevant for corneal surgeries, understanding hydrops and pathology of dystrophies • Came only from donor corneas of pa?ents with a median age of 82, is this an ar?fact? 10 Not everyone is sold! PDL May Be An Important Part Of Structural Tissue That Helps To Maintain Intraocular Pressure. Medwire (2/27, Freeman) reports that researchers “have found that a newly discovered layer of the human eye is an important part of the structural tissue that helps to maintain intraocular pressure and thus may play a role in the development of glaucoma .” The investigators found that “the pre-Descemet’s layer (PDL), which is also known as Dua’s layer after the academic professor of ophthalmology who discovered it, is an important extension of the trabecular meshwork (TM).” The findings were published in the British Journal of Ophthalmology. 11 # 9 Specific parts of the cornea can be replaced 13 • In February 2014, McKee et al stated that they had "read the recent claim of the discovery of a new corneal layer by Dua et al with incredulity. The existence of pre-Descemet stromal tissue remaining after pneumodissection is well known. Their further investigation of this pre-Descemet stroma confirms that it is stroma, and not a new corneal layer." [6][8] • They also criticized the self-chosen name Dua's Layer, adding that "despite current trends to avoid medical eponyms", if such a medical eponym was desired then '‘the Feizi stroma’ would be more appropriate."[8] 12 Does anybody know what happened on December 7, 1905 in Olmutz, Slovakia? 14 2 10/13/15 It had to do with this guy… a 45 year old Czech day laborer 15 16 Slaking lime 17 18 Does anybody know what happened on December 7, 1905 in Olmutz, Slovakia? • The first cornea was transplanted by Eduard Zirm in a pa?ent who was blind from ALKALI lime injury. • Both corneas were scarred centrally with HM vision • An 11 year old boy was the donor and he lost his cornea to a metallic i injury 19 20 3 10/13/15 Alois Glogar had the first transplant in 1905 So we’ve come a long way… • His lej eye shows a small clear corneal transplant, 4 mm in diameter. • The corneal scarring in the right eye is from an alkali burn with corneal transplant failure in that eye. • PKP • Lamellar Keratectomy—anterior and posterior • Descemet’s and Endothelial replacement 21 Penetra?ng Keratoplasty (PKP) 22 PKP • Running sutures: Merseline anchored by cardinal sutures • Full thickness corneal graj (most common) • Host cornea is removed with an 8mm trephine • Replaced with donor (removed in situ) corneal bumon • Low rejec?on rates 17.9% • Success rates excellent (98% to 100%) • Most will likely need spectacles (30%) or CL’s (47%) postopera?vely • Older pa?ents do bemer with Nylon and interrupted sutures for selec?ve removal 23 24 25 26 4 10/13/15 Avellino Italy Avellino-‐GENE detec?on system • Somewhat new! Screening test…mouth swab, 48 hour results • First Gene?c Test for Avellino corneal dystrophy (AKA granular dystrophy type 2) • Amempt to iden?fy carriers so that they do NOT progress or manifest disease ajer Lasik surgery -‐-‐-‐ 27 28 S?ll evolving… • The company now has a second test for another gene?c muta?on; namely, granular corneal dystrophy type 1. It is now called Avellino DNA Dual Test for LASIK Safety • Other gene?c tests include the Asper Biotech corneal dystrophy test, which can be used to screen for 333 muta?ons in the following 13 different genes: COL8A2, TGFBI, VSX1, CHST6, KRT3, KRT12, GSN, TACSTD2, CYP4V2, SOD1, TCF8/ZEB1, SLC4A11 and UBIAD1. 29 OCT of an Anterior Lamellar Keratoplasty 30 • Very common FUCHS • Ranges from asymptoma?c gumata to stromal edema with epithelial bullae • Onset >age 50 • Females 5.7 x more likely to have edema! lamellar keratoplasty 31 image courtesy of Dr. L. Buratto ENDOTHELIAL DYSTROPHIES • Dysfunc?on of endo cells and deposi?on of collagen: pump malfunc?ons • Cornea can swell up to 1,000 microns (avg 545) and epithelial and stromal edema develops • Corneal Pachymetry 76514 • Specular Microscopy 92286 2,000-‐3,500 cells/mm² normal cell density • Pain if bullae rupture 32 5 10/13/15 FUCHS Deep Lamellar Endothelial Keratoplasty DLEK • Treatment: aimed at reducing edema 1. Muro 128 5% qid /ung qhs -‐Topical Hyperosmo?cs 2. AT’s and High Dk BSCL for ruptured bullae 3. Ocular hypotensives 4. Blow dryer in morning 5. Penetra?ng Keratoplasty OR just replacing JUST the ENDOTHELIAL LAYER! • Replaces just the endothelium from a donor cornea • Prospec?ve clinical trials since 2000 in US by Mark Terry, MD • No sutures or surface incisions so less pain and less as?gma?sm • • • • 33 Anterior Segment OCT Endothelial Keratoplasty • In one study: 6 months-‐-‐ 98 grajs clear Mean VA 20/46 +0.28 D induced as?gma?sm Deep lamellar endothelial keratoplasty visual acuity, as=gma=sm, and endothelial survival in a large prospec=ve series; Ophthalmology. 2005 Sep;112(9):1541-‐8. 34 DMEK—the latest (DSEK) 5 weeks post op • Fascina?ng surgical procedure • Almost NON-‐Detectable donor-‐recipient interface! • Brings WOW effect associated with Lasik -‐-‐highest consistent promise of 20/20 PO VA • Least amount of corneal graj rejec?on • -‐-‐1% rejec?on year one • -‐-‐1% year two • (DSEK is 8% and 12%) 36 image courtesy of Dr. W. Culbertson 37 DMEK • Donor ?ssue has NO stromal ?ssue in the disk • The Donor Descemet’s rolls up on itself, with the endothelial cells on the outside • The surgeon must delicately unroll it, NOT touch it and use fluid currents to float it into place 38 39 6 10/13/15 DMEK Implanta?on Cartridge • • • • Cornea: September 2014 -‐ Volume 33 -‐ Issue 9 -‐ p 880-‐886 doi: 10.1097/ICO.0000000000000206 Clinical Science • • Randomized Comparison of Topical Prednisolone Acetate 1% Versus Fluorometholone 0.1% in the First Year Ajer Descemet Membrane Endothelial Keratoplasty Price, Marianne O. PhD*; Price, Francis W. MD†; Kruse, Friedrich E. MD‡; Bachmann, Bjöern O. MD‡; Tourtas, Theofilos MD‡ 40 41 42 44 # 8 Solu?ons do mamer… Purpose: • The aim of this study was to compare the efficacy and side effects of prednisolone acetate 1% versus fluorometholone 0.1% ajer Descemet membrane endothelial keratoplasty (DMEK). • Methods: • DMEK recipients used prednisolone acetate 1% for 1 month, and they were randomized to either prednisolone or fluorometholone for months 2 through 12. Dosing was 4 ?mes daily in months 1 to 3, thrice daily in month 4, twice daily in month 5, and once daily in months 6 to 12. The main outcomes were immunologic rejec?on episodes and intraocular pressure (IOP) eleva?on (defined as ≥24 mm Hg or ≥10 mm Hg increase over the preopera?ve baseline level), assessed by the Kaplan–Meier survival analysis. • Results: • The study included 325 eyes (99% were white, 96% had Fuchs dystrophy, and 9% had a previous glaucoma diagnosis). No eyes (0%) assigned to prednisolone versus 2 eyes (1.4%) assigned to fluorometholone experienced a possible (n = 1) or probable (n = 1) rejec?on episode (P = 0.17). Both rejec?on episodes resolved successfully with increased topical steroids. In the prednisolone arm, a significantly higher propor?on exceeded the defined IOP eleva?on threshold (22% vs. 6%, P = 0.0005), and glaucoma medica?ons were ini?ated or increased more ojen (17% vs. 5%, P = 0.0003). The most frequent reasons for discon?nuing the assigned interven?on were IOP management (n = 13 eyes assigned to prednisolone) or inflamma?on management (n = 3 eyes assigned to fluorometholone). One-‐ year endothelial cell loss was comparable in both arms (30% vs. 31%, P = 0.50). • • Conclusions: DMEK has a remarkably low rejec?on episode rate (<1% through 1 year), as confirmed in this prospec?ve randomized study. This provides a unique opportunity to reduce postopera?ve topical cor?costeroid strength and thereby reduce the risk of steroid-‐associated complica?ons. 45 46 7 10/13/15 Solu?ons—transient superficial SPK 47 Interven?ons that you can do if you see staining • Carefully choosing and prescribing a different combina?on of lens material and care product is ojen sufficient to prevent SICS. • Peroxide care systems have been shown to be associated with very limle corneal staining when used with silicone hydrogel lenses. • Research also indicates that rubbing lenses with the preserved care product prior to storage may reduce the level of SICS. • Avoiding the use of solu?ons by refi^ng the pa?ent into daily disposables will obviously prevent SICS. 48 Ahh, but solu?ons don’t really mamer…or do they? • Much further work is being undertaken to understand the relevance of SICS, but it has become clear that it is not simply a solu?on-‐related phenomenon; it also depends on the lens material with which a solu?on interacts.-‐source clinical insight 49 This walks in off the street…with a foreign body sensa?on and some Vigamox Now what? 50 Now what? 51 52 8 10/13/15 This pa?ent presented to our office ajer three days of Vigamox therapy… 42 y/o cl wearer “Do you sleep in your lenses” –NO “Do you swim/shower in your lenses”—NO “Did you injure your eye while working outside” –NO “Do you have HIV”—NO “Steroid Use?”—NO NO, NO, NO… 53 FUNGAL KERATITIS • Rare 5% of cases • Usually associated with trauma of plant or vegetable mamer -‐-‐Risk factors: gardening, c.l. related trauma, steroid use, surgery • Caused by Filamentous fungi (fusarium) and yeasts (candida) that are ubiquitous and found in organic material • I recommended a cornea consulta?on at NYEE with a specialist for presumed fungal kera??s and she was lost to follow-‐up 54 So what was up with my pa?ent? • Presenta?on: fewer inflammatory signs early (vs. Bacterial) can take ?me to develop (weeks) • Gray-‐white dry infiltrate with feathery borders • Satellite lesions can develop • Deep stromal infiltrate with endothelial plaque and hypopyon 55 One year later… 56 Fungal Kera??s Pearls • I received a call from Bausch and Lomb inves?ga?ng the Fusarium Outbreak • The pa?ent had been using Moisture Loc and was awai?ng corneal transplant at Will’s Eye Hospital in Philadelphia 57 • Specific signs for fungal kera??s: Feathery infiltrate with a rough texture and elevated edges; satellite lesions are common • Most common risk factors: Trauma, contact lenses or solu?ons, topical medica?ons including steroids, corneal surgery, chronic kera??s (fungal develops secondarily) • Ojen takes weeks to develop and months to treat • Must culture to confirm diagnosis and tailor treatment for appropriate combina?on of topical or oral an?fungals and insure suscep?bility 58 9 10/13/15 Which of the following is indicated in the treatment of fungal kera??s? • • • • Which of the following is indicated in the treatment of fungal kera??s? • A. Natamycin 5%-‐-‐ only commercially available topical an?fungal in US; average length of therapy is 30-‐39 days A. Natamycin 5% B. Prednisolone Acetate 1% C. Besivance (Fluoroquinolones) D. Oral Amphotericin • B. Prednisolone Acetate 1%-‐-‐steroids are absolutely contraindicated ****** • C. Besivance(Fluoroquinolones)—not effec?ve • D. Oral Amphotericin-‐-‐Oral used to treat Thrush • Usually given intravenously 59 60 P :Which of the following is an accepted method of trea?ng fungal kera??s orally? P: Which of the following is an accepted method of trea?ng fungal kera??s orally? • A. Ketoconazole 400-‐800 mg PO daily • B. Doxycycline 50 mg PO BID • C. Natamycin 5% gms TID • D. Levaquin 500 mg QD • A. Ketoconazole 400-‐800 mg PO daily • B. Doxycycline 50 mg PO BID • C. Natamycin 5% gms TID • D. Levaquin 500 mg QD 61 62 Treatment of Discussion FUNGAL KERATITIS • Though Natamycin (Natacyn 5%) is an accepted treatment for fungal kera??s it is only available topically. • • • • • • In conjunc?on with the topical therapy, oral an?-‐fungals are given to kill aspergillus, fusarium and candida • Some oral an?-‐fungals include: Ketoconazole, Voriconazole, Fluconazole and Posaconazole 63 Must confirm with culture 1. Natamycin 5% q30 2. Scop 0.25% TID 3. NO Steroid or Patch 4. Role of Amph-‐B drops • 5. Orals Imidazoles: Fluconazole 200 mg p.o. (Diflucan), ketoconazole, itraconazole; Posaconazole • (Admission to hospital usually necessary, long course, may need PK 65 10 10/13/15 # 7 The peripheral cornea is different… • S: 56 year old white male presents with a red eye • He has been tearing for a few days and the eye is moderately painful and light sensi6ve. 66 • He does not wear contact lenses and denies any associated illness. • He states that he has had blephari?s for many years, but has been poorly compliant with the recommended lid hygiene. In addi?on he has been bothered by recurrent “styes.” 67 Objec?ve findings • A single well circumscribed, circular, dense focal infiltrate involving the anterior corneal stroma, with significant conjunc?val injec?on, especially adjacent to infiltrate. • A clear zone exists between infiltrate and limbus. 68 Assessment 70 Assessment • Based on the clinical appearance what is the diagnosis? • Based on the clinical appearance what is the diagnosis? • A. Herpes Simplex Kera??s • B. Contact Lens Related Peripheral Ulcer (CLPU) • C. Staph Marginal Kera??s • D. Superior Limbal Keratoconjunc?vi?s (SLK) • A. Herpes Simplex Kera??s • B. Contact Lens Related Peripheral Ulcer (CLPU • C. Staph Marginal Kera==s • D. Superior Limbal Keratoconjunc?vi?s (SLK) 71 72 11 10/13/15 The pathogenesis of Staph Marginal infiltra?on is due to? The pathogenesis of Staph Marginal Infiltra?on is due to? • A. Immunogenic response of the cornea to Staphylococcus aureus bacterial cell wall • B. Immunogenic response of the cornea to Staphylococcus aureus exotoxin • C. Hypoxic environment created from blephari?s • D. Nocturnal hypoxia • A. Immunogenic response of the cornea to Staphylococcus aureus bacterial cell wall • B. Immunogenic response of the cornea to Staphylococcus aureus exotoxin • C. Hypoxic environment created from blephari?s and contact lens wear • D. Nocturnal hypoxia 73 74 In contrast to herpes simplex kera??s, Staph marginal kera??s is characterized by…? In contrast to herpes simplex kera??s, Staph marginal kera??s is characterized by…? • A. Epithelial defect forms before the infiltrate • B. The stroma is invaded with live bacteria • C. Diagnosis must be confirmed with laboratory culture • D. Infiltrate develops first and then the epithelium is affected • A. Epithelial defect forms before the infiltrate • B. The stroma is invaded with live bacteria • C. Diagnosis must be confirmed with laboratory culture • D. Infiltrate develops first and then the epithelium is affected; Ini?ally the epithelium is intact, but later in disease a defect can develop making diagnosis more difficult 75 Which is not an appropriate interven?on? • • • • 76 Which is not an appropriate interven?on? A. Topical cor?costeroids B. Topical an?bio?cs C. Lid Hygiene D. All of the above are appropriate interven?ons • A. Topical cor?costeroids • B. Topical an?bio?cs • C. Lid Hygiene • D. All of the above are appropriate interven?ons 77 78 12 10/13/15 Staph Marginal Ulcer Treatment Staph Marginal Ulcer or Sterile Ulcer • 1. Treat the Bleph with Lid scrubs and Erythromycin • 2. Treat with Topical Steroids ?d-‐qid: -‐Durezol -‐Pred Acetate 1% -‐Lotemax 0.5% -‐Fluorometholone .1% -‐Zylet or Tobradex or TDST 79 • Hypersensi?vity reac?on to exogenous an?gens • Staph aureus exotoxin • From longstanding Blephari?s • Lucid limbal clear zone • Spreads circumferen?ally • Infiltrate first then epithelial defect (opposite of Herpes) 80 • Usually inferior Peripheral Ulcera?ve Kera??s • Generally a corneal manifesta?on of a systemic immune-‐mediated disease • PUK has been associated with nearly all connec?ve ?ssue disease or vasculi?des -‐-‐the most common include rheumatoid arthri=s, Wegener’s granulomatosis and Polyarteri?s nodosa, also can occur ajer trauma or surgery -‐-‐circula?ng immune complexes deposit in limbal vessels inci?ng local inflamma?on and ini?ates the ulcera?ve process 81 Peripheral ulcera?ve kera??s 82 Peripheral Ulcera?ve Kera??s 83 • Treatment is very difficult and underlying disease must be evaluated. Without control of systemic disease the ulcera6on relentlessly progresses. • Most cases need rapid high dose systemic cor?costeroids and then long term immunosupressives • Mooren’s Ulcer is a unique presenta?on in that it is an idiopathic ulcera?on thought to be from an autoimmune amack against CORNEAL an?gens -‐-‐(in contrast to non-‐specific circula?ng immune complexes) 84 13 10/13/15 # 6 stuff can get deposited in the cornea Meet Michael… • Michael is a 25 year old asian male, that is enjoying grad school, but not enjoying his contacts! • He is a soj lens wearer and complains of end of day discomfort and irrita?on Having trouble remembering things and feeling a “limle off” mentally 86 He was diagnosed with… What is this? • Dry eye and given • Also… a limle something ar?ficial tears, punctal unrelated was noted in plugs and it was his peripheral cornea recommended that he try Silicone Hydrogel contact lenses and a peroxide based solu?on • A. Arcus Senilis • Ajer a few weeks he felt a limle bemer… • D. Amyloidosis • B. Band Keratopathy • C. Kayser-‐Fleischer Ring • E. White Castle Keratopathy What is this? Serum Copper Test Ordered • A. Arcus Senilis • B. Band Keratopathy • C. Kayser-‐Fleischer Ring • D. Amyloidosis • What tests should you order next? 14 10/13/15 A Kayser-‐Fleischer Ring is associated with what systemic disease? • A. Wilson’s Disease • B. Paget’s Disease • C. Tuberous Sclerosis • D. Harada’s Disease A Kayser-‐Fleischer Ring is associated with what systemic disease? • A. Wilson’s Disease • B. Paget’s Disease • C. Tuberous Sclerosis • D. Harada’s Disease VORTEX KERATOPATHY COPPER Metabolism Disorder • AR disorder characterized • Copper has affinity for by generalized basement membranes accumula?on of copper in and accumulates in the liver, brain, kidneys and Descemet’s membrane corneas, leading to ?ssue aka Kayser-‐Fleischer injury and if untreated Ring death. • Associated with Liver • Sunflower cataract also Disease: hepa??s, associated with cirrhosis, etc. Wilson’s Disease # 5 There are some cool things being done to the cornea for cataract and refrac?ve surgery • Biochemical deposi?on in whorl-‐like pamern • Associated with Fabry’s Disease-‐causes renal failure • More commonly drug toxicity: Amiodarone, Chloroquine, Indomethacin, tamoxifen • New limbal cells migrate towards central cornea causing whorl-‐like pamern • Usually no visual significance 95 Ohh ohh… 96 15 10/13/15 So here’s how the exchange goes… Mrs. Jones…these glasses are no good Hold the phone! • You: Which is bemer number 3 or 4? • Mrs Jones: Number 2 was bemer • You: “Mrs. Jones you have cataracts.” • Mrs Jones: “so I just need new glasses right” • You: “No, I have determined that you need surgery and glasses won’t help” • Mrs. Jones: “they do lasers for that right” • You: “No, they use ultrasound to break up the lens… 98 99 What I think of when I hear of laser… Laser for Cataract Surgery? 100 Lasers for Cataract Surgery?...Yes! • • • • • Femtosecond Laser—Now being used for 1. Anterior Capsulorhexis 2. Crea?on of wound incision 3. Removal of as?gma?sm (AK) 4. Fragmenta?on of the lens Guess who is being trained to do these? 101 Can anyone translate this? • Solo 20 segundos para decir adios a sus gafas para leer! 103 16 10/13/15 Intracor Technolas Perfect Vision GmbH So how are Lasik and PRK done? NO Flap crea?on • New Surgical Treatment for Presbyopia • Intrastromal femtosecond laser abla?on where the laser beam is focused into the mid-‐stroma about 100 microns deep • -‐-‐ver?cally placed bubbles of carbon dioxide in five ring cuts to compensate for presbyopia • -‐-‐takes 20 seconds • -‐-‐2012 study of 63 eyes said 71% sa?sfied and 20% dissa?sfied • Flap is created with Lasik • Epithelium is ablated with PRK -‐Issues with flap healing • -‐Poten?al for infec?on 104 • hmp://www.intracor.net/dasat/index.php?cid=100233 105 106 107 109 What is this? KAMRA Inlay TM • T LC Laser Eye Centers 108 17 10/13/15 110 111 Cosmesis Summary • Over 15,000 inlays implanted to date, excellent outcomes • Improvement in near and intermediate visual func?onality • Minimal effect on distance vision • Minimal compromise in visual quality • Versa?le: emmetropes, ametropes, LASIK/PRK, IOLs • Robust: Results maintained over the long-‐term • Follow-‐up care shares features of LVC and MF implants • Design allows for ocular assessments and/or secondary surgical procedures • The Best Presbyopic Surgical Op=on to Date • The inlay may be visible in light eyes from an oblique angle or when a patient has a pupil smaller than 3.8mm in the non-implanted eye. Actual patient images courtesy of David Allamby, MD, Focus Clinics London CHECK OUT THIS INTERFACE ... Penetra=ng Keratoplasty 112 Cataract Surgery Post-‐Inlay • Completed cataract surgery with the IOL visible behind the inlay. penetrating keratoplasty Images courtesy of Kevin Waltz, OD, MD 113 Femtosecond…can help with PK precision 114 115 18 10/13/15 116 117 # 4 We need to do a bemer job with erosions… One Month PO 118 Are you eyeballing me? 119 How would you manage this pa?ent? • A. Topical An?bio?c qid • B. An?bio?cs qid and bandage soj contact lens • C. Do A and B and add(NSAID) • D. An?bio?c drop with Tylenol #3 E. Pressure Patch 120 19 10/13/15 How I manage most corneal abrasions… Anesthe?c drop in office… Look for loose edges to debride 1. Besivance,Zymaxid, Moxeza BID-‐QID 2. Nevanac or Acuvail QID 3. High Dk Bandage Soj Contact Lens either Oasys, Pure Vision or Air Op?x Watch each day as epithelial defect slowly closes • Can either leave BSCL in place or replace with new one 92071 Procedure Code for BSCL –fi^ng of a cl for tx of ocular surface disease What if BSCL is unable to be inserted or contraindicated This pa?ent loved you and your office staff so much that he returns a month later! • How else could we manage the pa?ent’s acute corneal abrasion? • awakened with extreme pain, tearing, redness and photophobia Pressure Patch • Findings: area of nega?ve staining with hanging epithelium • What about Oral Analgesics? What is the most likely diagnosis? • 1. Corneal Abrasion • 2. Recurrent Corneal Erosion • 3. Acanthamoeba Kera??s • 4. EBMD • 5. Synergy Hybrid lens gone bad What is the most likely diagnosis? • 1. Corneal Abrasion • 2. Recurrent Corneal Erosion • 3. Acanthamoeba Kera??s • 4. EBMD • 5. Synergy Hybrid lens gone bad 20 10/13/15 RECURRENT CORNEAL EROSION RECURRENT CORNEAL EROSION • Answer: Trauma 45% then EBMD 29% • Loca?on 87% on inferior cornea • What is the most common cause of RCE? 1. EBMD 2. Fuchs Dystrophy 3. Trauma 4. Schiotz Tonometry 5. Contact Lens Wear • Epithelial abrasion heals rapidly with poor adhesion to underlying basement membrane Which oral medica?on has been shown to be an effec?ve way to reduce the recurrence of RCE? Which oral medica?on has been shown to be an effec?ve way to reduce the recurrence of RCE? • • • • • • 1. Omega-‐3 Famy Acid 1 TAB PO BID 2. Azithromycin Z-‐pak as directed 3. Benedryl 50 mg PO BID 4. Doxycycline 50 mg PO BID 5. Augmen?n 875mg PO BID 6. Betadine swab then irrigate • • • • • • Oral Treatment of RCE • Treatment of recalcitrant, recurrent corneal erosions with Doxycycline and Pred Forte • Oral Doxycyline 50 mg BID for 2 months • Prednisolone Acetate 1% TID x 3 weeks • (LOTEMAX QID according to MT) • Eyes that had previously failed with conven?onal methods; Doxycycline and PF inhibit metalloproteinase-‐9 and promote wound healing • All healed within 2-‐10 days and no recurrences were noted in 2 year follow-‐up • -‐Dursun D et al. Treatment of recalcitrant recurrent corneal erosions with inhibi?on of matrix metalloproteinase-‐9, doxycycline and cor?costeroids. Am J Ophthal. 2001 Jul;132(1):8-‐13. 1. Omega-‐3 Famy Acid 1 TAB PO BID 2. Azithromycin Z-‐pak as directed 3. Benedryl 50 mg PO BID 4. Doxycycline 50 mg PO BID 5. Augmen?n 875mg PO BID 6. Betadine swab then irrigate RCE Medical TREATMENT • • • • • • Treat acute phase: (premy much just like the K abrasion) 1. An?bio?c QID or BID 2. Cycloplege: Homatropine 5% BID 3. NSAIDs: QID for pain 4. High Dk Bandage Soj Contact Lens 5. Oral Analgesics or Pressure Patching • Long Term Maintenance • Ar?ficial Tears • MURO 128 5% NACL ung/gms (Hyperosmo?c) or Bland Ointments • Azasite? 21 10/13/15 Could we just leave a BSCL in? Second Level Management • In a 2011 study, subjects who previously had failed medical-‐only therapy were assigned to treatment with a plano power, 8.6mm base curve Ciba Night and Day BSCL (Alcon) and prophylac?c topical ofloxacin ophthalmic drops (dosed BID). • The pa?ents con?nued this treatment for three consecu?ve months, repor?ng back to clinic every two weeks for lens replacement and evalua?on. Of the group, 75% had no recurrence over one year ajer discon?nuing therapy. 143 Stromal Puncture CPT 65600 • Suppor?ve treatment: • 1. Debridement of loose epithelium • 2. Anterior Stromal Puncture works best for trauma induced erosions • 3. Superficial Keratectomy works best for basement membrane dystrophy • 4. YAG Laser-‐photo induced adhesion • 5. Excimer Phototherapeu?c Keratectomy Stromal Puncture • Bent 25 g needle or rubinfeld needle used to make microperfora?ons into corneal stroma • 100 µm average depth • Scars fade over ?me, cau?on on VA July 2014 HIS OS Cornea 147 148 22 10/13/15 March 2015 149 151 Is a neurotrophic ulcer infec?ous or inflammatory? 152 Possible Treatment for Neurotrophic Kera??s Amnio?c Membrane Shields What causes a neurotrophic ulcer? Mul=ple ocular and systemic causes can be responsible for neurotrophic keratopathy • • • • • • ►Herpes zoster or simplex2 ► Trigeminal nerve palsy: (trigeminal neuralgia), tumor (acous?c neuroma), aneurysm, facial trauma ► Ocular surface injury (chemical/thermal burn) ► Diabetes mellitus ► Mul?ple surgical procedures (cornea, refrac?ve, glaucoma, conjunc?va, vitreo-‐ re?nal)► Vitamin A deficiency ► Topical drugs (glaucoma, anesthesia, eye drop preserva?ves) ► Congenital (Riley-‐Day), Goldenhaar, Bassen-‐Kornzweig ► Corneal dystrophy (la^ce, granular) ► Aging ► Contact lens wear ► Infec?on ficanthamoeba, leprosy, Lyme) • ► Other chronic epithelial injury and/or stromal inflamma?on • • • • • • 153 • Prokera • AmbioDisk • BIOD Op?x • There are now 8-‐10 different companies selling amnio?c grajs for anterior segment placement! 154 23 10/13/15 Neurotrophic Before and Ajer Why Placental Tissues? The placental ?ssues have been used for over a century as a biological dressing with a broad range of clinical applica?ons. The unique biologic structure of placental ?ssues, coupled with the low risk of an immune response, Unique Biologic provides an ideal choice for Structure: homologous clinical use. Structure, Signals, Cells 156 The Structure of the Fetal Amnio?c Membrane Maternal Birth Tissues Anatomy Amnio?c Fluid Uterus Epithelium • Made up type IV, V and VII collagen (also found on conjunc?val and corneal basement membranes) Amnion Membrane Placenta • Metabolically ac?ve cuboidal cells with microvilli present on its apical surfacce Basement Membrane • Fibronec?n and Laminin Umbilical Cord Stroma • Compact Layer provides tensile strength • Fibroblast Layer • Spongy Layer 158 Growth Factors Present in Placental Tissues Mechanisms of Ac?on Mechanical Promote Epithelializa?on An?-‐fibro?c and an?-‐inflammatory Proper?es An?-‐Angiogenic An?-‐microbial • • • • • • • • Thrombospondin – 1 Endostatin TIMP 1,2,3,4 Bactricidin Beta-lysin Lysozyme Transferin AM prevents Expression of MHC-Class II Antigens AntiAngiogenesis & Anti-Microbial • Transforming Growth Factor-β (TGF-β) • Insulin-Like Growth Factor-1 (IGF-1) • Insulin-Like Growth Factor-2 (IGF-2) • Epidermal Growth Factor (EGF) • Interleukin-1 receptor antagonists (IL-1Ra), • Interleukin – 2, • Interleukin - 8 • Interferon-y • Tumor Necrosis Factor – B • Platelet-Derived Growth Factor (PDGF) • Fibroblast Growth Factor (FGF) Influence Proliferation Differentiation AntiInflammatory and Pain 24 10/13/15 Specific Types of Amnio?c Membranes Clinical Indica?ons RCE Filamentary Kera??s Severe SPK/DES Corneal Scarring Persistent Neurotrophic Corneal Defects • Chemical /Thermal Burns • • • • • • Limbal Stem Cell Deficiency • Recalcitrant Corneal Inflamma?on (Herpe?c, bacterial) • Concommitant with oculoplas?c surgery • Stevens-‐Johnson Sx • Prokera – large 15mm amnio?c disk • Dissolves ajer 1-‐3 weeks • Applied to cornea via a ring • Smaller 9mm disk available • Expensive to acquire-‐ excep?onal reimbursement • CPT code -‐65778 Specifica?ons • • • • • • Diameter ranges between 17mm-‐23mm Tissue thickness – 100 or 200 microns Tissue is assembled on a corneal ring Tissue dissolves in 4-‐8 days Ring has to be removed Can use drops concommimantly ProKera—Biological Bandage! What is it?-‐-‐ made of a clipping of piece of amnio6c membrane ?ssue in between two rings made out of a clear, flexible material • ProKera • What does Prokera treat ? -‐-‐recurrent corneal erosion, infec?ons / inflammatory kera??s, neurotrophic ulcers, herpes, superficial epithelial defects, chronic SPK, and other corneal diseases. • What does Prokera do ? -‐Helps the eye heal, the amnio?c membrane ?ssue in Prokera has natural therapeu6c ac6ons of cytokines and growth factors that help damaged eye surfaces heal faster. -‐Eyes treated with Prokera have quicker healing , less pain, less scarring, and less inflamma?on. • Can we get paid? • Reimbursement on Prokera . 65788 -‐ placement of amnio?c membrane on the ocular surface for wound healing, self -‐ retaining. global period 10 days. • Medicare average office payment is -‐-‐-‐$1600 -‐ 1200. Supply code is V2790 . • NON -‐ Medicare varies by contract, same codes but on supply code it can be V2790 or L8610 • • 166 Can OD’s do this? YES! 167 25 10/13/15 Inser?on Technique Prokera Iner?on Technique Anesthe?ze eye Pa?ent looks down Doctor holds/elevates upper lid Membrane Shield is placed under upper lid first then centered using 2 fingers or blunt forceps • Pa?ent uses drops as prescribed • Follow up depends upon severity of condi?on • • • • Prokera inser?on Removal Technique • • • • Apply topical anesthesia Pull down lower lid, pa?ent looks up Grab edge of ring with blunt forceps Having pa?ent look down may facilitate removal • CPT code -‐65778, 10 day global period 170 Other examples where Prokera had a profound effect on healing! • RCE • Infec?ous Kera??s 172 26 10/13/15 Smaller Graj • Indicated for more focal defects • More persistant epithelial erosions or ulcera?ons • 9mm diameter, 35 microns thick • Easier to apply • Placed on a very dry cornea • Held in place with a bandage CL • Same reimbursement and procedure codes AmbioDisk AmbioDisk by IOP ophthalmics • Simple Storage and Prepara=on • Ambio2 Allograjs are provided dehydrated for room-‐temp storage. No freezing or refrigera?on required. Ambio2 ac?vates with sterile saline within minutes. No thawing or soaks required. • AmbioDisk • AmbioDry2 • Ambio5 • Poten?al Uses: • • • • • by IOP ophthalmics Non-‐healing epithelial defects Neurotrophic ulcers RCE Burns Post infec?ous kera??s • Held in place with BSCL 176 • Cheaper than Prokera • Same reimbursement • hmp://www.iopinc.com/store/ ambiodisk/ 177 179 27 10/13/15 Instruc?ons – Epithelial Defect • • • Product Sizes – 12mm disc – 15mm disc – 1.5 x 2.0 cm2 – 2.0 x 3.0 cm2 • • Debride as needed Place over defect stroma side down – for bemer adherence Use Weck-‐Cel® to smooth folds, edges Apply bandage contact lens Weck-‐Cel is a registered trademark of Beaver-‐Visitec Interna?onal 180 #3 The cornea can be strengthened 181 Did you know that…? • The Cornea can be strengthened… 189 WHY WOULD WE DO THIS? Corneal Collagen Cross-‐Linking • Clinical Indica?ons – Keratoconus – Forme-‐fruste keratoconus – Post-‐LASIK ectasia – Post-‐RK – Pellucid Marginal Degenera?on 190 Riboflavin/Ultraviolet-‐A-‐induced Collagen Crosslinking for Keratoconus PRK and Intacs treatment are techniques that treat the underlying cause of ectasia (progression not stopped) • Collagen crosslinking by photosensi?zer riboflavin and UVA similar to photopolymeriza?on developed by Wollensack et al. (2003) 28 10/13/15 Cornea Undergoing Cross-‐linking • How it is done? -‐epithelium is either denuded or LEFT ON -‐riboflavin 0.1% topically every 2 minutes for 30 minutes to saturate cornea Then 5 minutes of -‐370 nm of light – OR LONGER FOR EPI ON Post-‐op BSCL is placed on the eye and pa?ent given steroid, NSAID and an?-‐bio CCXL-‐ How It Works • Cornea is saturated with riboflavin • Cornea is exposed to UV light • Photosensi?za?on occurs, singlet oxygen released • The molecular oxygen causes extra cross-‐ linking of corneal collagen fibers and extracellular matrix proteins • This causes corneal s?ffening 201 • • • • • CCXL Post –op Process Some CCXL Par?culars Much like PRK post-‐op Watch for infec?on – an?bio?c Mi?gate corneal haze – steroid Moderate pain-‐ NSAID Final result may not be seen un?l 18 months out, so refrac?on may vary • Cornea must be saturated before UV light applica?on • 90% of the UV light absorbed within the anterior 400 microns of K • Riboflavin blocks deeper light penetra?on thus avoiding cytotoxicity at endothelium or lens capsule • Effect is not immediate, 3-‐6 months for new keratocytes to repopulate and remodel cornea • Improvement con?nues over 15 month period 29 10/13/15 May Halt K-‐conus progression for up to 5 years CCXL Benefits • • • • • • • New research published in the October 2014 Cornea suggests collagen crosslinking may be effec=ve in hal=ng keratoconus progression for up to five years. Twenty-‐one pa?ents with progressive keratoconus who underwent CLX were evaluated preopera?vely and postopera?vely at one-‐year intervals up to five years. Researchers observed mean uncorrected and best spectacle-‐corrected visual acuity improved significantly from the pre-‐op visit to the five-‐year postopera?ve visit. Addi?onally, mean steep and mean flat keratometry readings dropped significantly in the same ?me period. No significant change was observed in endothelial cell density or mean central corneal thickness. Improved regularity to corneal shape Decreased apical scarring Improved UCVA and BCVA Decreased as?gma?sm Improved ability to wear CL Improve outcomes with secondary ICCL • CCXL definitely works be6er on early diagnosed keratoconic pxs! 206 56 yr old male with Keratoconus: Epi-On CXL OS Pre Op 6 months Post Op UCVA CF 100 BSCVA 25 20 -‐7.75+0.75x150 -‐3.75 +1.50 x 180 Refrac?on William Trattler, MD case 6 months Preop Difference Map 211 CXL—The great debate epi on versus epi off EPI OFF • CONCERNS ABOUT PERMANENT HAZE • MORE PAINFUL • LONGER HEALING— SLOWER VA RECOVERY • CONCERNS ABOUT INFECTION (REMOVING EPITHELIUM) • SHORTER TX ?me • BETTER ON YOUNGER PX’S <35 The future for Collagen Cross-‐Linking • Treatment of recalcitrant bacterial corneal ulcers EPI ON • OD’S COULD DO IT • LESS PAINFUL • LESS INFECTIONS • LONGER Tx ?me • FASTER HEALING, FASTER VA RECOVERY • CAN BE SUCCESSFUL ON OLDER PX’S 50’S-‐60’S – Esp if in anterior 250 microns • Corneal melts • EBMD • As an adjunct to Orthokeratology!! 212 30 10/13/15 #1 What’s new? 3 things that are new! Corneal scars are they forever? December 2014 Science Transla?onal Medicine AND Review of Optometry Jan. 2015 • The researchers first obtained and cultured LBSCs from ?ssue harvested from the limbus region of human donor corneas • We found that delivery of stem cells ini?ates regenera?on of healthy corneal ?ssue rather than scar, leaving a clear, smooth surface • The study suggests LBSCs could eventually be used to treat corneal scarring in humans. Indeed, a small pilot study based on this research—in which a handful of pa?ents will receive their own corneal stem cells as 219 treatment—is underway in India. 218 Compound Restores Endothelial Cells Technique could have far-‐reaching effects. • • Cornea: April 2015 -‐ Volume 34 -‐ Issue 4 -‐ p 402–406 Clinical Science Ultraviolet A/Riboflavin Collagen Cross-‐Linking for Treatment of Moderate Bacterial Corneal Ulcers Purpose: To evaluate the therapeu?c effect of UV-‐A/riboflavin collagen cross-‐linking (CXL) on moderate bacterial corneal ulcers. • Methods: Thirty-‐two pa?ents with moderate bacterial kera??s were selected. All pa?ents were treated according to the standard medical treatment protocol. The pa?ents were randomly allocated to 2 groups: case and control groups of 16 pa?ents each using a numerical randomiza?on table. The case group received CXL treatment. In the CLX group, corneal epithelium was removed and 0.1% riboflavin drops were applied. Then the corneas were irradiated with UV-‐A (365 nm) with an irradiance of 3 mW/cm2 for 30 minutes. The grade of ulcers, size of epithelial defects, and area of infiltrates were recorded on days 1, 7, and 14 of treatment. • Results: There was no sta?s?cally significant difference between the groups 1 day ajer the treatment. The mean treatment dura?on was 17.2 ± 4.1 days in the CXL group and 24.7 ± 5.5 days in the control group. The epithelial defects were smaller in the CXL group at 7 days (P = 0.001) and 14 days (P = 0.001) ajer the beginning of treatment. The area of infiltrates in CXL group was smaller than the control group at both 7 days (P = 0.001) and 14 days (P < 0.001) ajer the start of treatment. • • A small group of pa?ents with Fuchs’ corneal dystrophy were successfully treated with a Rho-‐associated kinase (ROCK) inhibitor topical medica?on—a technique that could have far-‐reaching clinical implica?ons, according to researchers from Japan who presented their findings at the annual mee?ng of the American Academy of Ophthalmology in November. The preliminary study, conducted by inves?gators at Kyoto Prefectural University of Medicine, reported that a one-‐week treatment of the ROCK inhibitor Y-‐27632 s?mulated the prolifera?on of corneal endothelial cells in four test pa?ents with Fuchs’ corneal dystrophy. • Pa?ents showed corneal healing and restored visual acuity, as well as reduced corneal thickness from 700 cells/mm2 to 563 cells/mm2 by three months ajer treatment. • “Overall, it’s intriguing and, if it proves to be viable, may reduce the number of surgeries required for Fuchs’ and other endothelial diseases,” says Joseph Shovlin, OD, of Scranton, Pa. “ROCK inhibitors would represent the first successful medical treatment using a topical agent for certain forms of endothelial disease.” • The technique involves transcorneal freezing to remove damaged endothelial cells, and then applying the eye drops to promote prolifera?on in the remaining func?onal cells. This small study treated eight pa?ents—four with Fuchs’ and four with pseudophakic bullous keratophy. Although the technique was not effec?ve for pseudophakic bullous keratophy, it could pave the way for minimally invasive surgery for Fuchs’ and other forms of corneal problems, the researchers say. • While more research must be done before such a topical drop becomes available, “it’s crucial that ODs are aware of such poten?al non-‐surgical treatments in order to render the very best care possible, and also field ques?ons that may arise in the course of pa?ent care,” Dr. Shovlin says. 220 #2—WHICH IS ACTUALLY #1 WE need to be able to manage infec?ons… • Conclusions: Our results support the beneficial effect of CXL in pa?ents with moderate bacterial kera??s. In addi?on to accelera?ng epithelializa?on, this method shortens the course of treatment and may minimize or remove the need for surgery or other serious sequelae, such as corneal perfora?on. 221 Infec?ous Kera??s • Corneal disease caused by bacterial, viral, fungal or protozoal organisms • Key features: Cellular infiltra?on of the corneal epithelium or stroma, corneal inflamma?on and necrosis. 222 • Associated features: lid edema, conjunc?val inflamma?on, discharge, anterior chamber reac?on, hypopyon 223 31
