Update In Therapy Of Common Corneal Diseases

1. Update In Therapy Of Common Corneal Diseases Dr Laurence Sullivan MB BS FRANZCO Bayside Eye Specialists, Brighton Melbourne Eye Specialists, Fitzroy Lasersight Corneal Clinic, Royal Victorian Eye and Ear Hospital

2. Laurie Sullivan 2006 Introductions��.. Dr Laurie Sullivan MB BS FRANZCO fellowship-trained Corneal Specialist specialising in Cataract Surgery, Laser Vision Correction, Corneal Transplants Cornea Clinic of the RVEEH examiner for RANZCO and the VCO GCOT

3. Laurie Sullivan 2006 Dr Jessica Luzhansky MB BS FRANZCO Oculo-Plastics Fellowship in December 2006 (RVEEH) Specialising in Oculo-Plastic Surgery, Cataract Surgery, General Ophthalmology speaks fluent Russian

4. Laurie Sullivan 2006 Dr Michael S Loughnan MBBS PhD FRANZCO fellowship training in� diseases of the anterior segment at Massachusetts Eye and Ear Infirmary (Harvard University, Boston USA) Cataract, Corneal Graft and Pterygium Surgery

5. Laurie Sullivan 2006 Dr Joanne Dondey MB BS FRANZCO general ophthalmologist with a special interest in Cataract surgery and�Paediatric Ophthalmology and Strabismus Two fellowships in Paediatric Ophthalmology and Strabismus, at the RCH in Melbourne and then at the Hospital for Sick Children, Toronto, Canada

6. Laurie Sullivan 2006 Dr Michael Shiu MB BS FRACGP FRANZCO fellowship trained Glaucoma Specialist special interests include Cataract, Glaucoma and Refractive Surgery Dr Shiu is fluent in spoken and written Mandarin and Cantonese

7. Laurie Sullivan 2006 Dr Andrew Atkins MBBS FRANZCO has been performing cataract procedures for the last 15 years in Melbourne and country Victoria. fellowship in Strabismus in the UKat the Royal Victorian Infirmary in Newcastle examiner for RANZCO interests are Cataract Surgery, Strabismus and General Ophthalmology

8. Laurie Sullivan 2006 What is everyone talking about? Cornea Keratoconus C3R Intacs DALK - Deep lamellar keratoplasty Fuch�s Dystrophy, PBK DSAEK - Descemet�s Stripping Automated Lamellar Keratoplasty

9. Laurie Sullivan 2006 What else is everyone talking about? Our new Victoria Parade Surgery Centre @ 100 Victoria Parade, opposite St Vincent�s Hospital 5 dedicated ophthalmic theatres Lasersight has also relocated to this building

10. Laurie Sullivan 2006 Keratoconus Incidence 1 in 2000 Genetic (?dominant) predisposition Mechanism may be an excess of proteolytic enzymes (collagenase) breaks down corneal collagen ? corneal thinning and stretching

11. Laurie Sullivan 2006 Keratoconus Onset in late teens / twenties Stabilises 30s, 40s (except PMCD) Associated atopy, eye rubbing

12. Laurie Sullivan 2006 Keratoconus management Glasses RGP contact lenses Transplant (penetrating or lamellar) Then: Glasses 33%, RGP 33%, nothing 33% LASIK 1-5% 12 months after suture removal

13. Laurie Sullivan 2006 Keratoconus Q. Why do corneas become �stiffer� with age? Q. Why does keratoconus stabilise? A. Increased collagen crosslinking - ?related to lifelong UV exposure.

14. Laurie Sullivan 2006 C3R =�Corneal Collagen Crosslinking With Riboflavin� Keratoconic corneas show less crosslinking of collagen fibrils than normals This causes decreased resistance to stretch Treatment with UVA light can promote collagen x-linking Riboflavin is a very good sensitiser to UVA

15. Laurie Sullivan 2006 RVEEH C3R Trial - Inclusion Criteria 400 �m minimum thickness (UVA is toxic to endothelium) � i.e. early keratoconics. Ideally soon after definitive diagnosis with progression. >16 years old No other corneal pathology

16. Laurie Sullivan 2006 RVEEH C3R Trial - Inclusion Criteria Progression of KCN: A decrease in the BOZR of = 0.1mm in RGP wearers. A myopic shift (SE) on manifest refraction of = 0.50D An increase in regular astigmatism on manifest refraction of = 1.00D An increase in the steepest K / sim K measured by keratometry or computerised videokeratography of = 1.00D

17. Laurie Sullivan 2006 Can refer suitable patients directly to RVEEH with refractive and keratometric data Pachymetry may not be available to you all � can be done in clinic (or we can do it here for you)

18. Laurie Sullivan 2006 Aims of C3R Treatment Slow or stop progression of KCN Some reversal in ~20%? Better spectacle corrected vision longer duration of tolerability, fittability of rigid contact lenses Fewer transplants?

19. Laurie Sullivan 2006 C3R - the treatment 8mm epithelial debridement Sore eye Blurry(er) vision for a week Risk of infection 2- 4 weeks out of RGP CL Soaked with riboflavin drops every 5 minutes 30 minutes UVA light under an operating microscope Padded, ointment, antibiotics, steroids, lubricants

20. Laurie Sullivan 2006 Corneal Collagen Crosslinking � C3R

21. Laurie Sullivan 2006 C3R side effects and complications Postoperative pain or irritation Postoperative corneal haze (generally temporary) Changes in the focus of the eye Contact lens intolerance for 2 to 4 weeks Delayed healing of the surface of the eye Infection (microbial keratitis) Worsening of keratoconus Allergy to medications including antibiotic and steroid eye drops

22. Laurie Sullivan 2006 Crosslinking treatment of progressive keratoconus: new hope. Curr Opin Ophthalmol. 2006 Aug;17(4):356-60 Authors: Wollensak G et al Biomechanical measurements have shown an increase in corneal rigidity of 300% in human corneas after crosslinking. The 3 and 5-year results of the Dresden clinical study have shown that in all treated 60 eyes the progression of keratoconus was at least stopped. In 31 eyes there also was a slight reversal and flattening of the keratoconus by up to 2.87 diopters. BCVA improved slightly by 1.4 lines. A cytotoxic level of UVA for endothelium was found to be 0.36 mW/cm which would be reached in human corneas with a stromal thickness of less than 400 �m at the intensity used.

23. Laurie Sullivan 2006 Duration of effect? �may need repeat treatment at 5 years ??Long term adverse effects (later OSSN / CIN?)

24. Laurie Sullivan 2006 Intacs for KCN

25. Laurie Sullivan 2006 Intacs for KCN � who can benefit Mild to moderate keratoconus Decreased or decreasing spectacle corrected vision, intolerant of RGP Can expect improved BCVA with spectacles

26. Laurie Sullivan 2006 Intacs � who can benefit Not for advanced keratoconus May be combined with C3R to �set� the cornea in the new shape? The Intacs procedure is safer with channels formed with the femtosecond laser (Intralase) May also be used in post LASIK ectasia

27. Laurie Sullivan 2006 DALK �Deep Anterior Lamellar Keratoplasty� Remove full thickness cornea, leaving only endothelium, Descemet�s membrane and minimal posterior stroma Less stroma, less interface haze

28. Laurie Sullivan 2006 DALK benefits Maintains host endothelium, which cannot be rejected Slightly better structural integrity than full thickness transplant

29. Laurie Sullivan 2006 DALK Who? Keratoconus, anterior scars Severe atopy Rejection other eye Unreliable patients, Down�s syndrome, trauma risk

30. Laurie Sullivan 2006 DALK results Best VA on average 6/7.5 to 6/9 (compared to 6/6) due to interface haze or irregularity No benefit for astigmatism Slightly earlier suture removal Can still have wound and suture problems, infection

31. Laurie Sullivan 2006 DSAEK in endothelial failure Fuch�s dystrophy or PBK

32. Laurie Sullivan 2006 Fuch�s Dystrophy Heritable Dominant Females more than males Corneal guttae (bumps in Descemet�s Membrane) Endothelium decreased in number and increased in size. Variable size, shape.

33. Laurie Sullivan 2006 Fuch�s Dystrophy Symptoms Morning blur which clears Poor low contrast acuity Signs Corneal thickening ? Microcystic corneal oedema ? Bullae

34. Laurie Sullivan 2006 Fuch�s Dystrophy

35. Laurie Sullivan 2006 Fuch�s Dystrophy Avoid intraocular (cataract) surgery Avoid low Dk SCL Avoid SCL? (RGP) Control IOP Dehydrate cornea Hair dryer 5% Saline drops

36. Laurie Sullivan 2006 DSAEK �Descemet�s Stripping Automated Endothelial Keratoplasty�

37. Laurie Sullivan 2006 DSAEK Indications Fuch�s Dystrophy Endothelial failure / PBK

38. Laurie Sullivan 2006 DSAEK Remove host Descemet�s membrane Replace with lenticle of donor Descemet�s membrane and posterior stroma (100 �m) Air bubble to hold in place No corneal sutures, minimal astigmatism Only for pseudophakic patients

39. Laurie Sullivan 2006 DSAEK

40. Laurie Sullivan 2006 DSAEK Main benefit is rapid rehabilitation 1 to 2 months compared to 3 to 12 months for PK Better structural integrity than PK

41. Laurie Sullivan 2006 DSAEK Main disadvantage is increased postoperative interventions for detached and displaced donor lenticles Shorter survival of transplanted tissue due to trauma (to endothelium) of insertion

42. Laurie Sullivan 2006 PTERYGIUM UV exposure, inflammation Surgery for cosmesis, comfort, VA (wtr astigmatism) No Bray now Autologous conjunctival grafting is routine

43. Laurie Sullivan 2006 PTERYGIUM The procedure takes about 45 minutes, requires a hospital day stay and the use of the operating microscope. Local anaesthetic Topical steroid drops for 6 weeks

44. Laurie Sullivan 2006 RECURRENT CORNEAL EROSION SYNDROME Epithelial basement membrane dystrophy (EBMD) + trauma Sudden onset of unilateral pain watering photophobia and redness Usually overnight or on first waking (?hypoxia) Debride, CL, micropuncture, PTK

45. Laurie Sullivan 2006 Atopic Eye Disease New drugs: Olapatadine (Patanol) MCS and anti-H1, topical cyclosporine A (CSA)(RVEEH) as steroid sparing agent CSA also of benefit in Thygeson�s SPK

46. Laurie Sullivan 2006 Corneal hysteresis Measurement of corneal hysteresis with the Reichert Ocular Response Analyzer provides useful information on the dynamic biomechanical properties of the cornea before and after refractive surgery, and it may have a role in predicting postoperative keratectasia

47. Laurie Sullivan 2006 Thank You Questions?