AAOSub2017 COR Syllabus

Cornea 2017
Keeping the Old,

or Breaking the Mold?
Program Directors
Bennie H Jeng MD, Carol L Karp MD, Jennifer Y Li MD
In conjunction with the Cornea Society
Ernest N Morial Convention Center

New Orleans, Louisiana
Saturday, Nov. 11, 2017
Presented by:
The American Academy of Ophthalmology
Supported in part by an unrestricted

educational grant from Shire
2017 Cornea Planning Group 2012 Anthony J Aldave MD R Michael Siatkowski MD

Bennie H Jeng MD Natalie A Afshari MD Kuldev Singh MD
Program Director Kathryn A Colby MD PhD Nicolas J Volpe MD
Carol L Karp MD 2011 Christopher J Rapuano MD Maria M Aaron MD
Program Director Natalie A Afshari MD Secretary for Annual Meeting
Anthony J Aldave MD
Jennifer Y Li MD 2010 Michael W Belin MD
Program Director Staff
David B Glasser MD Melanie R Rafaty CMP DES, Director,
Christopher J Rapuano MD Scientific Meetings
Former Program Directors 2008 Michael W Belin MD
2016 Shahzad I Mian MD Ann L’Estrange, Scientific Meetings
David B Glasser MD Specialist
Bennie H Jeng MD Mark J Mannis MD
Carol L Karp MD Lisa Romero, Presenter Coordinator
2007 Michael W Belin MD Debra Rosencrance CMP CAE, Vice
2015 Stephen C Kaufman MD PhD David B Glasser MD
Bennie H Jeng MD President, Meetings & Exhibits
R Doyle Stulting MD PhD Patricia Heinicke Jr, Copy Editor
Shahzad I Mian MD
2014 William Barry Lee MD Mark Ong, Designer
Subspecialty Day Advisory Committee Gina Comaduran, Cover Design
Elmer Y Tu MD Daniel S Durrie MD
Stephen C Kaufman MD PhD Associate Secretary
2013 Kathryn A Colby MD PhD
William Barry Lee MD Julia A Haller MD
Elmer Y Tu MD Francis S Mah MD
©2017 American Academy of Ophthalmology. All rights reserved. No portion may be reproduced without express written consent of the American Academy of Ophthalmology.
ii Planning Group 2017 Subspecialty Day | Cornea
2017 Cornea Subspecialty Day Planning Group

On behalf of the American Academy of Ophthalmology and the Cornea Society, it is our pleasure
to welcome you to New Orleans and Cornea 2017: Keeping the Old, or Breaking the Mold?
Bennie H Jeng MD Carol L Karp MD Jennifer Y Li MD

Program Director Program Director Program Director
CoDa Therapeutics: C None None
EyeGate Pharmaceuticals Inc.: O
Jade Therapeutics: C
Kedrion: C
Santen Inc.: C
2017 Subspecialty Day | Cornea Planning Group iii
2017 Subspecialty Day R Michael Siatkowski MD AAO Staff

(Pediatric Ophthalmology)
Advisory Committee National Eye Institute: S Ann L’Estrange
None
Daniel S Durrie MD, Chair Kuldev Singh MD (Glaucoma)
(Refractive Surgery) Abbott Medical Optics Inc.: C Melanie Rafaty
Abbott Medical Optics: L,C Aerie: C None
AcuFocus, Inc.: C,L,O Alcon Laboratories, Inc.: C
Alcon Laboratories, Inc.: C Allergan: C Lisa Romero
Alphaeon: C,L,O Belkin Laser Ltd: C None
Avedro: L,O,C Glaukos Corporation: C
Hoopes Durrie Rivera Research InjectSense: C Debra Rosencrance
Center: C Ivantis: C None
Strathspey Crown LLC: C,L,O Mynosys: C
National Eye Institute: S Beth Wilson
Julia A Haller MD (Retina) Novartis Institute for Biomedical None
Celgene: O | Janssen: C Research: C
KalVista: C Santen, Inc.: C
Merck & Co., Inc.: C Shire: C
Novartis Pharmaceuticals Thieme Medical Publishers: C
Corporation: C U.S. Food and Drug
ThromboGenics, Inc.: S Administration: S,C
Francis S Mah MD (Cornea) Nicholas J Volpe MD

Abbott Medical Optics Inc.: C,L,S (Neuro-Ophthalmology)
Aerie: C Opthotech: C
Alcon Laboratories, Inc.: C,L,S Opticent Inc.: O
Allergan: C,L,S
Bausch Lomb: C,L
CoDa: C | ForeSight: C
NovaBay: C
Ocular Science: C,O
Ocular Therapeutix: C,S
PolyActiva: C | Shire: C
Slack Publishing: C
Sun Pharma: C
Sydnexis: C | TearLab: C
2017 Subspecialty Day | Cornea Contents v
Cornea 2017 Contents
Program Planning Group ii
CME vi
Faculty Listing viii
How to Use the Audience Interaction Application xii
Program Schedule xiii
Section I: Corneal Infections—Old Bugs, New Drugs 1
Section II: Keratoplasty—Are We Doing the Right Thing? 10
Advocating for Patients 18
Section III: Conjunctival Tumors—What’s Old, What’s New? 20
Section IV: Anterior Segment Imaging—What’s Recent, What’s Decent? 27
Section V: Keratoconus, A Steep Learning Curve—The Newest in Diagnosis and Management 36
Section VI: Inflammatory Conditions of the Anterior Segment—It’s Burning Me Up! 44
Faculty Financial Disclosure 51
Presenter Index 54
vi CME 2017 Subspecialty Day | Cornea
CME Credit
Academy’s CME Mission Statement Scientific Integrity and Disclosure of Financial

Interest
The purpose of the American Academy of Ophthalmology’s
Continuing Medical Education (CME) program is to present The American Academy of Ophthalmology is committed to
ophthalmologists with the highest quality lifelong learning ensuring that all CME information is based on the application
opportunities that promote improvement and change in physi- of research findings and the implementation of evidence-based
cian practices, performance, or competence, thus enabling such medicine. It seeks to promote balance, objectivity, and absence
physicians to maintain or improve the competence and profes- of commercial bias in its content. All persons in a position to
sional performance needed to provide the best possible eye care control the content of this activity must disclose any and all
for their patients. financial interests. The Academy has mechanisms in place to
resolve all conflicts of interest prior to an educational activity
being delivered to the learners.
2017 Cornea Subspecialty Day Meeting Learning
The Academy requires all presenters to disclose on their first
Objectives
slide whether they have any financial interests from the past 12
Upon completion of this activity, participants should be able to: months. Presenters are required to verbally disclose any finan-
cial interests that specifically pertain to their presentation.
■■ List common causes of corneal infections and best prac-
tices for management
■■ Discuss the role of keratoplasty in the management of Control of Content
patients with corneal disease
The American Academy of Ophthalmology considers present-
■■ Review the role of imaging and in-office diagnostics in
ing authors, not coauthors, to be in control of the educational
the treatment of corneal disorders
content. It is Academy policy and traditional scientific publish-
■■ Provide a rationale for treatment of ocular surface disease
ing and professional courtesy to acknowledge all people con-
and inflammatory disorders
tributing to the research, regardless of CME control of the live
presentation of that content. This acknowledgment is made in a
2017 Cornea Subspecialty Day Meeting Target similar way in other Academy CME activities. Though they are
Audience acknowledged, coauthors do not have control of the CME con-
tent, and their disclosures are not published or resolved.
The intended audience for this program is cornea surgeons,
comprehensive ophthalmologists with an interest in anterior
segment, and allied health personnel who are performing or Attendance Verification for CME Reporting
assisting with cornea surgery.
Before processing your requests for CME credit, the American
Academy of Ophthalmology must verify your attendance at
2017 Cornea Subspecialty Day CME Credit Subspecialty Day and/or AAO 2017. In order to be verified for
CME or auditing purposes, you must either:
The American Academy of Ophthalmology is accredited by
the Accreditation Council for Continuing Medical Education ■■ Register in advance, receive materials in the mail, and
(ACCME) to provide CME for physicians. turn in the Subspecialty Day Syllabi exchange voucher(s)
The Academy designates this live activity for a maximum onsite;
of 7 AMA PRA Category 1 Credits™. Physicians should claim ■■ Register in advance and pick up your badge onsite if
only the credit commensurate with the extent of their participa- materials did not arrive before you traveled to the m
eeting;
tion in the activity. ■■ Register onsite; or
■■ Scan the barcode on your badge as you enter an AAO
2017 course or session room.
Teaching at a Live Activity
Teaching instruction courses or delivering a scientific paper or
CME Credit Reporting
poster is not an AMA PRA Category 1 Credit™ activity and
should not be included when calculating your total AMA PRA Lobby B and Lobby G and Academy Resource Center,
Category 1 Credits™. Presenters may claim AMA PRA Cat- Hall G – Booth 3140
egory 1 Credits™ through the American Medical Association.
Attendees whose attendance has been verified (see above) at
To obtain an application form please contact the AMA at
AAO 2017 can claim their CME credit online during the meet-
www.ama-assn.org.
ing. Registrants will receive an email during the meeting with
the link and instructions on how to claim credit.
Onsite, you may report credits earned during Subspecialty
Day and/or AAO 2017 at the CME Credit Reporting booth.
2017 Subspecialty Day | Cornea CME vii
Academy Members: The CME credit reporting receipt is not Proof of Attendance
a CME transcript. CME transcripts that include AAO 2017
The following types of attendance verification will be available
credits entered onsite will be available to Academy members on
during AAO 2017 and Subspecialty Day for those who need it
the Academy’s website beginning Dec. 7, 2017.
for reimbursement or hospital privileges, or for nonmembers
After AAO 2017, credits can be claimed at www.aao.org.
who need it to report CME credit:
The Academy transcript cannot list individual course atten-
dance. It will list only the overall credits spent in educational ■■ CME credit reporting/proof-of-attendance letters
activities at Subspecialty Day and/or AAO 2017. ■■ Onsite registration receipt
Nonmembers: The Academy will provide nonmembers ■■ Instruction course and session verification
with verification of credits earned and reported for a single
Visit www.aao.org/cme for detailed CME reporting informa-
Academy-sponsored CME activity, but it does not provide CME
tion.
credit transcripts. To obtain a printed record of your credits,
you must report your CME credits onsite at the CME Credit
Reporting booths.
viii Faculty Listing 2017 Subspecialty Day | Cornea
Faculty
Mohamed F Abou Shousha MD Renato Ambrósio Jr MD Mazen Y Choulakian MD

Pembroke Pines, FL Rio de Janeiro, RJ, Brazil Sherbrooke, QC, Canada
No photo
available
Anthony J Aldave MD Michael W Belin MD Victoria M Cohen FRCOphth

Los Angeles, CA Marana, AZ Cambridgeshire, United Kingdom
Eduardo C Alfonso MD Winston D Chamberlain MD PhD Denise de Freitas MD

Miami, FL Portland, OR São Paulo, SP, Brazil
Zaina N Al-Mohtaseb MD David F Chang MD Deepinder K Dhaliwal MD

Houston, TX Los Altos, CA Pittsburgh, PA
2017 Subspecialty Day | Cornea Faculty Listing ix
William J Dupps MD PhD Hans E Grossniklaus MD Carol L Karp MD

Bay Village, OH Atlanta, GA Miami, FL
Marjan Farid MD Sadeer B Hannush MD William Barry Lee MD

Irvine, CA Langhorne, PA Atlanta, GA
Anat Galor MD Deborah S Jacobs MD Jennifer Y Li MD

Miami, FL Needham, MA Sacramento, CA
Darren G Gregory MD Bennie H Jeng MD Thomas M Lietman MD

Denver, CO Baltimore, MD San Francisco, CA
x Faculty Listing 2017 Subspecialty Day | Cornea
Marian Sue Macsai-Kaplan MD Shahzad I Mian MD Stephen C Pflugfelder MD

Glenview, IL Ann Arbor, MI Houston, TX
Parag A Majmudar MD Darby D Miller MD Francis W Price Jr MD

South Barrington, IL Jacksonville, FL Indianapolis, IN
Mark J Mannis MD Wuqaas M Munir MD Christopher J Rapuano MD

Sacramento, CA Baltimore, MD Philadelphia, PA
No photo
available
Todd P Margolis MD PhD Afshan A Nanji MD Jennifer R Rose-Nussbaumer

Saint Louis, MO Portland, OR MD
San Francisco, CA
2017 Subspecialty Day | Cornea Faculty Listing xi
Carol L Shields MD Donald Stone MD Mark A Terry MD

Philadelphia, PA Rockville, MD Portland, OR
Arun D Singh MD Donald Tan MD FRCS FRCOphth Elmer Y Tu MD

Cleveland, OH Singapore, Singapore Glenview, IL
xii How to Use the Audience Interaction Application 2017 Subspecialty Day | Cornea
Ask a Question Live During the Meeting

Using the Mobile Meeting Guide
To ask a question during the meeting, follow the directions below.
■ Access at www.aao.org/mobile
■ Select “Program Handouts & Evaluations”
■ Filter by Meeting—Cornea Meeting
■ Select Current Session
■ Select “Ask the presenter a question (live)” Link
■ Click Submit Question

2017 Subspecialty Day | Cornea Program Schedule xiii
Cornea 2017: Keeping the Old,

or Breaking the Mold?
In conjunction with the Cornea Society
Saturday, Nov. 11
7:00 AM CONTINENTAL BREAKFAST
8:00 AM Welcome and Introductions Bennie H Jeng MD*
Carol L Karp MD
Jennifer Y Li MD
Section I: Corneal Infections—Old Bugs, New Drugs

Moderator: Jennifer Y Li MD
8:02 AM Introduction Jennifer Y Li MD
8:04 AM Bacterial Keratitis: Are Fortified Antibiotics Still Necessary? Shahzad I Mian MD 1
8:13 AM ’Roid Rage: The Controversy over Steroids for Bacterial Keratitis Thomas M Lietman MD 2
8:22 AM Fungal Keratitis: Detecting and Disabling the Fungus among Us Eduardo C Alfonso MD* 3
8:31 AM Acanthamoeba Keratitis: Embracing the Challenge Denise de Freitas MD 4
8:40 AM Viral Keratitis: What’s New that We Can Do Todd P Margolis MD PhD 6
8:49 AM Cut It Out! Nonmedical Approaches to Infectious Keratitis Jennifer R Rose-Nussbaumer 7
MD
8:58 AM Case: The Most Unusual Keratitis Mark J Mannis MD 9
9:03 AM Panel Discussion
Section II: Keratoplasty—Are We Doing the Right Thing?

Moderator: Bennie H Jeng MD*
Virtual Moderator: Zaina N Al-Mohtaseb MD
9:13 AM Introduction Bennie H Jeng MD*
9:15 AM Should We Still Be Doing DSAEK? Winston D Chamberlain MD 10
PhD
9:24 AM Spicing Up Penetrating Keratoplasty: Does Femto Really Help? Marjan Farid MD* 12
9:33 AM Regrafting the Failed Penetrating Keratoplasty: Should We Still Re-PK? Donald Tan MD FRCS 13
FRCOphth*
9:42 AM Done with Regrafting? When Is KPro a Better Choice? Anthony J Aldave MD* 15
9:51 AM Breaking the Mold: Surgery Starts in the Eye Bank! Marian Sue Macsai-Kaplan 16
MD*
10:00 AM Case: What Do I Do with This Cornea?! Mark A Terry MD* 17
10:15 AM REFRESHMENT BREAK and AAO 2017 EXHIBITS
* Indicates that the presenter has financial interest. No asterisk indicates that the presenter has no financial interest.
xiv Program Schedule 2017 Subspecialty Day | Cornea
Section III: Conjunctival Tumors—What’s Old, What’s New?

Moderator: Carol L Karp MD
10:50 AM Introduction Carol L Karp MD
10:52 AM Advocating for Patients Darby D Miller MD 18
10:57 AM Ocular Surface Squamous Neoplasia: Should I Excise, Hans E Grossniklaus MD* 20
Or Do Something Else?
11:06 AM What to Do When the Tumor Goes Viral? Carol L Shields MD 22
Conjunctival Papilloma Management
11:15 AM Does Imaging Help in the Diagnosis of Conjunctival Tumors? Afshan A Nanji MD 23
Biopsy or Image?
11:24 AM Pigmented Lesions: Watch, or Worry? Victoria M Cohen FRCOphth 24
11:33 AM Pterygium: An Evidence-Based Look Darren G Gregory MD 25
11:42 AM Case: A Lump that Stumped Me Arun D Singh MD* 26
11:57 AM LUNCH and AAO 2017 EXHIBITS
Section IV: Anterior Segment Imaging—What’s Recent, What’s Decent?

Moderator: Carol L Karp MD
1:22 PM Introduction Carol L Karp MD
1:24 PM How Many Technologies Does It Take to Implant a Toric IOL? David F Chang MD* 27
1:33 PM Is Aberrometry Necessary? Parag A Majmudar MD* 28
1:42 PM Corneal Imaging to Improve Surgical Outcomes Mohamed F Abou Shousha 29
MD*
1:51 PM Tomography: How This Helps Me Renato Ambrósio Jr MD* 30
2:00 PM Do We Need an Intraoperative OCT? Francis W Price Jr MD* 34
2:09 PM Case: Imaging Saved the Day Sadeer B Hannush MD 35
2:14 PM Panel Discussion
Section V: Keratoconus, A Steep Learning Curve—The Newest in Diagnosis and Management

Moderator: Jennifer Y Li MD
2:24 PM Introduction Jennifer Y Li MD
2:26 PM How to Diagnosis Keratoconus: Tried and True vs. New View Michael W Belin MD* 36
2:35 PM Contact Lenses in Keratoconus: What Options Do We Have Now? Deborah S Jacobs MD* 37
2:44 PM Deep Anterior Lamellar Keratoplasty vs. Penetrating Keratoplasty: William Barry Lee MD* 38
Is One Clearly Better?
2:53 PM Considerations Concerning Corneal Collagen Crosslinking William J Dupps MD PhD* 40
3:02 PM Tearing Up the Old Paradigm for Management of Acute Hydrops Mazen Y Choulakian MD 42
3:11 PM Case: A Corneal Conundrum Elmer Y Tu MD* 43
3:26 PM REFRESHMENT BREAK and AAO 2017 EXHIBITS
2017 Subspecialty Day | Cornea Program Schedule xv
Section VI: Inflammatory Conditions of the Anterior Segment—It’s Burning Me Up!

Moderator: Bennie H Jeng MD*
4:01 PM Introduction Bennie H Jeng MD*
4:03 PM Point-of-Care Testing for Dry Eyes: Tears of Joy, or Tears from the Expense? Anat Galor MD* 44
4:12 PM Scratching the Old: What’s New in Allergic Conjunctivitis? Deepinder K Dhaliwal MD* 45
4:21 PM Stevens-Johnson Syndrome: A Chronic Problem Wuqaas M Munir MD 47
4:30 PM Revisiting a Dry Topic: Is Anything New with Sjögren Syndrome? Stephen C Pflugfelder MD* 48
4:39 PM Sclera on Fire: What Labs Do I Really Need to Check? Donald Stone MD 49
4:48 PM Case: Not Just Another Red Eye Christopher J Rapuano MD* 50
5:03 PM Closing Remarks Bennie H Jeng MD*
Carol L Karp MD
Jennifer Y Li MD
5:05 PM ADJOURN
2017 Subspecialty Day | Cornea Section I: Corneal Infections—Old Bugs, New Drugs 1
Bacterial Keratitis:
Are Fortified Antibiotics Still Necessary?
Shahzad I Mian MD
NOTES
2 Section I: Corneal Infections—Old Bugs, New Drugs 2017 Subspecialty Day | Cornea
’Roid Rage: The Controversy over Steroids

for Bacterial Keratitis
Thomas M Lietman MD
I. History of the Controversy C. Secondary outcomes

A. Antibiotics typically eliminate bacterial infection 1. Severe ulcers tended to do better with steroids.
before corneal perforation, although a large por-
2.
Pseudomonas aeruginosa tended to do better
tion of cases still end up with scars and permanent
with steroids.
visual impairment. Adjunctive steroids have been
considered since they were introduced, although 3.
Nocardia species did worse with steroids.
given the risks, including suppressing the immune
4. Steroids earlier in the course proved beneficial.
response, their widespread use has been limited.
5. Longer-term results (1-4 years) suggested
B. Animal and retrospective human studies have
improvement with steroids.
mixed results.
III. Other Trials
C. Corneal specialists have become more comfortable
with adding steroids through experience. IV. Other Options
II. Steroids for Corneal Ulcer Trial A. Other steroid preparations
A. 500-patient, multicenter, randomized controlled B. Other immunosuppressive agents
trial comparing adjunctive prednisolone phosphate
C. Warnings about using steroids in the absence of
to placebo in laboratory-proven bacterial ulcers
effective antimicrobial treatment. Necessary to be
B. Primary outcome, spectacle-corrected visual acuity certain etiology is bacterial.
at 3 months, similar in both arms
Fungal Keratitis: Detecting and Disabling

the Fungus among Us
Eduardo C Alfonso MD
Detection Surgical Interventions

There are more than 50,000 species of fungi, but only about Surgical interventions include corneal scraping, which removes
100-150 cause human disease, and fewer cause ocular infec- epithelium and necrotic material allowing better penetration of
tions. These vary by geographic region and climate. topical antifungals, and penetrating keratoplasty, which may be
Why are ocular fungal infections increasing? Use of antibi- necessary, usually after 2-4 weeks of medical treatment. Other
otics, immunosuppression, steroids, corneal surgery, contact surgical measures include tissue adhesives, amniotic membrane,
lenses, evolution of pathogens, and environmental changes may and conjunctival flaps. Recent studies have supported early ker-
all play a role. Identification is important in the outcome. Clini- atoplasty (2 weeks), showing eradication of infection in 92.7%
cal diagnosis for fungal keratitis is correct only in 45% of cases, of cases. Intraoperative management includes culture and
and pretreatment decreases the predictive value and recovery of pathology of all removed tissues to determine extension, lavage
organisms. with BSS, new instruments for donor tissue, intraocular ampho-
Cultures and smears are the gold standard for the identifica- tericin B (5-10 mg), or voriconazole (50-100 μg/cc), and use of
tion of the cause of the infection. Ninety-one percent of smears interrupted sutures. Postoperative management consists of topi-
correlate with culture results, 92% of isolates are recovered in cal and systemic antifungals, cyclosporin A or tacrolimus, and
agar within 72 hours, and fungi grow in an average of 2.7 days. no topical or systemic steroids in the immediate postop period.
The most accurate diagnosis is obtained using molecular tech- Recent success in the use of crosslinking is limited to infec-
niques for identification. tions on the anterior 250 microns, but there are no definitive
recommendations for every case. We have recently shown that
photodynamic therapy may be an additive option for treatment.
Target Gene
ITS, the nuclear ribosomal internal transcribed spacer region,
Selected Readings
lies within the ribosomal DNA and contains the ITS1, ITS2,
and 5.8S rDNA sites. It can identify the organism, the source 1. Ali TK, Amescua G, Miller D, et al. Contact-lens-associated
of the organism, and its sensitivity profile, pathogenicity, and Purpureocillium keratitis: risk factors, microbiologic character-
mycotoxin production. Other methods to identify the cause and istics, clinical course, and outcomes. Semin Ophthalmol. 2017;
32(2):157-162.
extent of the infection are using the confocal microscope and
anterior segment OCT. 2. Abou Shousha M, Santos AR, Oechsler RA, et al. A novel rat con-
tact lens model for Fusarium keratitis. Mol Vis. 2013; 19:2596-
2605.
Treatment
3. Oechsler RA, Feilmeier MR, Miller D, Shi W, Hofling-Lima AL,
The only commercially available topical antifungal is natamycin Alfonso EC. Fusarium keratitis: genotyping, in vitro susceptibility
5% (Alcon); others can be prepared extemporaneously: ampho- and clinical outcomes. Cornea 2013; 32(5):667-673.
tericin B (methyl ester), voriconazole (Vfend, Pfizer), caspofun- 4. Keay LJ, Gower EW, Iovieno A, et al. Clinical and microbiological
gin (Cancidas, Merck), and posaconazole (Noxafil, Merck), characteristics of fungal keratitis in the United States, 2001-2007:
among others. Latest information on effectiveness comes from a multicenter study. Ophthalmology 2011; 118(5):920-926.
the Mycotic Ulcer Treatment Trial (MUTT), which showed
5. Garg P, Das S, Roy A. Collagen cross-linking for microbial kerati-
that topical natamycin is superior to voriconazole against fila-
tis. Middle East Afr J Ophthalmol. 2017; 24(1):18-23.
mentous fungi, is better for Fusarium cases, and showed no
difference between treatments for non-Fusarium cases. Fur- 6. Jeng BH. Challenges in the management of fungal keratitis. JAMA
ther observations from molecular analysis show not only that Ophthalmol. 2017; 135(6):525-526.
molecular classification is important in assisting clinical deci- 7. Prajna NV, Krishnan T, Rajaraman R, et al.; Mycotic Ulcer Treat-
sion making but that natamycin is better against F. solani, and ment Trial Group. Adjunctive oral voriconazole treatment of
voriconazole, not as effective, but equal against others. F. solani fusarium keratitis: a secondary analysis from the Mycotic Ulcer
infections are less likely to respond to medical treatment and Treatment Trial II. JAMA Ophthalmol. 2017; 135(6):520-525.
more likely to require a keratoplasty than are non-solani Fusar-
ium. Use of steroids is not recommended, dangerous if used too
early, but may be used as a diagnostic challenge. Topical drops
can be augmented with intrastromal injections of voriconazole
(50 micrograms) around the infiltrate, with repeated injections
as necessary. The MUTT II showed that oral adjunctive vori-
conazole is indicated in the treatment of Fusarium keratitis.
Acanthamoeba Keratitis: Embracing the Challenge

Denise de Freitas MD
Acanthamoeba is an organism widely dispersed naturally in ment of AK has not been standardized and can vary between
water and soil. Acanthamoeba keratitis (AK) is considered one different specialized outpatient services. The use of antimicro-
of the most difficult infections to diagnose and treat. The prog- bial drops for AK treatment depends on previous authorization
nosis is related to the precision of the clinical laboratory diagno- and certification by the health regulatory agency regarding the
sis and precocity of the treatment. marketing of medicines in each country. Basically, 2 classes of
drugs are used: biguanides and diamidines. Among the bigu-
anides, polyhexamethylene biguanide (PHMB) is used in con-
Clinical Features
centrations ranging from 0.02% to 0.06%; and chlorhexidine,
Patients with AK present with a chronic history of mild keratitis in concentrations ranging from 0.02% to 0.2%, depending on
with nonspecific symptoms of intolerance to contact lens (CL) the response. Among the diamidines, propamidine isethionate
use. Left undiagnosed, the condition can progress to red eye, (Brolene) and hexamidine diisethionate (Désomédine) are used
photophobia, tearing, and usually pain that is disproportionate at a concentration of 0.1%. The primary therapeutic profile for
to the clinical findings, although some patients do not report AK includes topical antimicrobial eye drops hourly around the
pain. The biomicroscopic signs include limbitis; dotted and clock, generally for 2 days according to toxicity, with gradual
dendritic keratitis; perineural infiltrates; epithelial defects; and reduction as the symptoms and clinical signs improve. The
corneal thinning, which can evolve to nonspecific perforation treatment time can vary from case to case (average duration:
and nonspecific or ring-shaped stromal infiltrates and uveitis 4-6 months). The tissue chemical toxicity caused by continu-
with varying degrees of severity, with or without hypopyon. ous use of antimicrobial drops should be evaluated frequently
Nonspecific mydriasis and cataract and glaucoma syndrome throughout treatment. If necessary, the medication can be
can be observed in severe and advanced cases. Acanthamoeba reduced or stopped for a certain period until the tissue toxicity
coinfection, mainly infectious crystalline keratopathy, has been abates. The USFDA recently approved topical miltefosine for
described in the literature. treating AK in the United States.
Therapeutic / tectonic corneal transplantation is indicated
only in cases of refractory AK, which is characterized by persis-
Diagnosis
tent positive cultures; in difficult-to-control abscesses; in per-
The clinical diagnosis of AK is confirmed through complemen- forations that cannot be managed with adhesive tissue; and in
tary laboratory tests such as culture (the gold standard); direct cases of mydriasis, cataracts, and glaucoma, in which combined
examination; and molecular biology analysis, such as poly- corneal transplantation, lens extraction, IOL implantation, and
merase chain reaction (PCR), confocal microscopy, and histo- iridoplasty might prevent development of secondary glaucoma
pathology. Culturing is performed using non-nutrient agar and/ refractory to treatment. Anterior lamellar keratoplasty should
or soy agar supplemented with Escherichia coli avirulent as a be performed with caution, since the protozoa tend to reach
nutrition source for protozoan proliferation. In the direct exam- the deep corneal layers. Different studies have shown that the
ination, the Acanthamoeba species cysts on the slide containing corneal crosslinking technique using riboflavin associated with
the smear of the clinical sample can be visualized using different application of ultraviolet-A light is ineffective for treating AK.
staining methods, with fluorescent dye calcofluor white being
the most suitable for microscopic analysis of specific structures,
Prevention
such as cyst size, pleomorphism, and morphology. Other pos-
sible dyes are Giemsa and Acridine orange. PCR generally has Prevention is essential because the disease has great potential to
high sensitivity (> 80%) and specificity (100%). Histology iden- cause marked visual acuity loss and blindness. Patients should
tifies with reasonable ease the protozoa in the cystic form that be instructed to always wash and dry their hands thoroughly
is characterized by rounded, pleomorphic structures. From the before handling the CL. A multipurpose cleaning and disinfect-
specific characteristics of the cellular refraction of the proto- ing solution should not be “topped-off” or reused in the CL
zoa, confocal microscopy allows observation of the cystic form case. The CL case should be washed daily with the multipur-
and also the keratoneuritis pattern associated with infection. pose solution, not tap water. The CL should not be exposed
Depending on the clinical picture, apparatus, and observer, to nonsterile solutions or water from the faucet, pool, pond,
confocal microscopy might facilitate significant sensitivity and bathtub, shower, or sauna, among others. The CL should be
specificity. rubbed for at least 15 seconds before and after use, because this
increases the effectiveness of cleaning and disinfection. The
CL and CL solutions should not be used beyond the expiration
Treatment
date; expired solutions should be discarded. If symptoms or
Early treatment, preferably within 2 to 3 weeks of the onset of signs of eye irritation occur, the CLs should be removed imme-
symptoms and signs, is mandatory for a better disease prog- diately from both eyes and emergency medical attention sought.
nosis. The trophozoites are sensitive to most chemotherapeutic
agents; however, the cysts have greater resistance. The treat-
Selected Readings
1. Dart JK, Saw VP, Kilvington S. Acanthamoeba keratitis: diag-
nosis and treatment update 2009. Am J Ophthalmol. 2009;
148(4):487-499.e2.
2. Alkharashi M, Lindsley K, Law HA, Sikder S. Medical inter-
ventions for Acanthamoeba keratitis. Cochrane Database
Systematic Reviews 2015, Issue 2. Art. No. CD010792. doi:
10.1002/14651858.CD010792.
3. Siddiqui R, Khan NA. Biology and pathogenesis of Acantham-
oeba. Parasit Vectors. 2012; 5:6.
4. Robaei D, Carnt N, Minassian DC, Dart JK. Therapeutic and
optical keratoplasty in the management of Acanthamoeba kera-
titis: risk factors, outcomes, and summary of the literature. Oph-
thalmology 2015; 122(1):17-24.
5. Tu EY, Joslin CE, Nijm LM, Feder RS, Jain S, Shoff ME. Polymi-
crobial keratitis: Acanthamoeba and infectious crystalline kera-
topathy. Am J Ophthalmol. 2009; 148(1):13-19.e2.
6. Polat ZA, Obwaller A, Vural A, Walochnik J. Efficacy of milt-
efosine for topical treatment of Acanthamoeba keratitis in Syrian
hamsters. Parasitol Res. 2012; 110(2):515-520.
Viral Keratitis: What’s New that We Can Do?

Todd P Margolis MD PhD
Herpes Simplex Virus (HSV) Varicella Zoster Virus (VZV)

Since the days of the ancient Egyptians, corneal epithelial Herpes zoster ocular disease is treated in a manner very similar
debridement has been used as a treatment option for HSV to treatment of HSV ocular disease (oral antivirals to control
epithelial keratitis. Whereas the average healing time of an the virus and topical corticosteroids to control inflammation),
untreated HSV epithelial dendrite is 9-10 days, treatment with except that there is almost never a role for topical antivirals in
debridement and patching reduces healing time to 2.5 days. treating ocular zoster. Treatment doses of the oral antivirals are
Several thousand years later, topical antivirals (idoxuridine), higher than that generally used for HSV (acyclovir 800 5x/day,
followed by vidarabine, trifluorothymidine, acyclovir, and famciclovir 500 mg t.i.d., valacyclovir 1000 mg t.i.d.). Note that
most recently ganciclovir, were introduced for the treatment these doses of antivirals barely reach the ID50 for controlling
of HSV epithelial keratitis. The healing time of HSV epithelial VZV, so these full doses should always be used (except in cases
keratitis treated with any of these topical antivirals is about of renal failure).
7 days. Over the years these agents have also been widely The key management issues for VZV that repeatedly come
used as part of therapeutic regimens for the treatment of HSV up in my consultation practice are (1) the need for chronic
stromal disease and iritis, but the role of these topical antiviral corticosteroids to control chronic VZV ocular inflammation
agents in the management of these immunologically mediated (the patient may be on topical corticosteroids for years), (2)
diseases is not clear, other than to prophylax against recurrent recurrent and chronic infectious ocular zoster (requiring
infectious keratitis when treating HSV stromal keratitis with a chronic oral antivirals), (3) neurotrophic keratopathy (this is
topical corticosteroid (they do not get into the corneal stroma not managed with topical lubricants), and (4) postherpetic
or aqueous at therapeutic levels in the absence of an epithelial neuralgia.
defect).
Despite the introduction of topical antivirals in the 1970s,
Epidemic Keratoconjunctivitis (EKC)
the rates of corneal transplantation for HSV keratitis remained
high until the 1990s, corresponding with the increased use of Several recent studies on adenoviral DNA recombination have
oral acyclovir in the management of HSV keratitis. The average made it pretty clear that our current methods of serotyping
healing time of HSV epithelial keratitis treated with oral virus to identify strains of adenovirus responsible for EKC
acyclovir is also about 7 days. However, prophylaxis with oral are deeply flawed. So, it is probably not a bad idea to empty
antivirals reduces overall recurrences of HSV ocular disease by your brain of the adenoviral serotypes responsible for EKC,
up to 95%, depending on the agent and dosage used. Generic thus making room for some new concepts in the diagnosis and
forms of oral acyclovir, valacyclovir, and famciclovir are all management of EKC.
widely available. All 3 of these drugs are easy to take, have The AdenoPlus system has been heralded as a sensitive and
a long shelf life, and are extremely well tolerated, even when specific point-of-care assay for the diagnoses of adenoviral
taken for years. After oral administration, all 3 drugs reach conjunctivitis. The company reports an 85% sensitivity and
therapeutic levels in the tear film and aqueous. 98% specificity for this assay, as compared to polymerase
Many clinicians seem to be excited about the availability chain reaction (PCR). However, an independent study out
of ganciclovir for ocular HSV. Clinical trials support the fact of Moorfields Eye Hospital (Kam et al, Br J Ophthalmol.,
that topical ganciclovir is noninferior to topical acyclovir in 2015) could not replicate this level of sensitivity, finding that
the treatment of HSV epithelial keratitis. There is no published the AdenoPlus system reached a sensitivity of only 39.5%
evidence at this time that topical ganciclovir is effective for as compared to PCR. Ongoing studies are investigating the
the treatment of HSV stromal keratitis or iritis, or for the treatment of EKC with topical povidone iodine and a topical
prophylaxis of recurrent ocular disease. Topical ganciclovir is povidone iodine dexamethasone combination.
more expensive than oral antiviral medications. It is preserved For years topical corticosteroids have been used to manage
with benzalkonium chloride, and 60% of patients using topical the corneal infiltrates associated with ocular adenoviral
ganciclovir report blurred vision, 20% report irritation, and infection. Tacrolimus and cyclosporine have also been reported
5% develop punctate keratitis. Thus, topical ganciclovir is to be useful in the management of the superficial keratitis of
a reasonable alternative to the use of oral antivirals for the EKC.
treatment of HSV epithelial keratitis (not stromal disease or
iritis). However, it is significantly more expensive and has
significantly more side effects than oral antivirals.
Cut It Out! Nonmedical Approaches to

Infectious Keratitis
Jennifer Rose-Nussbaumer MD
I. Corneal Crosslinking (CXL) for Infectious Keratitis B. Outcomes

A. In vitro studies suggest that photochemically acti- 1. TPK is usually reserved for severe, progres-
vated riboflavin is effective against common ocular sive infections for tectonic support, or to avoid
pathogens.1 scleral extension.
B. CXL may also have anti-inflammatory effects and 2. High risk of graft rejection and failure6
promote resistance of corneal tissue to enzymatic
3. Optimal timing to prevent these complications
degradation.2,3
is unknown.
C. To date, randomized clinical trials (RCTs) have
C. Deep anterior lamellar keratoplasty may be bet-
yielded mixed results (see Table 1).
ter due to preservation of host endothelium and
II. Intrastromal Injection: Voriconazole for Fungal reduced risk of intraocular spread of infection.7
Keratitis
A. May provide steady-state drug concentrations at References
the site of infection and avoid intervals of subthera- 1. Martins SA, Combs JC, Noguera G, et al. Antimicrobial efficacy
peutic drug dosing of riboflavin / UVA combination (365 nm) in vitro for bacterial
B. Case series have suggested a role, but 1 RCT com- and fungal isolates: a potential new treatment for infectious kera-
titis. Invest Ophthalmol Vis Sci. 2008; 49(8):3402-3408.
paring intrastromal injection to topical voricon-
azole found significantly improved 3-month visual 2. Alio JL, Abbouda A, Valle DD, Del Castillo JM, Fernandez JA.
acuity in the topical voriconazole group.4 Corneal cross linking and infectious keratitis: a systematic review
with a meta-analysis of reported cases. J Ophthalmic Inflamm
III. Therapeutic Penetrating Keratoplasty (TPK) Infect. 2013; 3(1):47.
A. Risk factors 3. Papaioannou L, Miligkos M, Papathanassiou M. Corneal colla-
gen cross-linking for infectious keratitis: a systematic review and
1. Perforation is more common in fungal than bac- meta-analysis. Cornea 2016; 35(1):62-71.
terial keratitis.
4. Sharma N, Chacko J, Velpandian T, et al. Comparative evalua-
2. Baseline clinical features such as presence of tion of topical versus intrastromal voriconazole as an adjunct to
hypopyon and deep and large infiltrate are pre- natamycin in recalcitrant fungal keratitis. Ophthalmology 2013;
dictors of perforation and/or need for TPK. 120(4):677-681.
3. Culture positivity after starting treatment is a 5. Ray KJ, Lalitha P, Prajna NV, et al. The utility of repeat culture
predictor of eventuating to TPK and may be used in fungal corneal ulcer management: a secondary analysis of the
as an early indicator of response to therapy.5 MUTT I Randomized Clinical Trial. Am J Ophthalmol. Epub
ahead of print 2017 Apr 03.
6. Tan DT, Janardhanan P, Zhou H, et al. Penetrating keratoplasty
in Asian eyes: the Singapore Corneal Transplant Study. Ophthal-
mology 2008; 115(6):975-982 e971.
Table 1. Relevant Randomized Clinical Trials Assessing Corneal Crosslinking
Trial Question N Finding Comment

Bamdad et al., 20158 Adjuvant CXL vs. standard 32 Adjuvant CXL shortened the Small sample size, investigator
therapy for moderate bacterial treatment course and resulted in was partially unmasked, enrolled
keratitis improved outcomes. exclusively in Iran
Said et al., 20149 Adjuvant CXL vs. standard 40 No benefit of adjuvant CXL Inappropriate randomization,
therapy for bacterial, fungal, inclusion of multiple types of ker-
Acanthamoeba, or mixed atitis and mixed keratitis, small
keratitis sample size, enrolled exclusively
in Egypt
Uddaraju et al., 201510 Adjuvant CXL vs. standard 13 Adjuvant CXL resulted in an Small sample size, inclusion of
therapy for deep fungal keratitis increased rate of perforation. only severe fungal ulcers, enrolled
exclusively in South India
7. Sarnicola E, Sarnicola C, Sabatino F, Tosi GM, Perri P, Sarnicola

V. Early deep anterior lamellar keratoplasty (DALK) for Acan-
thamoeba keratitis poorly responsive to medical treatment. Cor-
nea 2016; 35(1):1-5.
8. Bamdad S, Malekhosseini H, Khosravi A. Ultraviolet A/riboflavin
collagen cross-linking for treatment of moderate bacterial corneal
ulcers. Cornea 2015; 34(4):402-406.
9. Said DG, Elalfy MS, Gatzioufas Z, et al. Collagen cross-linking
with photoactivated riboflavin (PACK-CXL) for the treatment of
advanced infectious keratitis with corneal melting. Ophthalmol-
ogy 2014; 121(7):1377-1382.
10. Uddaraju M, Mascarenhas J, Das MR, et al. Corneal cross-link-
ing as an adjuvant therapy in the management of recalcitrant deep
stromal fungal keratitis: a randomized trial. Am J Ophthalmol.
2015; 160(1):131-134 e135.
Case: The Most Unusual Keratitis

Ophthalmia Nodosa: Tarantula-Induced Keratouveitis
Mark J Mannis MD and Enrique O Graue Hernandez MD
C ase
Background Discussion
Keratitis or ophthalmia nodosa is an entity attributed to expo- Ophthalmia nodosa was first described in 1906 as a reaction to
sure to the urticating hairs that cover the dorsal abdomen of the sensory setae of caterpillars. Most contemporary cases have
New World tarantula species, which are catapulted into the air been described in relation to tarantulas (Theraphosidae family),
by the arachnid as a protective mechanism when it is threat- which are popular household pets.
ened. The tarantula vibrates its hind legs across the dorsal The clinical course commonly begins with involvement of
abdomen, projecting the hairs into the surrounding air. The the skin and conjunctiva, followed by sometimes deep corneal
urticating hairs are sturdy, sharp-pointed shafts, 0.3-1.2 mm in stromal infiltrates and anterior chamber reaction.
length, and with reverse barbs. They are capable of penetrating
the skin, conjunctiva, and cornea. Hairs may be embedded in
the cornea either directly through the air or by transfer from the
surface of the fingers after contact with the spider or its enclo-
sure. Over time, the hairs with reverse barbs can migrate into
the deep cornea or anterior chamber. The corneal findings are
characteristic, and management consists of removing protrud-
ing hairs and controlling inflammation.
Case Presentation
■■ 17-year-old male, owner of a pet tarantula
■■ Negative past medical and ocular history
■■ History of present illness:
●● Two-week history of foreign body sensation
●● Pruritis, photophobia, tearing
●● Conjunctival injection Figure 2.

●● Periocular rash, resolved at time of presentation
■■ Examination Tarantula hairs have been classified, and the Type III hair is
●● Diffuse conjunctival injection; no discharge sharp and barbed, facilitating its penetration and hindering its
●● Nummular stromal opacities extrusion or extraction. If possible, hairs should be removed.
However, the mainstay of therapy is topical corticosteroid.
Key Clinical Points

■■ Recognition of typical nummular infiltrates with con-
comitant conjunctival inflammation
■■ High index of suspicion for contact with a tarantula
■■ Long-term follow-up for recurrent inflammation
Selected Readings
1. Hamill MB. Mechanical injury. In: Mannis M and Holland E,
eds. Cornea. Philadelphia: Elsevier; 2017:1100-1102.
2. Cooke J, Miller F, Grover R, et al. Urticaria caused by tarantula
hairs. Am J Trop Med Hyg. 1973; 22:130-133.
3. Chang PCT, Soong HK, Barnett JM. Corneal penetration by
Figure 1.
tarantula hairs [letter]. Br J Ophthalmol. 1991; 75(4): 253-254.
●● Anterior chamber: 2+ cell and flare 4. Watts P, Mcpherson R, Hawksworth N. Tarantula keratouveitis.
●● IOP = 17 mmHg Cornea 2000; 19(3):393-394.
●● Normal posterior segment
■■ Management
●● Topical corticosteroids
●● Follow-up observation
10 Section II: Keratoplasty—Are We Doing the Right Thing? 2017 Subspecialty Day | Cornea
Should We Still Be Doing DSAEK?

DMEK vs. Ultrathin DSAEK: The 6-Month DETECT Trial Results
Winston Chamberlain MD PhD, Jennifer Rose-Nussbaumer MD,
Charles Lin MD, and Thomas Lietman MD
Endothelial keratoplasty (EK) techniques have evolved rapidly Ultrathin DSAEK (UT-DSAEK) involves donor preparation
in recent years, and Descemet membrane endothelial kerato- with a deep microkeratome pass to produce donor grafts near to
plasty (DMEK) has gained in popularity.1 Recent studies sug- or less than 100 μm thick. A recent randomized controlled trial
gest that near anatomic replacement of endothelial tissue pro- demonstrated excellent results with UT-DSAEK that outper-
duces more rapid recovery and improved visual acuity results formed thicker DSAEK in visual acuity outcomes up to 1 year
with DMEK than with Descemet-stripping automated endo- after surgery, with no difference in endothelial cell densities or
thelial keratoplasty (DSAEK).2,3 Yet according to the Eye Bank graft dislocation.6 This procedure may have similar results to
Association of America, DMEK still accounted for only ~23% DMEK but without the technical difficulties.
of endothelial keratoplasties in the United States in 2016 (up A recent survey suggested that there is an interest among
from 15% in 2015), while DSAEK accounted for about 46% EK experts to understand UT-DSAEK’s role in current EK sur-
of all corneal transplants involving endothelial replacement, gery.12 We previously proposed a randomized controlled trial to
including penetrating keratoplasties.4 compare UT-DSAEK with DMEK.5 Randomized controlled tri-
Thus a majority of EK surgeries in the United States are still als are the gold standard in determining preferred surgical and
DSAEK. This is true for various reasons. Many surgeons have medical interventions and therefore are a necessary next step in
not yet adopted DMEK or are early on the DMEK learning the DMEK / DSEK literature.
curve. Experienced EK surgeons without fellowship training We have since completed enrollment in the 2-year DETECT
in DMEK may be reluctant to adopt the newer technique since (Descemet Endothelial Thickness Comparison Trial; Clinical-
they have excellent and reliable results with DSAEK. Donor Trials.gov identifier NCT02373137). DETECT is an interven-
preparation, increased intraoperative times, and problems tional, randomized, patient- / assessor-masked clinical trial.
with donor detachment in DMEK can create reluctance among We report here on the 6-month data of this trial in 50 eyes with
experienced DSAEK surgeons. In addition, many surgeons still either Fuchs dystrophy or bullous keratopathy that were treated
feel that DMEK is not applicable to all eyes that require EK, either with UT-DSAEK (graft thickness: 70-90 microns) or
including those that have undergone pars plana vitrectomy, tra- DMEK. The study has an 80% power to detect 1 line of differ-
beculectomy, or aqueous shunt devices or that have significant ence in BSCVA between the study groups with an alpha of 0.05.
anterior chamber abnormalities, such as peripheral anterior syn- The patient and the refracting technician are masked to the sur-
echiae, or iris loss. Even in routine cases of Fuchs dystrophy and gery type for a 2-year follow-up. Our primary outcome measure
bullous keratopathy, the complication rate, including iatrogenic is BCVA (ETDRS) at 6, 12, and 24 months. Secondary outcome
graft failure and graft detachments, is expected to be higher, at measures include endothelial cell loss, immunological rejection,
least on the surgeon’s learning curve, which could be anywhere graft thickness (pre- and postop), corneal higher-order aber-
from 20-75 cases.2,5 rations, interface haze / light scatter, NEI visual functioning
In my DMEK learning curve experience, there were signifi- questionnaire (NEI VFQ), and complications, including graft
cantly higher numbers of primary graft failures and successful detachments and rebubble rates. Other outcome measures will
grafts with low endothelial counts as compared to the contem- also be assessed.
poraneous DSAEK surgeries I was performing.5 Since many
U.S. surgeons are still on that learning curve, we may experi-
References
ence a higher range of iatrogenic graft failures in the United
States over the next several years. 1. Price FW, Price MO. Evolution of endothelial keratoplasty. Cor-
However, DMEK may produce better outcomes. There are nea 2013; 32(suppl 1):S28-32.
3 potential mechanisms by which DMEK may provide better 2. Phillips PM, Phillips LJ, Muthappan V, Maloney CM, Carver
visual acuity outcomes than DSAEK: graft thickness,6,7 inter- CN. Experienced DSAEK surgeon’s transition to DMEK: out-
face haze,8 and corneal higher-order aberrations.9 Graft thick- comes comparing the last 100 DSAEK surgeries with the first
ness has been correlated with BSCVA outcomes among thinner 100 DMEK surgeries exclusively using previously published tech-
grafts. One retrospective case series found that 71% of thin niques. Cornea 2017; 36(3):275-279.
endothelial grafts (defined as < 131 μm) had BSCVA of 20/25 3. Droutsas K, Lazaridis A, Papaconstantinou D, et al. Visual out-
or better, while only 50% of thick grafts (defined as ≥ 131 μm) comes after Descemet membrane endothelial keratoplasty versus
achieved this.7 In addition, higher-order aberrations, in particu- Descemet stripping automated endothelial keratoplasty: compari-
lar of the posterior cornea, are increased after DSAEK.9 Theo- son of specific matched pairs. Cornea 2016; 35(6):765-771.
retically, given the decreased tissue thickness transplanted after 4. Eye Bank Association of America. 2016 Eye Banking Statistical
DMEK, this would be lessened; however, 1 retrospective series Report. Washington, DC: Eye Bank Association of America; 2016.
looking at higher-order aberrations in DMEK compared with
5. Rose-Nussbaumer J, Alloju S, Chamberlain W. Clinical outcomes
DSAEK found no difference in posterior aberrations between
of Descemet membrane endothelial keratoplasty during the sur-
the 2 groups.10 Finally, interface haze may be increased in geon learning curve versus Descemet stripping endothelial kerato-
DSAEK and has been correlated with BSCVA.11 plasty performed at the same time. J Clin Exp Ophthalmol. 2016;
7(5):599.
2017 Subspecialty Day | Cornea Section II: Keratoplasty—Are We Doing the Right Thing? 11
6. Dickman MM, Kruit PJ, Remeijer L, et al. A randomized mul- 10. Maier AK, Gundlach E, Gonnermann J, et al. Retrospective
ticenter clinical trial of ultrathin Descemet stripping automated contralateral study comparing Descemet membrane endothelial
endothelial keratoplasty (DSAEK) versus DSAEK. Ophthalmol- keratoplasty with Descemet stripping automated endothelial kera-
ogy 2016; 123(11):2276-2284. toplasty. Eye (Lond). 2015; 29(3):327-332.
7. Neff KD, Biber JM, Holland EJ. Comparison of central corneal 11. Mencucci R, Favuzza E, Tartaro R, Busin M, Virgili G. Descemet
graft thickness to visual acuity outcomes in endothelial kerato- stripping automated endothelial keratoplasty in Fuchs’ corneal
plasty. Cornea 2011; 30:388-391. endothelial dystrophy: anterior segment optical coherence tomog-
raphy and in vivo confocal microscopy analysis. BMC Ophthal-
8. Kobayashi A, Yokogawa H, Yamazaki N, Masaki T, Sugiyama
mol. 2015; 15:99.
K. In vivo laser confocal microscopy after Descemet’s membrane
endothelial keratoplasty. Ophthalmology 2013; 120(5):923-930. 12. Chamberlain W, Austin A, Terry M, Jeng BH, Rose-Nussbaumer
J. Survey of experts on current endothelial keratoplasty tech-
9. Chamberlain W, Omid N, Lin A, Farid M, Gaster RN, Steinert
niques. J Clin Exp Ophthalmol. 2016; 7(5):608.
RF. Comparison of corneal surface higher-order aberrations after
endothelial keratoplasty, femtosecond laser-assisted keratoplasty,
and conventional penetrating keratoplasty. Cornea 2012; 31(1):6-
13.
Spicing Up Penetrating Keratoplasty:

Does Femto Really Help?
Marjan Farid MD
I. Early Challenges with Penetrating Keratoplasty 3. Femtosecond laser zig-zag PKPs

A. Surgical technique a. Consistent levels of astigmatism up to 5 years
follow-up
B. Suturing
i. Includes suturing by 10 different fellows
C. Tissue availability and preservation
in majority of PKs
D. Graft infection and rejection
ii. Data reported include patients with
II. Current Challenges with Penetrating Keratoplasty sutures out.
A. Rate of visual recovery iii. Majority of cases with zig-zag C (9 outer
mm) → larger graft → lower levels of cyl
B. Astigmatism
b. Most eyes reaching full potential CDVA by
C. Recovery time and postop healing
postop month 3, maintained through study
D. Tissue clarity period
E. Refractive goals (contact lens freedom) c. UCVA / CDVA / cylinder are stable even after
suture removal.
III. Advances in Corneal Surgery
4. Zig-zag DALK
A. Disease-targeted surgery
a. Combined “big-bubble” DALK technique
1. Descemet-stripping automated endothelial kera-
with femtosecond laser zig-zag incision
toplasty (DSAEK) / Descemet membrane EK
(DMEK) b. Risk of rejection becomes almost zero
2. Deep anterior lamellar keratoplasty (DALK) c. Extraocular surgery, minimizing risks of
open eye surgery
3. Stem cell transplant
The femtosecond has given surgeons new tools for
B. Femtosecond laser technology
achieving better and faster visual recovery.
1. Photodisruption: Creates precise cuts at speci-
fied depths, various trephination cut patterns
2. Femtosecond laser “zig-zag” incision
a. Wound integrity: More surface area for
wound healing, greater mechanical stability
of wound incisions, better incision align-
ment–less torsional or vertical misalignments
b. Self-sealing laser incisions: Less suture ten-
sion with resulting less astigmatism, earlier
suture removal, easier suturing, radial inci-
sion marks to guide suturing
Regrafting the Failed Penetrating Keratoplasty:

Should We Still Re-PK?
Donald T H Tan MD FRCS FRCOphth
I. Challenges for Repeat PK for Failed PK D. Generally better BCVA in PK-EK groups (4 studies)
A. Higher allograft rejection rate E. Ang et al: Retrospective analysis within the Singa-
pore Cornea Transplant Study (SCTS)
B. Higher graft failure rate, shorter graft survival
period: Studies show long-term survival rates to 1. 113 eyes, all pseudophakic bullous keratopathy
range between 21% and 70% (8 studies). (PBK) with failed PKs: 81 PK-PKs, 32 PK-EKs
II. Current Alternatives to Repeat PK for Failed PKs 2. Five surgeons, EndoGlide DSAEKs, same ste-
roid regimes
A. Endothelial keratoplasty (EK): Descemet-stripping
automated EK (DSAEK) or Descemet membrane 3. Cumulative graft survival probability: PK-PK,
EK (DMEK) 51.3% vs. PK-EK, 86.5% (P = .013)
B. Boston type 1 keratoprosthesis a. 1-year survival: PK-PK, 91.9%; PK-EK,
96.2%
III. Advantages of Performing DSAEK (or DMEK) in
Failed PKs b. 2-year survival: PK-PK, 82.6%; PK-EK,
91.6%
A. Potentially lower risk of rejection
c. 3-year survival: PK-PK, 66.8%; PK-EK,
B. EK advantages: tectonically stronger eye, closed eye
86.4%
surgery, sutureless, faster visual rehabilitation
d. 5-year survival: PK-PK, 51.3%; PK-EK,
IV. Disadvantages of Performing DSAEK in Failed PKs
86.4%
A. More complex surgery
4. More rejection episodes in PK-PK group: 13.6%
B. Higher risk of donor dislocation compared to stan- vs. 3.1%
dard DSAEK
5. Multivariate Cox regression analysis: Repeat PK
C. Residual PK stromal haze or distortion may limit was the only significant risk factor for graft fail-
visual acuity. ure; hazards ratio, 10.17 (95% CI, 1.10-93.63; P
= .041)
D. Adoption of original ametropic status of the PK
6. Study conclusion: Performing DSAEK for failed
V. Advantages of Performing Boston Type 1 KPro in
PK is far superior to repeat PK for PBK eyes.
Failed PKs
VIII. Current Suggested Approach
A. No risk of donor rejection affecting central vision
Attempt to perform DSAEK for failed PKs, unless
B. Minimal astigmatism, enhanced visual acuity
there is significant pre-existing, irreversible stromal
C. Relative ease of performing surgery (compared to damage or distortion in the PK, as studies show less
complex EK surgery) rejection, and longer-term graft survival.
VI. Disadvantages of Performing Boston Type 1 KPro in IX. Should We Still Be Performing Repeat PK in Eyes with
Failed PKs a Previously Failed PK?
A. Complications of Boston type 1 KPro (extrusion, Yes, but generally only in eyes with end-stage chronic
infection, etc.) stromal scarring or distortion in the PK.
B. Shorter follow-up rates in literature; longer follow- X. What about the Role of Boston KPro Type 1 for
up, more complications Repeat PKs?
VII. Comparative Studies Comparing Repeat PK (PK-PK) Current short-term studies comparing graft survival
with DSAEK for Failed PK (PK-EK) rates between repeat PK and Boston KPro surgery
for failed PKs suggest that graft survival is better for
A. PK-EK 1-year failure rates ranging from 55% to
the Boston KPro, but graft survival for EKs after PK
100% (3 studies)
appears better than Boston KPro results; more long-
B. Anshu et al: EK-PK graft survival of 74% at 4 years term KPro results are needed to compare Boston KPro
with EK for failed PK.
C. Kitzmann et al: Trend toward better 3-year sur-
vival in PK-EK group
References
1. Weisbrod DJ, Sit M, Naor J, Slomovic AR. Outcomes of repeat 5. Kitzmann AS, Wandling GR, Sutphin JE, et al. Comparison of
penetrating keratoplasty and risk factors for graft failure. Cornea outcomes of penetrating keratoplasty versus Descemet’s strip-
2003; 22(5):429-434. ping automated endothelial keratoplasty for penetrating kerato-
plasty graft failure due to corneal edema. Int Ophthalmol. 2012;
2. Patel NP, Kim T, Rapuano CJ, et al. Indications for and outcomes
32(1):15-23.
of repeat penetrating keratoplasty, 1989-1995. Ophthalmology
2000; 107(4):719-724. 6. Ang M, Ho H, Wong CW, Htoon HM, Mehta JS, Tan D. Endo-
thelial keratoplasty after failed penetrating keratoplasty: an
3. Ezon I, Shih CY, Rosen LM, et al. Immunologic graft rejection
alternative to repeat penetrating keratoplasty. Am J Ophthalmol.
in Descemet’s stripping endothelial keratoplasty and penetrat-
2014; 58:1221-1227.
ing keratoplasty for endothelial disease. Ophthalmology 2013;
120(7):1360-1365. 7. Lee WB, Shtein RM, Kaufman SC, et al. Boston keratoprosthesis:
outcomes and complications—a report by the American Academy
4. Anshu A, Price MO, Price FW Jr. Descemet’s stripping endothelial
of Ophthalmology. Ophthalmology 2015; 122:1504-1511.
keratoplasty under failed penetrating keratoplasty: visual rehabili-
tation and graft survival rate. Ophthalmology 2014; 92(2):167-
170.
Done with Regrafting?

When Is KPro a Better Choice?
Anthony J Aldave MD, Sumayya Ahmad MD, Priya M Mathews MD MPH,
Kristina Lindsley MS, Majed Alkharashi MD, Frank S Hwang MD, Sueko M Ng MHS,
and Esen Karamursel Akpek MD
Background Graft Failure / Keratoprosthesis Retention

In nearly every published series of the Boston type 1 kerato- One, 2, and 5 years after surgery, the cumulative percentage of
prosthesis, the most frequently implanted keratoprosthesis PKs that failed was 21%, 33%, and 53%, while the percentage
worldwide, the most common indication for surgery is repeat of keratoprosthesis retention failures was 1%, 6%, and 25%,
corneal transplant failure. However, no controlled clinical tri- respectively.
als have been performed to compare the outcomes of repeat
keratoplasty to keratoprosthesis implantation for graft failure.
Complications
Thus, in order to attempt to develop evidence-based guidelines
regarding optimal management of repeat keratoplasty failure, Glaucoma either developed or progressed in 25% of eyes fol-
the published outcomes of repeat penetrating keratoplasty (PK) lowing PK and in approximately 30% of eyes following kerato-
were compared to those of a multicenter, retrospective review prosthesis implantation. Infectious keratitis developed in 18%
of Boston type 1 keratoprosthesis performed for corneal trans- of eyes following PK and in 3% of eyes following keratoprosthe-
plant failure. sis implantation.
Methods Summary
A literature search was performed to identify publications that The Boston type 1 keratoprosthesis is the evidence-based pro-
reported the outcomes of PK for corneal transplant failure. In cedure of choice for the management of corneal graft failure.
addition, data were collected from surgeons at 5 centers regard- However, superior visual outcomes must be weighed against
ing the outcomes following implantation of the Boston type 1 greater risk of sight-threatening complications.
keratoprosthesis for corneal transplant failure. The primary
outcome measure was the percentage of eyes with corrected
Selected Readings
distance visual acuity (CDVA) ≥ 20/200 at 2 years after surgery,
while secondary outcome measures included the percentage of 1. Akpek EK, Alkharashi M, Hwang FS, Ng SM, Lindsley K. Artifi-
eyes with CDVA ≥ 20/40 at 2 years after surgery; the incidence cial corneas versus donor corneas for repeat corneal transplants.
of graft failure or keratoprosthesis retention failure at 1, 2, and Cochrane Database of Systematic Reviews 2014, Issue 11. Art.
No.: CD009561.
5 years after surgery; and the incidence of postoperative compli-
cations, such as infectious keratitis and development or progres- 2. Ahmad S, Mathews PM, Lindsley K, et al. Boston Type 1 kerato-
sion of glaucoma. prosthesis versus repeat donor keratoplasty for corneal graft fail-
ure: a systematic review and meta-analysis. Ophthalmology 2016;
123:165-177.
Results
3. Akpek EK, Cassard SD, Dunlap K, Hahn S, Ramulu PY. Donor
The literature search revealed 26 studies that described the corneal transplantation vs Boston type 1 keratoprosthesis in
results of repeat PK for corneal transplant failure in approxi- patients with previous graft failures: a retrospective single center
mately 5600 patients. During the specified study period, 104 study (an American Ophthalmological Society Thesis). Trans Am
eyes (98 patients) underwent implantation of the Boston type 1 Ophthalmol Soc. 2015; 113:T3.
keratoprosthesis for corneal transplant failure at the 5 centers. 4. Hager JL, Phillips DL, Goins KM, et al. Boston type 1 keratopros-
thesis for failed keratoplasty. Int Ophthalmol. 2016; 36:73-78.
Visual Acuity
Two years after surgery, the percentage of eyes with CDVA
≥ 20/200 following repeat PK vs. keratoprosthesis implantation
were 42% vs. 57%, while the percentage of eyes with CDVA
> 20/40 were 16% vs. 20%, respectively.
Breaking the Mold:

Surgery Starts in the Eye Bank!
Marian Sue Macsai-Kaplan MD
NOTES
Case: What Do I Do with This Cornea?!

The Surgical Management of Total Corneal Melts with Perforation:
Novel Techniques to Save the Eye, Minimize Rejection,
and Preserve the Angle
Mark A Terry MD
Management of extensive corneal and limbal melts from auto- A 46-year-old indigent woman with history of “scratch” 6 days
immune disease or infection can be more challenging than ago presented with total corneal infiltrate and necrosis involv-
managing more central ulcerations and/or perforations. Due ing the limbus inferiorly. There was near perforation of the
to the proximity of a graft to the scleral vasculature, any large inferior third of the cornea and a 95% hypopyon. There was no
penetrating keratoplasty procedure in this area puts the graft view of the anterior chamber. Patient had been on moxifloxacin
at higher risk of rejection and vascularization. When replacing (Vigamox) from the E.R. for 3 days. Seidel-negative with pres-
full-thickness tissue in close proximity to the anterior chamber sure B-scan showed no involvement of the posterior segment.
angle, there is a high risk of extensive iridocorneal adhesions, Preop vision was light perception only. IOP was by palpation,
angle closure, and resultant intractable glaucoma. In this pre- and the eye was felt to be “soft.”
sentation, I will present a case for the panel members to discuss
regarding their approach to saving the eye, preserving vision, Medical therapy
and preventing glaucoma. I will then show a unique surgical Cultures and Gram stain were taken and patient was placed on
strategy to minimize common complications following repair of fortified drops of vancomycin and tobramycin every half hour,
total corneal melts with limbal involvement. as well as oral doxycycline. Cultures grew out Streptococcus
pneumoniae. After 2 days of antibiotics, perforation seemed
imminent, and so the patient was taken to the operating theater.
What Do I Do with This Cornea?
Surgical therapy
What are the options here?
1. Penetrating keratoplasty with a 12-mm limbus-to-limbus
graft?
2. Lamellar keratoplasty?
3. Keratoprosthesis?
4. Descemet membrane endothelial keratoplasty?
5. Corneal crosslinking?
6. Enucleation?
7. Referral to your competition?
Figure 1.
18 Advocating for Patients 2017 Subspecialty Day | Cornea
2017 Advocating for Patients

Darby Miller MD
Ophthalmology’s goal to protect sight and empower lives ■■ Derailed the onerous global surgery data collection
requires active participation in and commitment to advocacy proposal
from every ophthalmologist. Contributions to the following ■■ Preserved global surgical payments
three critical funds are a part of that commitment: ■■ Halted the Part B Drug Demonstration
■■ Continued efforts in collaboration with subspecialty soci-
■■ OPHTHPAC® Fund
eties to preserve access to compounded and repackaged
■■ Surgical Scope Fund (SSF)
drugs such as Avastin
■■ State Eye PAC
Contributions to OPHTHPAC can be made here at AAO
Please join the dedicated community of ophthalmologists
2017 or online at www.aao.org/ophthpac by clicking “Join.”
who are contributing to protect quality patient eye care for
Leaders of the Cornea Society are part of the Academy’s
everybody. The OPHTHPAC Committee is identifying Con-
Ophthalmic Advocacy Leadership Group (OALG), which
gressional Advocates in each state to maintain close relation-
meets every January in the Washington, D.C., area to provide
ships with federal legislators in order to advance ophthalmology
critical input and to discuss and collaborate on the Academy’s
and patient causes. At Mid-Year Forum 2017, we honored nine
advocacy agenda. The topics discussed at the 2017 OALG
of those legislators with the Academy’s Visionary Award. This
agenda included panel discussions on the Merit Based Incen-
served to recognize them for addressing issues important to
tive Payment System (MIPS) and APM implementation, as well
us and to our patients. The Secretariat for State Affairs is col-
as Academy analysis initiatives related to the IRIS® registry. In
laborating closely with state ophthalmology society leaders to
addition, meeting participants discussed the changing paradigm
protect Surgery by Surgeons at the state level. This year has seen
for optometric scope battles, held a roundtable to discuss chal-
an unprecedented effort by optometry to advance its scope of
lenges for surgical subspecialties, and considered opportunities
practice via legislation rather than education. Our mission of
to ensure physician and patient choice regarding access to phar-
protecting sight and empowering lives requires robust funding
maceuticals.
of both the Surgical Scope Fund and the OPHTHPAC Fund.
At Mid-Year Forum 2017, the Academy and the Cornea
Each of us has a responsibility to ensure that these funds are
Society ensured a strong presence of cornea specialists to sup-
strong.
port ophthalmology’s priorities, and a record number of oph-
thalmologists visited members of Congress and their key health
OPHTHPAC® Fund staff to discuss ophthalmology priorities as part of Congressio-
nal Advocacy Day. The Cornea Society remains a crucial part-
OPHTHPAC is a crucial part of the Academy’s strategy to pro-
ner with the Academy in its ongoing federal and state advocacy
tect and advance ophthalmology’s interests in key areas, includ-
initiatives.
ing physician payments from Medicare and protecting ophthal-
mology from federal scope of practice threats. Established in
1985, OPHTHPAC is one of the oldest, largest, and most suc- Surgical Scope Fund
cessful political action committees in the physician community.
The Surgical Scope Fund (SSF) provides grants to state ophthal-
We are very successful in representing your profession to the
mology societies to support their efforts to derail optometric
U.S. Congress.
surgery proposals that pose a threat to patient safety. Since
As one election cycle ends, a new one starts, yet the pres-
its inception, the Surgery by Surgeons campaign and the SSF,
sure to remain vocal on our issues remains. Advocating for our
in partnership with state ophthalmology societies, has helped
congressional issues is a continuous battle, and OPHTHPAC
32 state / territorial ophthalmology societies reject optometric
is always under financial pressure to support our incumbent
scope of practice expansion into surgery.
friends as well as to make new friends with candidates. These
In 2017, your colleagues serving on the Academy’s Secre-
relationships allow us to have a seat at the table with legislators
tariat for State Affairs, along with State Governmental Affairs
willing to work on issues important to us and our patients.
staff and the leaders of state ophthalmology societies, have been
The relationships OPHTHPAC builds with members of
put to the task while dealing with an unprecedented number of
Congress is contingent on the financial support we receive from
simultaneous legislative battles. Eleven states have been affected
Academy members. Academy member support of OPHTHPAC
so far this year:
allows us to advance ophthalmology’s federal issues. We need to
increase the number of our colleagues who contribute to OPH- ■■ Alaska ■■ Maryland
THPAC and the other funds. Right now, major transformations ■■ California ■■ Massachusetts
are taking place in health care. To ensure that our federal efforts ■■ Florida ■■ Nebraska
and our PAC remain strong, we need the support of every oph- ■■ Georgia ■■ North Carolina
thalmologist to better our profession and ensure quality eye ■■ Illinois ■■ Pennsylvania
care for our patients. ■■ Iowa
The significant impacts that OPHTHPAC has made include
the following:
2017 Subspecialty Day | Cornea Advocating for Patients 19
Surgical Scope Fund OPHTHPAC® Fund State EyePAC

To derail optometric surgical scope of practice Ophthalmology’s interests at the federal level Support for candidates for state House,
initiatives that threaten patient safety and Senate, and governor
Support for candidates for U.S. Congress
quality surgical care
Political grassroots activities, lobbyists, PR Campaign contributions, legislative education Campaign contributions, legislative education
and media campaigns
No funds may be used for campaign contribu-
tions or PACs.
Contributions: Unlimited Contributions: Limited to $5,000 Contribution limits vary based on state
regulations.
Individual, Practice, and Organization
Contributions are 100% confidential. Contributions above $200 are on the public Contributions are on the public record
record. depending upon state statutes.
Patient safety setbacks as well as victories will be reviewed Please respond to your Academy colleagues and be part of
during the presentation, but do know that in each of these the community that contributes to OPHTHPAC, the SSF, and
legislative battles, the benefits from SSF distributions are abun- your State Eye PAC. Please be part of the community advocat-
dantly clear. The best lobbyists and public relations consultants ing for your patients now.
are contracted as necessary, and media campaigns (including
TV, radio, and social media) to educate the voting public are
*OPHTHPAC Committee
launched when needed to secure success and stop optometry
from expanding its scope of practice to include surgery. Each Jeffrey S Maltzman MD (AZ)–Chair
of these endeavors is very expensive, and no one state has the Janet A Betchkal MD (FL)
resources to wage one of these battles on its own. Ophthal- William S Clifford MD (KS)
mologists must join together and donate to the SSF to fight for
Sidney K Gicheru MD (TX)
patient safety when a state faces a scope battle over optometric
surgery. Sohail J Hasan MD PhD (IL)
The Academy relies not only on the financial contributions Gary S Hirshfield MD (NY)
to the SSF from individual ophthalmologists and their practices, David W Johnson MD (CO)
but also on the contributions made by ophthalmic state, sub-
Stephanie J Marioneaux MD (VA)
specialty, and specialized interest societies. The Cornea Society
contributed to the SSF in 2016, and we thank them and look Dorothy M Moore MD (DE)
forward to their contribution in 2017. Contributions to the SSF Niraj Patel MD (WA)
can be made here at AAO 2017 or online at www.aao.org/ssf. John D Roarty MD (MI)
Diana R Shiba MD (CA)
State Eye PAC Woodford S Van Meter MD (KY)
It is also extremely important for all ophthalmologists to sup- John (“Jack”) A Wells 3rd MD (SC)
port their respective State Eye PACs because campaign contribu-
tions to legislators at the state level must come from individual Ex-Officio Members
ophthalmologists and cannot come from the Academy, OPH- Cynthia A Bradford MD (OK)
THPAC, or the SSF. The presence of a strong State Eye PAC Daniel J Briceland MD (AZ)
providing financial support for campaign contributions and
Michael X Repka MD MBA (MD)
legislative education to elect ophthalmology-friendly candidates
to the state legislature is critical, as scope of practice battles and George A Williams MD (MI)
many regulatory issues are all fought on the state level.
**Surgical Scope Fund Committee
Action Requested: ADVOCATE FOR YOUR Kenneth P Cheng MD (PA)–Chair
PATIENTS Amalia Miranda MD (OK)
Academy SSF contributions are used to support the infrastruc- Matthew F Appenzeller MD (NE)
ture necessary in state legislative / regulatory battles and for Vineet (“Nick”) Batra MD (CA)
public education. PAC contributions are necessary at the state
Cecily A Lesko MD FACS (NJ)
and federal levels to help elect officials who will support the
interests of our patients. Contributions to each of these three C Blake Myers MD (SC)
funds are necessary and help us protect sight and empower William (“Chip”) W Richardson 2nd MD (KY)
lives. SSF contributions are completely confidential and may be David E Vollman MD MBA (MO)
made with corporate checks or credit cards, unlike PAC contri-
butions, which must be made by individuals and are subject to Ex-Officio Members
reporting requirements. Daniel J Briceland MD (AZ)
Kurt F Heitman MD (SC)
20 Section III: Conjunctival Tumors—What’s Old, What’s New? 2017 Subspecialty Day | Cornea
Ocular Surface Squamous Neoplasia:

Should I Excise, or Do Something Else?
Hans E Grossniklaus MD
I. Ocular Surface Neoplasms 2. 10 million IU/1 cc (injected) perilesional every

1-2 weeks (x 3-4 injections)
A. Dysplasia (corneal intraepithelial neoplasia [CIN])
a. “Flu in a bottle”
1. Mild: up to 1/3 thickness
b. Give acetaminophen / aspirin at time of injec-
2. Moderate: 1/3 to 2/3 thickness
tion
3. Severe: 2/3 to full thickness
c. May be given in OR at time of excision /
4. Carcinoma-in-situ: full thickness biopsy in some cases
B. Focal (actinic keratosis variety) vs. diffuse CIN IV. Diffuse CIN: Consider Other Diagnoses
C. Squamous cell carcinoma (SCC) = invasion of sub- A. Ocular cicatricial pemphigoid (OCP) biopsies sub-
stantia propria mitted in formalin and Michel’s media for immu-
nofluorescence
D. Variants of SCC
B. Pagetoid spread of sebaceous carcinoma
1. Spindle cell carcinoma
1. Great mimicker
2. Mucoepidermoid carcinoma
2. Biopsy for histology
II. Treatment
3. May have false immunofluorescence (IF) stain-
A. Excision vs. biopsy
ing
1. Focal (actinic keratosis variety): Excise
V. Should I Excise, or Do Something Else?
2. Diffuse: Map biopsies
A. Get tissue diagnosis including IF, if needed (OCP,
B. Excision technique pagetoid spread of sebaceous carcinoma)
1. Topical / subconjunctival anesthesia B. Actinic keratosis, localized variant, excision usu-
ally works; may need adjuvant chemotherapy (IFN)
2. Mark borders of lesion
if + margins and/or high grade (severe dysplasia,
3. Excise with 0.12 forceps and Wescott scissors CIS)
4. Excise corneal portion with crescent or 69 blade C. Diffuse variant, map biopsies, then treat with adju-
vant chemotherapy (IFN)
5. Double freeze thaw margins (and base) to
−80°C D. Mode of chemotherapy depends on severity, extent
of dysplasia, patient compliance, etc.; may use topi-
6. Close with 6-0 plain suture
cal, injections or both for IFN
7. Place on cardboard / foam pad and orient
E. If SCC with deep margin positive, re-excise or con-
8. Margins determined based on size of lesion sider plaque brachytherapy if needed.
9. Corneal (limbal) margin often positive F. If spindle cell carcinoma or mucoepidermoid carci-
noma, may need further surgery; monitor for intra-
III. Adjuvant Therapy
ocular invasion.
A. Mitomycin C (MMC)
1. 0.02%-0.04% q.i.d.; 2 weeks on, 2 weeks off; Selected Readings
may be repeated 1. Frucht-Pery J, Rozenman Y. Mitomycin C therapy for corneal
2. Occlude puncta intraepithelial neoplasia. Am J Ophthalmol. 1994; 117:164-168.
B. 5-fluorouracil 2. Wilson MW, Hungerford JL, George SM, Madreperla SA. Topical
mitomycin C for the treatment of conjunctival and corneal epithe-
1. 1% q.i.d. for 1-2 weeks; may be repeated lial dysplasia and neoplasia. Am J Ophthalmol. 1997; 124:303-
311.
2. May be used if refractory to MMC
3. Grossniklaus HE, Aaberg TM Sr. Mitomycin C treatment of con-
C. Interferon (IFN) α2B junctival intraepithelial neoplasia [editorial]. Am J Ophthalmol.
1997; 124:381-383.
1. 10 million IU/10 cc (compounded) q.i.d. topi-
cally for 3-4 months
2017 Subspecialty Day | Cornea Section III: Conjunctival Tumors—What’s Old, What’s New? 21
4. Yeatts RP, Engelbrecht NE, Curry CD, et al. 5-fluorouracil for the
treatment of intraepithelial neoplasia of the conjunctiva and cor-
nea. Ophthalmology 2000; 107:2190-2195.
5. Yamamoto N, Ohmura T, Suzuki H, Shirasawa H. Successful
treatment of conjunctival intraepithelial neoplasia refractive to
mitomycin-c. Ophthalmology 2002; 109:249-252.
6. Maskin SL. Regression of limbal epithelial dysplasia with topical
interferon. Arch Ophthalmol. 1994; 112:1145-1146.
7. Karp CL, Moore JK, Rosa Jr RH. Treatment of conjunctival and
corneal intraepithelial neoplasia with topical interferon α-2b.
Ophthalmology 2001; 108:1093-1098.
8. Karp CL, Galor A, Chhabra S, Barnes SD, Alfonso EC. Subcon-
junctival / perilesional recombinant interferon α2b for ocular sur-
face squamous neoplasia: a 10-year review. Ophthalmology 2010;
117:2241-2246.
9. Grossniklaus HE, Bergstrom C, Hubbard GB, Wells JR. Surgi-
cal techniques. In: Grossniklaus HE, ed. Pocket Guide to Ocular
Oncology and Pathology. Berlin: Springer; 2013:47-69.
10. Brown HH, Wells JR, Grossniklaus HE. Tissue preparation for
pathological examination. In: Grossniklaus HE, ed. Pocket Guide
to Ocular Oncology and Pathology. Berlin: Springer; 2013:61-67.
What to Do When the Tumor Goes Viral . . .

Literally
Conjunctival Papilloma Management
Carol L Shields MD
I. Basic Facts B. Conjunctival papilloma treatments

A. Conjunctival papilloma is related to human papil- 1. Surgery: Excision and cryotherapy, “no-touch”
lomavirus (HPV) infection. technique
B. Facts from VaccinateYourFamily.org, founded in 2. Immunotherapy: Good choice
1991 by former first lady Rosalynn Carter to pro-
a. Interferon, topical: 1 million IU/cc q.i.d. for
tect families from vaccine-preventable diseases:
3 months
1. HPV is a common virus that can cause cervi-
b. Interferon injection ≤ 10 million IU per cc
cal, vaginal, and vulvar cancers in females and
under the mass every 1 month x 4
penile cancer in males. HPV can also cause anal
cancer, throat cancer, genital warts, and con- c. Cimetidine: 300 mg PO t.i.d.
junctival papillomas.
3. Chemotherapy: We avoid mitomycin C and
2. About 79 million Americans are currently 5-fluorouracil for papillomas due to toxicity.
infected with HPV.
4. Antiviral therapy: Cidofovir
3. About 14 million new infections occur per year
5. Photodynamic therapy: Can be effective
in the United States.
6. Laser therapy: Be careful, as this aerosolizes the
4. HPV leads to approximately 11,000 cases of
HPV and can cause throat papillomas in health-
cervical cancer per year in the United States.
care workers.
5. HPV is common; nearly all sexually active men
7. What to do with failures: Check immune status
and women will be infected at some point in
and use immunotherapy.
their lives.
III. HPV Vaccine: Types of Vaccines
6. Some infected people have no symptoms and the
HPV can resolve. A. Cervarix: Bivalent against types 16 and 18
C. HPV types B. Gardasil: Quadrivalent against types 6, 11, 16, 18
1. There are > 100 types of HPV. C. Gardasil 9: Nonavalent against types 6, 11, 16, 18,
31, 33, 45, 52, 58
2. Types 6 and 11 cause the common wart of skin,
genitals, and conjunctiva. At delivery through 1. Released 2014 for girls and boys ages 9-15 years
the vaginal canal, a child can pick up the moth- old
er’s HPV and eventually develop conjunctival
2. Three injections
papilloma or respiratory papilloma.
3. Anticipate 90% of genital warts and cervical
3. Types 6a, 33, and 45 are less commonly found
cancer prevented
in conjunctival papilloma.
D. Anticipate reduction in conjunctival papillomas
4. Types 16 and 18 can cause carcinoma of the cer-
and perhaps squamous cell carcinoma
vix and conjunctiva.
II. Conjunctival Papilloma Facts
Selected Readings
A. Conjunctival papilloma features 1. Vaccinate Your Family website, vaccinateyourfamily.org.
1. Can occur in children (10%) or adults (90%) 2. Shields CL, Lally MR, Singh AD, et al. Oral cimetidine (Tagamet)
2. Related skin warts (18%), genital warts (3%), for recalcitrant, diffuse conjunctival papillomatosis. Am J Oph-
thalmol. 1999; 128:362-364.
and HIV (1%) are noted.
3. Kaliki S, Arepalli S, Shields CL, et al. Conjunctival papilloma:
3. Occurs in the fornix (19%), tarsus (14%), or features and outcomes based on age at initial examination. JAMA
plica / caruncle (40%) Ophthalmol. 2013; 131(5):585-593.
4. Those in children are larger and more multifo- 4. Reithmuller D, Jacquard AC, St Guily L, et al. Potential impact of
cal, with greater recurrence. a nonavalent HPV vaccine on the occurrence of HPV-related dis-
eases in France. BMC Public Health. 2015; 15:453.
Does Imaging Help in the Diagnosis of

Conjunctival Tumors? Biopsy or Image?
Afshan Nanji MD
I. Case Presentations E. Biopsy

II. Ocular Surface Squamous Neoplasia (OSSN) 1. Allows for definitive diagnosis
A. Vital dyes: Rose bengal, methylene blue, and tolu- 2. Limitations: invasive, possibility of incomplete
idine blue are sensitive tests, but are not specific for sampling, side effect of scarring
OSSN.
III. Conjunctival Melanoma
B. Cytology
A. Cytology
1. Impression and aspiration cytology are mini-
1. Impression cytology takes advantage of the
mally invasive techniques that use cell sampling
ascent of atypical melanocytes to the epithelial
to evaluate for atypia.
surface that it is indicative of malignancy.
2. Atypical features include enlarged nuclei,
2. Limitations: false negative errors, low utility in
irregular nuclear outline, coarse chromatin, and
early precursors to melanoma
presence of prominent nucleoli.
B. In vivo confocal microscopy
3. Limitations: superficial sampling, decreased
sensitivity with keratotic lesions, need for expe- 1. Allows detection of cellular changes and inva-
rienced cytologist sion
C. In vivo confocal microscopy 2. Cellular features suggesting atypia: large cells
with prominent nuclei / nucleoli
1. Noninvasive technique allowing en face images
of the ocular surface down to the cellular level 3. Limitations: false negatives and only 1 study
showing its utility
2. Atypical features include hyper-reflective pleo-
morphic cells of varying shapes and sizes, large C. Anterior segment OCT
and bright nuclei.
1. High-resolution images can detect cysts that
3. Mixed results regarding its diagnostic capabili- may not be seen on clinical examination.
ties across various studies
2. Clear differentiation between epithelial and sub-
4. Limitations: requires operator expertise, epithelial tumors
decreased visualization in highly keratinized
3. Limitations: no ability to detect atypia with
lesions
primary acquired melanosis, optical shadowing
D. Anterior segment OCT with thick or highly pigmented tumors
1. Noninvasive technique allowing in vivo, cross- D. Ultrasound biomicroscopy
sectional, high-resolution images of the ocular
1. Noninvasive technique with ability to penetrate
surface
opaque tumors, allows for posterior border of
2. Classic characteristics: abrupt transition tumors to be imaged and to evaluate for inva-
between normal and abnormal epithelium, epi- sion
thelial thickening, and hyper-reflectivity in the
2. Limitations: limited resolution and restricted
area of the tumor
availability of the technology
3. Easy to learn and perform
E. Biopsy
4. Limitations: shadowing with thick or pigmented
1. Allows for definitive diagnosis of sampled site
tumors, limited ability to detect invasion
2. Increased risk of local recurrence, metastatic
disease, and tumor-related death with incisional
biopsy
Pigmented Lesions: Watch, or Worry?

Victoria M L Cohen FRCOphth
I. History: Key Questions IV. Surgical Approach

A. What was the age of onset? A. Avoid incision biopsy
B. Has it grown? B. Consider controlled map biopsy if multiple sites of
primary acquired melanosis.
C. Can the pigment be found in both eyes, or one?
C. Dry field
D. What is the genetic background of the patient?
D. No-touch technique
E. Is the patient immunosuppressed?
E. Avoid subconjunctival injection.
F. Is there a history of sun exposure?
F. Absolute alcohol for superficial corneal epitheliec-
G. Is there a history of a treated intraocular mela-
tomy
noma?
G. Lamella dissection of sclera / cornea may be needed
II. Examination: Key Points
(previous surgical notes?).
A. Bilateral / unilateral
H. 2-3 mm margins
B. Is the pigment multifocal?
I. Prepare specimen for pathological reporting.
C. Is the pigment flat?
D. Are there cysts? Selected Readings
E. Is the pigment mobile? 1. Singh AD, De Potter P, Fijal BA, et al. Lifetime prevalence of uveal
melanoma in white patients with oculo(dermal)melanocytosis.
F. Are there feeder / intrinsic vessels? Ophthalmology 1998; 105:195-198.
G. Is there leukoplakia? 2. Shields CL, Shields JA, Gunduz K, et al. Conjunctival melanoma:
risk factors for recurrence, exenteration, metastasis and death
H. Is corneal epithelium / stroma involved? in 150 consecutive patients. Arch Ophthalmol. 2000; 118:1497-
I.
Double evert the lids at every examination. 1507.
J.
Palpate the neck for enlarged lymph nodes. 3. Toivonen P, Kivela T. Infiltrating macrophages in extratumoural
tissues after brachytherapy of uveal melanoma. Acta Ophthalmol.
III. Investigations 2012; 90:341-349.
A. Good documentation with slitlamp photography

B. Anterior segment OCT
C. Anterior segment, high-resolution B-scan ultra-
sound or ultrasound biomicroscopy
Pterygium Surgery: Evidence-based Approaches

Darren G Gregory MD
Introduction Evidence
Pterygium surgery is an underappreciated art. It is frequently The evidence regarding the superiority of the various surgical
treated as a trivial procedure, often being the first surgery options is somewhat flawed. Published studies vary with regard
one performs during residency. Recurrent pterygia, however, to patient populations, pterygium severities, surgical techniques,
can be highly problematic for patients and difficult to repair. postoperative care, and recurrence criteria. That being said, all
The potential complications of a recurrent pterygium include published reports show that the recurrence rate with amniotic
unsightly scarring, restricted ocular motility, ocular surface membrane grafts is approximately twice the rate of recurrence
dryness, and decreased vision. It is therefore important for sur- with conjunctival autografts.1,2 Fibrin glue for conjunctival
geons to choose a surgical technique that safely and effectively autografts seems to yield shorter surgical times and lower recur-
minimizes the risk for recurrence. rences rates than sutured conjunctival autografts.3 Adjunctive
mitomycin C lowers recurrence rates but risks causing severe,
vision-threatening complications such as scleral melts.1,2 Its use
Surgical Options
should be reserved for aggressively recurrent pterygia.
Simple excision leaving bare sclera has largely been abandoned
(or should be abandoned) as a surgical technique due to an
References
unacceptably high recurrence rate. Conjunctival autografts and
amniotic membrane grafts have been used to cover the con- 1. Clearfield E, Muthappan V, Wang X, Kuo IC. Conjunctival
junctival defect following pterygium excision and subsequently autograft for pterygium. Cochrane Database of Systemic Reviews
decrease the recurrence rate. The grafts can be fixated in place 2016, Issue 2. Art. No.:CD011349.
using sutures or fibrin tissue adhesive. Mitomycin C has also 2. Kaufman SC, Jacobs DS, Lee WB, et al. Options and adjuvants
been used as an adjunctive therapy to decrease fibroblast activ- in surgery for pterygium: a report by the American Academy of
ity and thus decrease the rate of pterygium recurrence. Ophthalmology. Ophthalmology 2013; 120(1):201-208.
3. Romano V, Cruciani M, Conti L, Fontana L. Fibrin glue versus
sutures for conjunctival autografting in primary pterygium sur-
gery. Cochrane Database of Systemic Reviews 2016, Issue 12. Art.
No.: CD011308.
Case: A Lump that Stumped Me

Recurrent Conjunctival Myofibrosarcoma:
Managed with Triple Application of Episcleral Brachytherapy
Arun D Singh MD
C ase
A 54-year-old man with history of a renal transplant presented

with a recurrent conjunctival tumor. Histopathologic diagnosis
was established with the use of immunohistochemistry. In total,
three 125Iodine radiation episcleral plaques were used over a
period of 49 weeks. Following cicatricial ectropion repair and
cataract surgery, visual acuity was 20/20 at 5-year follow-up
without evidence of recurrence or radiation retinopathy.
Discussion
Myofibrosarcoma is a rare mesenchymal tumor that can present
as ocular surface tumor. Final histopathologic diagnosis can be
challenging, and immunohistochemistry is important for evalu-
ation. Myofibrosarcoma should be considered in the clinical dif-
ferential diagnosis of atypical ocular surface lesions and the his-
topathologic differential diagnosis of ocular spindle neoplasms.
2017 Subspecialty Day | Cornea Section IV: Anterior Segment Imaging 27
How Many Technologies Does It Take to

Implant a Toric IOL?
Comparison of Toric IOL Rotational Stability
David F Chang MD and Bryan Lee MD JD
I. The Problem IV. Study Population

A. Astigmatic correction requires multiple steps. V. Repositioning Rate
B. Problem of stackable error Return to the OR because of rotated IOL:
II. The Critical Window (Inoue, Ophthalmology 2017) A. AcrySof: 1.6%
A. 72 Tecnis toric eyes at the end of surgery, then post- B. Tecnis: 3.1% (P = .10)
operative (PO) hour 1, PO Day 1, PO Month 1, and
VI. Conclusion
PO Year 1
A. AcrySof toric is more rotationally stable than the
B. Most rotation happened in the first hour after sur-
Tecnis toric.
gery; rotation of 4.1 degrees.
B. Tecnis toric clearly has a predisposition to rate
C. Between PO Hour 1 and PO Year 1, rotation 0.7
counterclockwise.
degrees
C. Trend toward a decreased need to return to the OR
III. Our Study
to rotate the AcrySof
A. All toric IOLs, April 2015 to September 2016
B. Only included eyes with Callisto
C. Retrospective study
1. Surgeon chose Alcon vs. Tecnis toric.
2. Capsular tension ring used at surgeon’s
discretion.
D. Primary outcome: % > 5 or > 10 degrees misalign-
ment at first postop visit
28 Section IV: Anterior Segment Imaging 2017 Subspecialty Day | Cornea
Is Aberrometry Necessary?
In-Office Aberrometry: Why Do I Care?
Parag A Majmudar MD
I. Basics of Aberrometry IV. Identifying Good Candidates for LASIK vs. Refractive
Lens Exchange
A. Ray tracing aberrometry uses a series of 256 laser
beams through the line of sight through the pupil. If patients have subtle lens changes, it may steer the
The location where the beams contact the retina is discussion toward a more appropriate lens-based pro-
captured by a sensor. In an ideal eye, the location cedure.
for all 256 rays is the fovea. However, lower- and
V. Identifying Candidates for Premium Lens
higher-order aberrations in various parts of the eye
will result in a wavefront error. A. Determining if significant corneal aberrations are
present
B. Is unlike Hartmann-Shack, which measures light
coming back out of the eye (This is not as physi- B. Measuring optical alignment (angle kappa and
ologic a measure as ray tracing.) angle alpha)
II. What Information Can Aberrometry Provide? VI. Toric IOL Check
A. Wavefront map of higher-order aberrations: coma, A. Quickly identifying toric IOL alignment
spherical aberration, trefoil
B. How much to rotate the lens?
B. Root mean square (RMS): Quantification of the
VII. As a Patient Education Tool
aberrations
Help patients visually understand their refractive error
C. Refractive maps
and benefits of correcting astigmatism at the time of
D. Point spread function cataract surgery
E. Snellen letter aberrations: Simulation of how the
letter “E” would look to a patient based on an Selected Readings
estimated mathematical derivation of higher-order 1. Castillo Gomez A, Verdejo del Rey A, Bautista CP, et al. Principles
aberration values and applications of ray-tracing aberrometry (part I). J Emmetro-
F. Internal optics aberration analysis: By subtracting pia. 2012; 3:96-110.
corneal aberrations from the total aberration data, 2. Castillo Gomez A, Verdejo del Rey A, Bautista CP, et al. Principles
it is possible to identify corneal vs. “other” aberra- and applications of ray-tracing aberrometry (part II). J Emmetro-
tions (typically from crystalline or artificial IOLs). pia. 2012; 3:157-165.
III. Troubleshooting the Unhappy Multifocal or Refrac- 3. Wakil JS, Padrick TD, Molebny S. The iTrace combination cor-
tive Surgery Patient neal topography and wavefront system by Tracey technologies. In:
Corneal Topography in the Wavefront Era. Thorofare, NJ: Slack,
A. Identifying the source of vision complaints: Inc.; 2006:177-188.
1. Blur / double vision: coma 4. Molebny VV, Panagopoulou SI, Molebny SV, Wakil YS, Pallikaris
IG. Principles of ray tracing aberrometry. J Refract Surg. 2000;
2. Glare / halo / night myopia: spherical aberration 16:S572-575.
3. Starburst: trefoil 5. Rozema JJ, Dirk EM, Van Dyck PhD, Tassignon MJ. Clinical
comparison of 6 aberrometers: Part I. Technical specifications. J
B. Wavefront maps can identify whether corneal or Cataract Refract Surg. 2005; 31:1114-1127.
“internal” aberrations are responsible.
6. Rozema JJ, Dirk EM, Van Dyck PhD, Tassignon MJ. Clinical
comparison of 6 aberrometers: Part II. Statistical comparison in a
test group. J Cataract Refract Surg. 2006; 32:33-44.
Corneal Imaging to Improve Surgical Outcomes

Mohamed Abou Shousha MD
Anterior segment OCT (AS-OCT) has become an essential 3. AS-OCT helps detect microperforation of the
diagnostic tool for the anterior segment specialist. It provides an Descemet membrane and double anterior cham-
in vivo optical biopsy of the cornea to guide the diagnosis and ber intraoperatively.
management of anterior segment pathologies.
4. AS-OCT helps avoid residual pathology intra-
I. AS-OCT for Corneal Surgery Planning operatively during DALK procedures.
A. Anterior lamellar keratoplasty: Femtosecond laser– B. Intraoperative OCT in Descemet membrane endo-
assisted lamellar keratoplasty (FALK)1 thelial keratoplasty and Descemet-stripping auto-
mated endothelial keratoplasty surgery (DSAEK):
1. Measure thickness of the corneal pathology
Confirm attachment of the graft intraoperatively.
using AS-OCT. If residual bed is more than
250 µm, then patient is a candidate for suture- III. AS-OCT for the Postoperative Evaluation of Corneal
less FALK. This is based on the literature on Surgeries
LASIK that suggested that around 250 µm of
A. To evaluate detachment of DSAEK grafts: We will
residual corneal bed is enough to prevent ectasia.
show a case with residual Descemet membrane
2. Program femtosecond laser machine to cut at rolled over in the interface, preventing the graft
the depth measured using the AS-OCT. from adhering to the back of the host cornea.
3. Cut both the donor and recipient using the same B. Evaluate visually significant interface opacities
settings.
C. Diagnosis of epithelial ingrowth3
4. Remove the recipient’s pathological corneal tis-
IV. The Future of AS-OCT
sue.
A. Corneal microlayer tomography
5. Replace it with the corneal donor lenticule.
B. OCT angiography of the anterior segment
6. Fit a bandage contact lens over the cornea.
B. Astigmatic keratotomy (AK) and limbal relaxing
References
incisions (LRI): Detect the depth of the cornea at
the location of the AK or LRI to decrease the risk 1. Shousha MA, Yoo SH, Kymionis GD, et al. Long-term results of
of perforation. femtosecond laser-assisted sutureless anterior lamellar kerato-
plasty. Ophthalmology 2011; 118(2):315-323.
C. Intrastromal corneal rings placement
2. Pasricha ND, Shieh C, Carrasco-Zevallos OM, et al. Needle
D. Excision of ocular surface tumors depth and big-bubble success in deep anterior lamellar kerato-
plasty: an ex vivo microscope-integrated OCT study. Cornea
II. Intraoperative OCT to Assist Corneal Surgery 2016; 35(11):1471-1477.
A novel technique that is evolving 3. Suh LH, Shousha MA, Ventura RU, et al. Epithelial ingrowth
after Descemet stripping automated endothelial keratoplasty:
A. DALK 2
description of cases and assessment with anterior segment optical
1. Real-time cross-sectional visualization of the coherence tomography. Cornea 2011; 30(5):528-534.
corneal layers during surgery without compro-
mising the view of the surgeon or the sterility of
the surgical field
2. AS-OCT helps to guide the depth of the needle
tip and air injection in big bubble technique, and
to confirm the absence of fluid and air in the
interface at the conclusion of surgery.
Tomography: How This Helps Me

Renato Ambrósio Jr MD
I. Key Points Technologies). Major advances in the development

of both topographic and tomographic algorithms
A. Refractive surgery has stimulated considerable
have occurred over the 2 decades since, especially
progress in corneal and anterior segment imaging
for the detection of keratoconus and other ectatic
and in optical characterization of the eye.
diseases.9-13
B. From front surface corneal topography, we evolved
D. The concept of segmental or layered evaluation
to 3-dimensional (3-D) corneal tomography with
of the corneal thickness was first introduced by
limbus-to-limbus characterization of the front and
Reinstein using digital very high frequency ultra-
back corneal surfaces and pachymetric mapping.
sound.14,15 More recently, the applications of OCT
C. Corneal anatomical evaluation has further evolved for allowing 3-dimensional visualization and
to layered or segmental tomography, with the analysis of different corneal layers became com-
ability to characterize the corneal epithelial thick- mercially available.16-18
ness profile and the elevation of the stromal front
III. Applications of Corneal Tomography
surface. Further characterization of even more
specific structures, such as the Bowman layer and A. Screening for ectasia risk prior to refractive surgery
Descemet membrane, have been also demonstrated.
1. The need to enhance sensitivity in detecting
D. There are many clinical applications of 3-D cor- mild or subclinical ectatic disease is also sup-
neal tomography and segmental or layered cor- ported by the reported cases of ectasia after
neal tomography for different corneal conditions LASIK without identifiable risk factors (clinical
beyond but including refractive srugery. example: see Figures 1 and 2).19,20
II. Introduction and History These cases, when a thick flap or excessive tissue
ablation are excluded, represent the closest to the
The continuous need to increase the safety and accu-
ideal population for the studies involving screen-
racy of refractive procedures has prompted evolution
ing for ectasia risk. In fact, the analysis of the
in corneal imaging, which in turn has impacted the
preoperative data from these cases has provided
management of many different corneal diseases.
the most important advances in the field.4,20-22
A. The quest to characterize corneal shape began in the
2. Corneal elevation data in maps depend on the
middle 1800s with Helmholtz and the keratometer,
reference surface chosen.23
or ophthalmometer, which was able to measure the
corneal curvature within 3 to 4 mm central area. a. The method of depicting the elevation is the
subtraction of the measured surface (either
B. The advent of Placido disc photokeratoscopy with
front or back) and a reference shape, which
subsequent development of color-coded maps to
is calculated to have the highest coincident
evaluate the anterior corneal surface represented a
points to a determined area of the cornea
major advance in the mid-1980s.1,2
that was analyzed. The best-fit sphere (BFS)
1. Placido disc–based corneal topography is sensi- to the 8-mm zone has been recommended, as
tive enough to detect abnormal front curvature it provides adequate data points without the
patterns of ectatic disease in patients with rela- need to use extrapolated data for the major-
tively normal distance corrected visual acuity ity of cases.13,24
and unremarkable biomicroscopy.3-5
b. The map pattern, the elevation values at
2. Corneal topography and central corneal thick- the thinnest point and those at maximum
ness have a recognized but limited role in the elevation within central 4-5 mm zone are
screening of refractive candidates.5 the most important characteristics for clini-
cal interpretation.13,24 Different reference
C. In the late 1990s, the ability to analyze both ante-
shapes, such as the best-fit toric and aspheric
rior and posterior corneal surfaces, along with the
ellipsoid (BFTA or BFTE), may be used.25
creation of a pachymetric map in a 3-dimensional
reconstruction of the cornea, became possible with i. Using the Pentacam, the cut-off criteria
corneal tomography devices.6 Horizontal slit scan- for the posterior elevation value at the
ning tomography was first introduced with the thinnest point using the BFS was 12 µm;
Orbscan (Bausch + Lomb),7 and later, rotational and using the BFTE, 8 µm—with respec-
scanning became accessible with the Pentacam tive sensitivity of 96.28% and 95.04%
(Oculus)8 and other technologies, such as the Gali- and specificity of 98.79% and 99.09% for
lei (Ziemer), the Sirius (CSO), and the Preciso (iVIS detecting keratoconus.13
Figure 1.
Figure 2.
ii. Using the Galilei Analyzer (Ziemer Oph- and specificity of 99.59% and 98.19% for
thalmic Systems AG; Port, Switzerland), keratoconus and 91.49% and 93.05% for
the cut-off values for maximum posterior FFKC. For ART-Max, 386 μm and 416 μm
elevation within the central 5-mm diam- were the cut-offs, with sensitivity and speci-
eter obtained by BFTA were 16 μm and ficity of 99.17% and 97.28% for keratoconus
13 μm for keratoconus and mild (forme and 85.11% and 93.05% for subclinical dis-
fruste) keratoconus (FFKC), respectively, ease, respectively.13
with sensitivities of 99% and 82%.25
B. The Pentacam Belin / Ambrósio Enhanced Ectasia
3. The concept of an enhanced elevation has been Display (BAD)
introduced by Belin and implemented on the
1. The BAD is a comprehensive display that com-
Pentacam.13,24 After calculating the standard
bines the standard and enhanced BFS elevation
BFS for the 8-mm corneal zone, a second,
maps of the front and back surfaces, and the
“enhanced” BFS for the same zone, excluding
thickness distribution data. Different tomo-
the 3.5-mm-diameter zone centered at the thin-
graphic parameters are presented as the stan-
nest point, is calculated. The difference map
dard deviation from normality toward disease
from the standard and enhanced BFS will exag-
(d values): anterior and posterior elevation at
gerate any differences (protrusions) within the
the TP (8-mm BFS), change in anterior and pos-
excluded zone. More than 5 μm of difference for
terior elevation of the standard and enhanced
the front elevation and 12 μm difference for the
BFS, thinnest value and location, PPI, ART and
back elevation are considered suspicious.13,24,26
maximal curvature (Kmax). The BAD-D final
Changes in posterior corneal elevation have been
parameter is calculated based on a regression
studied to document long-term stability after
analysis to maximize accuracy for detecting
LASIK, so that using the same BFS for the pre-
ectatic disease.13,24,26,29
operative corneal information, less than 7 µm
on the maximal difference in the central 4.0-mm 2. BAD-D higher than 2.11 was a criterion with
zone was found on stable LASIK cases.27 sensitivity and specificity of 99.59% and 100%
for diagnosing keratoconus, while for detecting
4. Corneal thickness maps enable the characteriza-
mild or subclinical disease, the criteria of higher
tion of the thinnest point (TP) value and its loca-
than 1.22 provided 93.62% sensitivity and
tion, along with thickness distribution.13,24,26
94.56% specificity.13
The TP is a more accurate parameter than
central thickness for screening ectatic corneal a. BAD-D (v3) values turn yellow in the display
diseases,13,24,26,28 as well as for calculating the when higher than 1.6.
PTA and residual stromal bed (RSB).4,26
b. Novel series studies demonstrate lower sen-
5. In the Pentacam, thickness distribution is sitivity for detecting abnormality among the
described as the average of thickness values normal topography eyes from VAE cases.
in concentric annular circles with increasing
i. This determines the need to further
diameters centered on the TP. These values are
improve the artificial intelligence method
presented in the corneal thickness spatial profile
for identifying ectasia susceptibility, and
(CTSP) and the percentage of thickness increase
even the need to further integrate novel
(PTI) graphs, which also contain reference data
data such as from segmental tomography
(mean and 95% confidence intervals) from a
(ie, epithelial thickness data) and corneal
normal population.13,24,26
biomechanics.
The pachymetric progression index (PPI) is cal-
ii. In a retrospective, nonrandomized study
culated for every 1 degree of meridians of the
involving preoperative LASIK data from
cornea, starting from the TP outward.
an international pool comprised of 23
a. This calculation considers the increase in post-LASIK ectasia cases and from 266
thickness, comparing to the TP at each point stable-LASIK cases with over 1 year of
of the cornea, referencing to a normal popu- follow-up, the criteria of BAD-D higher
lation. than 1.29 provided 87% sensitivity and
92.1% specificity.22 Even though the
b. Ambrósio’s relational thickness (ART) val-
BAD-D was the most accurate parameter
ues are calculated as the ratios of the TP and
in predicting ectasia risk, the data suggest
the average of the PPI at all meridians (ART-
room for further improvement.
Ave) and the meridian with maximal PPI
(ART-Max).13,26 See “Thin or thinned, thick C. Other applications
or thickened: should we care?”
1. Planning surface ablation with laser photothera-
www.youtube.com/watch?v=LhmBHYsLtjs
peutic keratectomy eptithelial scrape
c. The cut-off criteria for ART-Ave for clinical
2. Postoperative understanding of outcomes
and mild (FFKC) keratoconus were, respec-
tively, 474 μm and 521 μm, with sensitivity 3. Planning therapeutic corneal procedures
IV. Conclusions 14. Reinstein DZ, Silverman RH, Rondeau MJ, Coleman DJ. Epithe-
lial and corneal thickness measurements by high-frequency ultra-
A. Knowledge of corneal tomography and segmental sound digital signal processing. Ophthalmology 1994; 101:140-
tomography with epithelial profile represents a 146.
major advance in the anatomical and optical char-
15. Reinstein DZ, Silverman RH, Trokel SL, Allemann N, Coleman
acterization of the eye.
DJ. High-frequency ultrasound digital signal processing for bio
B. Such understanding is fundamental in enabling metry of the cornea in planning phototherapeutic keratectomy.
better results in therapeutic procedures for irregu- Arch Ophthalmol. 1993; 111:430-431.
lar corneas, including cases that had complications 16. Li Y, Tan O, Brass R, Weiss JL, Huang D. Corneal epithelial
related to corneal refractive surgery. While this thickness mapping by Fourier-domain optical coherence tomo
approach does augment confidence in refractive graphy in normal and keratoconic eyes. Ophthalmology 2012;
procedures, there is also a major impact on corneal 119:2425-2433.
diseases, such as corneal ectasia. 17. Li Y, Chamberlain W, Tan O, Brass R, Weiss JL, Huang D. Sub-
clinical keratoconus detection by pattern analysis of corneal and
epithelial thickness maps with optical coherence tomography. J
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1. Wilson SE, Ambrosio R. Computerized corneal topography and
18. Salomao MQ, Hofling-Lima AL, Lopes BT, et al. Role of the cor-
its importance to wavefront technology. Cornea 2001; 20:441-
neal epithelium measurements in keratorefractive surgery. Curr
454.
Opin Ophthalmol. 2017; 28:326-336.
2. Klyce SD. Computer-assisted corneal topography: high-resolution
19. Ambrosio R Jr, Dawson DG, Salomao M, Guerra FP, Caiado AL,
graphic presentation and analysis of keratoscopy. Invest Ophthal-
Belin MW. Corneal ectasia after LASIK despite low preoperative
mol Vis Sci. 1984; 25:1426-1435.
risk: tomographic and biomechanical findings in the unoperated,
3. Binder PS, Lindstrom RL, Stulting RD, et al. Keratoconus and stable, fellow eye. J Refract Surg. 2010; 26:906-911.
corneal ectasia after LASIK. J Refract Surg. 2005; 21:749-752.
20. Buhren J, Schaffeler T, Kohnen T. Preoperative topographic char-
4. Ambrosio R Jr, Randleman JB. Screening for ectasia risk: what acteristics of eyes that developed postoperative LASIK keratecta-
are we screening for and how should we screen for it? J Refract sia. J Refract Surg. 2013; 29:540-549.
Surg. 2013; 29:230-232.
21. Randleman JB, Trattler WB, Stulting RD. Validation of the Ecta-
5. Ambrosio R Jr, Klyce SD, Wilson SE. Corneal topographic and sia Risk Score System for preoperative laser in situ keratomileusis
pachymetric screening of keratorefractive patients. J Refract Surg. screening. Am J Ophthalmol. 2008; 145:813-818.
2003; 19:24-29.
22. Ambrósio Jr R, Ramos I, Lopes B, et al. Assessing ectasia suscep-
6. Ambrosio R Jr, Belin MW. Imaging of the cornea: topography vs tibility prior to LASIK: the role of age and residual stromal bed
tomography. J Refract Surg. 2010; 26:847-849. (RSB) in conjunction to Belin-Ambrósio deviation index (BAD-D).
Rev Bras Oftalmol. 2014; 73:75-80.
7. Cairns G, McGhee CN. Orbscan computerized topography:
attributes, applications, and limitations. J Cataract Refract Surg. 23. Belin MW, Khachikian SS. An introduction to understanding
2005; 31:205-220. elevation-based topography: how elevation data are displayed—a
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8. Quisling S, Sjoberg S, Zimmerman B, Goins K, Sutphin J. Com-
parison of Pentacam and Orbscan IIz on posterior curvature 24. Belin MW, Ambrosio R. Scheimpflug imaging for keratoconus
topography measurements in keratoconus eyes. Ophthalmology and ectatic disease. Indian J Ophthalmol. 2013; 61:401-406.
2006; 113:1629-1632.
25. Smadja D, Santhiago MR, Mello GR, Krueger RR, Colin J,
9. Wilson SE, Lin DT, Klyce SD. Corneal topography of keratoco- Touboul D. Influence of the reference surface shape for discrimi-
nus. Cornea 1991; 10:2-8. nating between normal corneas, subclinical keratoconus, and
keratoconus. J Refract Surg. 2013; 29:274-281.
10. Maeda N, Klyce SD, Smolek MK, Thompson HW. Automated
keratoconus screening with corneal topography analysis. Invest 26. Ambrosio R Jr, Nogueira LP, Caldas DL, et al. Evaluation of cor-
Ophthalmol Vis Sci. 1994; 35:2749-2757. neal shape and biomechanics before LASIK. Int Ophthalmol Clin.
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11. Ambrosio R Jr, Caiado AL, Guerra FP, et al. Novel pachymetric
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conus. J Refract Surg. 2011; 27:753-758. stability of the posterior cornea after laser in situ keratomileusis. J
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12. Ambrosio R Jr, Alonso RS, Luz A, Coca Velarde LG. Corneal-
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thalmol. 2013; 24:310-320. Detection of ectatic corneal diseases based on Pentacam. Z Med
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Do We Need an Intraoperative OCT?

Francis W Price Jr MD
Does one need an intraoperative OCT (iOCT)? It depends, DSEK for eyes with significant corneal and anterior segment
and it depends on the type of cases one does. In my experience, abnormalities. These eyes often have problems that make graft
iOCT definitely makes a significant difference for lamellar adherence challenging. Determining whether residual fluid is in
corneal surgery and intracorneal lens sizing. It may also have the graft interface can direct the surgeon to use either milking
potential for minimally invasive glaucoma surgery (MIGS) in maneuvers or drainage incisions. On the other hand, if no inter-
evaluating placement of implants like the XEN. face fluid is present, additional treatment is not needed. With
iOCT helps improve the safety and efficiency of Descemet both DSEK and DMEK, iOCT can help identify areas of scar
membrane endothelial keratoplasty (DMEK) surgery by tissue or synechia that might interfere with graft positioning
allowing evaluation of graft orientation while the graft is only and adherence.
partially uncurled. (Typically with the variety of different In deep anterior lamellar keratoplasty (DALK), a number
marking techniques, the graft has to be unfolded most of the of reports have shown the advantage of iOCT in positioning
way to determine if the endothelium is facing the iris.) iOCT the needle close to the Descemet membrane to improve big
even allows one to determine the orientation in younger, tightly bubble formation. I find the most significant advantage to be in
curled donor grafts when there is no separation between the determining the depth and uniformity of a manual dissection.
two tightly curled scrolls. Even with thickened, edematous, and With iOCT one can evaluate the quality of the dissection plane
hazy corneas, one can not only see the orientation of the graft to make sure the residual stroma is of uniform thickness; this
but also detect subtle problems that might prevent the graft cannot be accomplished with the coaxial view of the operating
from either completely unfolding or being positioned / centered microscope.
in the anterior chamber. Just as the operating microscope allows With intracorneal lens surgery, it can be difficult to deter-
us to see surgery more clearly because of the magnification, mine the exact sizing and vault of the implant. One can improve
iOCT allows us to see another dimension of the tissues: con- the final vault in the second eye by evaluating the vault of the
tours of both the donor and recipient that we cannot discern first eye. iOCT allows us to evaluate the vault in the first eye
with the coaxial view of operating microscopes. so the second eye can be more accurately treated the same day,
In Descemet-stripping endothelial keratoplasty (DSEK) sur- rather than splitting the surgery into two sessions and using in-
gery, iOCT allows us to see if the graft is actually in apposition office OCT to evaluate the vault in the first eye.
to the recipient cornea. In our practice we primarily reserve
Case: Imaging Saved the Day

Sadeer B Hannush MD
Perioperative imaging has changed the landscape of anterior 2. An 84-year-old gentleman with Fuchs dystrophy under-
segment surgery in recent years. Optical biometry, Placido- went successful Descemet membrane (DM) endothelial
based and elevation topography, aberrometry, specular and keratoplasty with marked clearing of his cornea and
confocal microscopy, and optical coherence tomography have improvement in his vision. Three months postoperatively
empowered the ophthalmic surgeon to make more accurate he presented with decreased vision and corneal edema
diagnoses and achieve better surgical results than the same in the same eye. He was advised that his graft had failed
surgeon was able to make just a short decade ago. On occasion, and that he needed regrafting. Anterior segment OCT
imaging can change the therapeutic approach so significantly revealed a very shallow DM detachment that was not
that it can save the day! We illustrate 2 such cases: detectable on slitlamp examination. Rebubbling (air des-
cemetopexy) reattached the DM with complete clearing
1. A 72-year-old woman with corneal edema was referred
of the cornea despite a low endothelial cell count.
for endothelial keratoplasty. She had a well-positioned
posterior chamber IOL and a limited view of the poste-
rior pole. OCT of the macula revealed marked cystoid
macular edema (CME). Medical treatment of the CME
improved the vision so significantly that the patient
elected to delay corneal surgery.
36 Section V: Keratoconus, A Steep Learning Curve 2017 Subspecialty Day | Cornea
How to Diagnose Keratoconus:

Tried and True vs. New View
Michael W Belin MD
As medicine has moved from treating advanced disease to pre-

venting disease and its sequalae, the treatment of keratoconus
and the prevention of ectatic disease have undergone a major
change. In the past, treatments were aimed at restoring vision
after visual loss, which typically occurs when there is significant
anterior corneal surface change to degrade vision. Treatments to
slow or prevent progression were not available, and so diagnos-
ing early disease in asymptomatic individuals was not important.
Two major changes have occurred that not only mandate
our ability to diagnose clinically evident disease but dictate that
we identify individuals in the early stage of disease (subclinical
keratoconus), and even patients who appear normal by all imag-
ing but who may be at risk for ectasia if subjected to corneal
stress (ie, refractive surgery). Concomitant with this increased
need has been a dramatic improvement in our corneal imaging
ability.
In the past, corneal diagnostic imaging was limited to ante-
rior surface curvature analysis. As visual loss almost always Figure 2.
parallels anterior change, this sufficed when our treatments
were limited to patients with significant visual loss. However, as Collagen corneal crosslinking (CXL) is another area where
noted above, the diagnosis of early (subclinical) disease is pos- full tomographic imaging has great potential advantages over
sible only with full tomographic imaging. Tomographic imaging anterior surface analysis. While CXL is currently used to slow
(available from different technologies, Scheimpflug and OCT or halt progression of symptomatic disease (ie, after visual loss),
being the most common) allows a 3-dimensional reconstruction the greatest potential benefit would be the ability to identify
of the anterior segment and measurement of both the anterior patients who show documented progression prior to visual loss.
and posterior corneal surfaces. Changes on the posterior cornea The example in Figure 3 is from a patient thought to have a non-
almost always predate anterior surface changes. These patients progressive disease followed over a 3.5-year period. After 3.5
have true disease, but they remain asymptomatic. They exhibit years, anterior surface changes resulted in mild visual loss, but
posterior ectasia, typically an abnormally displaced thinnest tomographic analysis would have identified significant change
point and abnormal pachymetric progression. 1.5 years earlier, prior to a loss of vision.
Figure 3.
Figure 1.
Corneal tomography (the “New View”) offers significant
advantages over older anterior curvature analysis. The phrase
These patients also present for refractive surgery evaluation
“Tried and True” may be more appropriately applied to this
and, while appearing normal on older technologies (anterior
technology.
curvature and central pachymetry), need to be excluded from
refractive surgery due to the high risk of ectatic progres-
sion. One tomographic screening program (Belin / Ambrósio
Enhanced Ectasia Display) demonstrates such a patient. There
are numerous abnormalities in this highly abnormal eye, in spite
of a normal anterior surface (see Figure 2).
2017 Subspecialty Day | Cornea Section V: Keratoconus, A Steep Learning Curve 37
Contact Lenses in Keratoconus:

What Options Do We Have Now?
Deborah S Jacobs MD
I. Contact Lens Use for Keratoconus / Ectasia Involves IV. New Paradigm for Contact Lens in Keratoconus
“Specialty Contact Lenses.”
A. Not a “contact lens failure” without trial of spe-
A. A “new” field within U.S. optometry cialty lenses
B. Offered by MDs or ODs globally, depending on B. New designs / materials more comfortable, physi-
national scope of practice / credentialing ologic
C. Specialty contact lens is a growth area in the global 1. Si-Hy RGP hybrid
contact lens industry.
2. Si-Hy keratoconus designs
II. Specialty Lenses
3. RGP sclerals / PROSE treatment: Increased
A. RGP corneal lenses, keratoconus designs expertise among specialty fitters
B. Piggyback systems C. Penetrating or lamellar keratoplasty only for axial
opacity limiting vision, assessed in specialty lens
C. Silicone-hydrogel (Si-Hy) lenses, keratoconus
designs D. No regraft for cylinder or recurrence of ectasia
without trial of specialty lens
D. Hybrid lenses
E. Mini scleral lenses
Selected Readings
F. Scleral lenses 1. Abdalla YF, Elsahn AF, Hammersmith KM, Cohen EJ. Synerg-
G. PROSE treatment (prosthetic replacement of the Eyes lenses for keratoconus. Cornea 2010; 29:5-8.
ocular surface ecosystem) 2. Baran I, Bradley JA, Alipour F, Rosenthal P, Le HG, Jacobs DS.
PROSE treatment of corneal ectasia. Cont Lens Anterior Eye.
III. Pearls
2012; 35:222-227.
A. New Si-Hy lenses with keratoconus designs have 3. DeLoss KS, Fatteh NH, Hood CT. Prosthetic replacement of the
extended the use of soft lenses in keratoconus. ocular surface ecosystem (PROSE) scleral device compared to ker-
B. New hybrid materials and designs address past fail- atoplasty for the treatment of corneal ectasia. Am J Ophthalmol.
2014; 158:974-82.
ures from lens fragility and hypoxia.
4. Fernandez Velazquez FJ. Kerasoft IC compared to Rose-K in the
C. Scleral lenses are in the repertoire of an increasing management of corneal ectasias. Cont Lens Anterior Eye. 2012;
number of specialty lens fitters. 35:175-179.
D. Scleral lenses are a useful option in cases of RGP 5. Schornack MM. Scleral lenses: a literature review. Eye Contact
corneal lens failure due to instability or tight lens Lens. 2015; 41(1):3-11
syndrome. 6. Schornack MM, Patel SV. Scleral lenses in the management of
E. The definition of scleral lenses is evolving. “Mini- keratoconus. Eye Contact Lens. 2010; 36(1):39-44.
scleral,” corneoscleral, and intralimbal lenses may 7. Ucakhan OO, Bayraktutar B. KeraSoft 3 contact lenses in corneal
not perform as well as scleral lenses. ectasia. Eye Contact Lens. 2014; 40:390-394.
F. PROSE treatment is a good option for contact lens 8. Van der Worp E, Bornman D, Ferreira DL, Faria-Ribeiro M,
and even scleral lens failures and can accommodate Garcia-Porta N, González-Meijome JM. Modern scleral contact
any cone. lenses: a review. Cont Lens Anterior Eye. 2014; 37(4):240-250.
G. PROSE treatment has favorable 1-year outcome in

comparison to keratoplasty for moderate to severe
keratoconus.
Deep Anterior Lamellar Keratoplasty vs.

Penetrating Keratoplasty: Is One Clearly Better?
W Barry Lee MD
I. Keratoplasty Trends in the United States B. Methods

II. Deep Anterior Lamellar Keratoplasty (DALK) 1. Corneas randomly assigned from:
Indications
a. Donors ≥ 66 years old
A. Central corneal scar
b. Donors < 66 years old
1. Previous infection
2. 1101 subjects enrolled 1/00 – 0
2. Previous trauma
VII. Endothelial Cell Density Over 5 Years by Donor Age
B. Anterior corneal dystrophy
VIII. Deep Anterior Lamellar Keratoplasty
C. Stromal corneal dystrophy
A. Advantages over PK
D. Keratoconus and ectasia
1. Retains host endothelium
III. DALK Techniques
a. Eliminates endothelial rejection
A. Manual dissection
b. Reduces endothelial cell loss over time
B. Microkeratome-assisted DALK
c. Prolongs graft survival
C. Anwar’s big bubble DALK
2. Eye bank issues
D. Femtosecond laser-assisted DALK
a. Do not need excellent endothelium
IV. DALK vs. PK
b. Saves good endothelial donors for EK
A. Complications of penetrating keratoplasty
3. Avoids open sky
B. Risk of intraocular complications
4. Decreased incidence of intraocular complica-
C. High astigmatism tions
D. Poor wound healing a. Glaucoma
1. Delayed vision return b. Cataract
2. Risk of rupture c. Retinal detachment
E. Endothelial cell loss d. Cystoid macular edema
F. Endothelial rejection e. Endophthalmitis
V. Penetration Keratoplasty Rejection f. Expulsive hemorrhage
A. Endothelial rejection (ER) 5. Stronger corneal wound
B. Incidence 6. Sutures can be removed sooner.
1. ~25% of all PKs undergo ER. 7. Shorter duration of topical steroid
2. ~5%-10% of all grafts fail from ER. B. Disadvantages
C. Significance 1. Longer surgical time
1. Endothelial cell damage 2. Technically more difficult
2. Graft failure 3. Visual outcome
3. High risk for regraft a. Interface haze can limit vision
VI. Cornea Donor Study b. More residual recipient stroma = increased
risk of haze; bare DM = better vision
A. Purpose
To determine whether donor age is associated with
corneal transplant success
IX. DALK Postoperative Complications XI. DALK vs. PK Rejection

A. Epithelial healing A. DALK vs. PK (corneal scarring or dystrophy) →
similar visual and refractive outcomes of 56 eyes
B. Suture-related complications
B. PK group: More endothelial cell loss, more rejec-
1. Suture erosion
tion episodes
2. Suture dehiscence
C. DALK group: No endothelial rejections
3. Suture infiltrate
XII. DALK Survival
C. Graft-host disparity
A. Retrospective study of 660 consecutive DALK pro-
D. Astigmatism cedures conducted on 502 patients
E. Interface haze B. Mean follow-up: 4.5 years
F. Rejection C. Average graft survival rate: 99.3% (rang: 98.5%-
100%)
1. Subepithelial
D. Indications
2. No endothelial rejection
1. Keratoconus (74%)
G. Mild endothelial cell loss
2. Post-herpetic keratitis scarring (15%)
H. Double anterior chamber
3. Corneal stromal opacities (11%)
X. DALK vs. PK
E. Endothelial loss averaged 11%.
A. Comparative case series of 30 keratoconus eyes
that underwent DALK vs. PK → similar visual out- ECD was unchanged between 6 months postopera-
comes tively and the last follow-up visits.
1. PK group: More postop astigmatism, endothe- XIII. Conclusions
lial cell loss, rejection episodes
A. DALK is technically challenging to learn but can be
2. DALK group: Shorter time to suture removal mastered with time.
3. DALK vs. PK graft survival: Kaplan-Meier B. DALK and PK have similar visual outcomes.
rejection-free survival curves showing DALK
C. DALK and PK have similar astigmatism outcomes.
with fewer rejections
D. DALK avoids endothelial rejection and expulsive
B. Randomized controlled trial of 76 keratoconus eyes
choroidal hemorrhage, and shows less endothelial
that underwent DALK vs. PK
cell loss.
1. DALK eyes recovered faster vision; topography,
E. DALK may have stronger tectonic support, less risk
spherical equivalent, and final visual outcomes
of IOP spikes and quicker vision recovery.
were not different.
2. DALK eyes showed less rejection and fewer IOP
spikes.
F. Rejection comparison: PK / DALK
1. Randomized comparative clinical trial: 77
keratoconus eyes that underwent DALK vs. PK
→ similar visual and refractive outcomes
2. PK group: Longer duration on steroids, more
rejection episodes
3. DALK group: No endothelial rejections, earlier
suture removal
Considerations Concerning Corneal

Collagen Crosslinking
Corneal CXL Bibliography
William J Dupps MD PhD, David Glasser MD
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5. Greenstein SA. J Cataract Refract Surg. 2011; 37:1282. Topo-guided PRK plus CXL, LASIK plus CXL
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7. Hafezi F. J Cataract Refract Surg. 2007; 33:2035. 2. Kanellopoulous AJ. J Refract Surg. 2009; 25:S812.
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11. Hersh PS. Ophthalmology. In press. 6. Li N. Int J Ophthalmol. 2014; 7:157.
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Complications
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CXL for Infectious Keratitis
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Tearing Up the Old Paradigm for

Management of Acute Hydrops
Mazen Y Choulakian MD
Introduction 0.2 mL of isoexpansile perfluorocarbon, such as 14% C3F8 or

20% SF6, is used to improve reapposition of the torn Descemet
Acute hydrops is a relatively rare condition, occurring in 2.6%-
to the posterior stroma. This helps close the cleft and promote
2.8% of patients diagnosed with keratoconus. There is a male
resolution of the corneal edema. Clinical resolution of edema
preponderance, and mean age of onset is 25.1 The pathogenesis
in these patients is significantly faster than in patients treated
of acute hydrops is the following: a break in Descemet mem-
solely with a medical approach.3 However, complications from
brane and endothelium is followed by aqueous humour entering
surgical management have been described: pupillary block,
the cornea, causing marked stromal and epithelial edema. Typi-
cataract formation, and persistent mydriasis. With anterior
cally, the edema resolves progressively within 2-4 months, often
segment imaging, either anterior segment OCT or ultrasound
leaving a visually significant scar in the central or paracentral
biomicroscopy, one can measure the size of the Descemet tear. If
cornea.2 Stromal neovascularization can also be present when
the tear is of appropriate size, injection of intracameral gas may
edema persists; this may further complicate patient manage-
be indicated. In cases where the tear is too large or too deep, the
ment.
gas may in fact impede recovery.4 Pre-Descemet compression
sutures placed perpendicular to the tear may also speed up reso-
Conservative Management lution of stromal edema.5 Finally, there are reported cases of
progressive Descemet tears that have been managed with endo-
Observation is a possible option since corneal edema is typically
thelial keratoplasty to close the gap from the hydrops.6 These
self-limiting. To help with patient comfort, use of lubrication
novel therapies, from intracameral gas injection to compression
is recommended. This approach should mostly be considered if
sutures to endothelial keratoplasty, may become the mainstays
the break in Descemet membrane is small and corneal edema is
in treatment for patients with acute hydrops in the future.
mild. Some physicians recommend using a therapeutic contact
lens; however, fitting can be difficult in cases of steeper corneas.
References
Medical Management 1. Tuft SJ, Gregory WM, Buckley RJ. Acute corneal hydrops in kera-
toconus. Ophthalmology 1994; 101(10):1738-1744.
Most ophthalmologists tend to use a combination of hypertonic
2. Fan Gaskin JC, Patel DV, McGhee CN. Acute corneal hydrops
saline drops, topical corticosteroids, cycloplegics, and hypoten-
in keratoconus—new perspectives. Am J Ophthalmol. 2014;
sives. The hypertonic saline drops cause an osmotic effect on the 157:921-928.
ocular surface to decrease epithelial and stromal edema. Topical
corticosteroids, such as prednisolone acetate 1%, are often pre- 3. Basu S, Vaddavalli PK, Ramappa M, Shah S, Murthy SI, Sangwan
scribed to reduce the inflammatory component of acute hydrops VS. Intracameral perfluoropropane gas in the treatment of acute
corneal hydrops. Ophthalmology 2011; 118(5):934-939.
and to help decrease progression of stromal neovascularization.
Moreover, topical cycloplegics are used to decrease pain. Topi- 4. Basu S, Vaddavalli PK, Vemuganti GK, Ali MH, Murthy SI.
cal hypotensives that decrease aqueous fluid production, such as Anterior segment optical coherence tomography features of acute
timolol maleate 0.5%, reduce aqueous egress in the stroma. corneal hydrops. Cornea 2012; 31(5):479-485.
5. Yahia Chérif H, Gueudry J, Afriat M, Delcampe A, Attal P, Gross
H, Muraine M. Efficacy and safety of pre-Descemet’s membrane
Surgical Management
sutures for the management of acute corneal hydrops in keratoco-
In recent years, surgical treatment of acute hydrops has been nus. Br J Ophthalmol. 2015; 99(6):773-777.
advocated to hasten resolution of corneal edema and to decrease 6. Palioura S, Chodosh J, Pineda R. A novel approach to the manage-
risk and/or progression of stromal neovascularization. Injection ment of a progressive Descemet membrane tear in a patient with
of intracameral gas, pre-Descemetic compression sutures, and keratoglobus and acute hydrops. Cornea 2013; 32(3):355-358.
keratoplasty have all been reported. Intracameral injection of
Case: A Corneal Conundrum

Elmer Y Tu MD
NOTES
44 Section VI: Inflammatory Conditions of the Anterior Segment 2017 Subspecialty Day | Cornea
Point-of-Care Testing for Dry Eyes:

Tears of Joy, or Tears from the Expense?
Anat Galor MD
I. What Is Dry Eye (DE)? IV. What Can These Tests Tell Us about DE?
A. Symptoms A. Underlying pathophysiology
B. Signs B. Predicting outcome
II. What Are Mechanisms Underlying DE? V. Information / Cost Analysis
A. Inflammation VI. What Can We Expect in the Future?
B. Nerve dysfunction
III. What Point-of-Care Testing Is Available for DE
(Including Cost)?
A. Osmolarity testing (TearLab)
B. MMP9 (Quidel)
C. Immunoglobulin E and lactoferrin (Advanced Tear
Diagnostics)
2017 Subspecialty Day | Cornea Section VI: Inflammatory Conditions of the Anterior Segment 45
Scratching the Old: What’s New

in Allergic Conjunctivitis?
Deepinder K Dhaliwal MD and Aimee Verner MD
Background zine, fexofenadine, loratadine etc. cause significant ocular dry-

ness. This can be problematic, especially if perioperative (prior
Allergic conjunctivitis is an extremely common condition, with
to laser vision correction or cataract surgery). Our protocol for
global prevalence of 40% and U.S. prevalence of approximately
treating ocular allergy patients is to stop oral antihistamines
20%1 (approximately 60 million Americans). Allergic conjuncti-
and instead treat the allergy locally with drops, nasal spray, or
vitis causes a significant reduction in quality of life.2 Treatment
inhaler. Also, the antileukotriene montelukast Singulair can be
needs to have a rapid onset of action and an extended duration
a helpful adjunct to treating allergy systemically without the
of action and should cause minimal side effects, since ocular
ocular drying effects.
allergy can be recurrent and chronic.
In patients preparing for surgery, it is not advisable to simply
The main symptom of allergic conjunctivitis is itching. If the
stop the oral antihistamine to avoid the ocular drying effects
patient does not complain of itching, rethink the diagnosis of
since untreated ocular allergy can cause severe corneal haze
ocular allergy. Additional symptoms may include tearing, burn-
with PRK and increased diffuse lamellar keratitis with LASIK.
ing, and foreign body sensation. Signs of allergic conjunctivitis
include tearing, conjunctival and eyelid hyperemia, chemosis,
and eyelid swelling. Treatment Options
The basic pathophysiology of the main forms of allergic ■■ Old: first-generation antihistamine with vasoconstrictor
conjunctivitis is a type 1 hypersensitivity reaction that involves ●● Problem: Short duration of action (q.i.d. dosing neces-
sensitization of the immune system upon first exposure of the
sary), tachyphylaxis, rebound effect
antigen. After repeated exposure, the antigen-specific IgE binds ●● Examples: pheniramine maleate + naphazoline (Naph-
to mast cells in the conjunctiva, triggering their degranulation.
con-A, Visine-A, Opcon-A)
Released from the mast cell are histamine, tryptase, chymase, ■■ Mast cell stabilizer
heparin, chondroitin sulfate, prostaglandins, thrombox- ●● Problem: Ineffective in relieving existing signs and
anes, and leukotrienes. This is the acute phase of the allergic
symptoms of ocular allergy, need to start prior to
response.
allergy symptoms
●● Examples: cromolyn sodium, lodoxomide trometh-
Histamine
amine, pemirolast potassiurelem, nedocromil sodium
■■ binds to H1 receptors on nerve endings and causes itching
■■ Antihistamine plus mast cell stabilizer
■■ binds to H1 and H2 receptors on conjunctival vessels and
●● Excellent first-line therapy due to rapid onset of action
causes vasodilation
and prolonged effect
●● Examples: olopatadine HCl (Patanol), ketotifen fuma-
Non-Vision Threatening Ocular Allergy (>90% of rate (Zaditor, Alaway), azelastine HCl (Optivar), epi-
cases) nastine HCl (Elestat), bepotastine (Bepreve)
■■ Topical steroids: loteprednol etabonate (Alrex and
■■ Seasonal allergic conjunctivitis (SAC): Caused by air-
Lotemax)
borne pollens from trees, grass, and weeds. Symptoms ■■ Nonsedating oral antihistamines
are episodic and can occur in spring, summer, or fall ■■ Immunotherapy: Allergy shots (subcutaneous immuno-
(depending on exact etiology).
therapy [SCIT])
■■ Perennial allergic conjunctivitis (PAC): Caused by mold, ■■ Nonpharmacologic
dust mites, cockroaches, animal dander (chronic expo- ●● Education is very important.
sure) ●● Allergy testing to figure out the cause of allergy
●● Allergen avoidance, avoid being outdoors during high
Vision-Threatening Ocular Allergy (small pollen days. Sunglasses can provide a barrier.
percentage of cases) ●● No eye rubbing because eye rubbing degranulates
mast cells → makes itching worse, creates vicious

■■ Vernal keratoconjunctivitis (VKC): Found in young boys
cycle.
in equatorial regions of the world ●● Ice cold compresses (stops itch), art tears (dilutes aller-
■■ Atopic keratoconjunctivitis (AKC): Ages 20-50, history of
gen). Avoid punctal plugs.
atopic dermatitis (eczema) as child ●● Wash hair, change clothes as soon as enter house. No
The majority of allergy patients have nasal symptoms (aller- animals sleeping in bed (if allergic).
gic rhinitis) in addition to conjunctivitis. Allergy can also affect ●● If dustmite allergy: Hypoallergenic bedding, wash
the mucous membranes in the airway and cause more throat sheets in hot water. Put pillows in dryer on high heat.
itching, as well as asthma. Treatment should be directed to the
site of allergy. Oral nonsedating antihistamines such as cetiri-
New Therapies References

■■ Sublingual immunotherapy (SLIT), in which a tablet is 1. Azari AA, Barney NP. Conjunctivitis: a systematic review of diag-
placed under the tongue daily nosis and treatment. Clin Rev Educ. 2013; 310(16):1-4.
■■ 4 FDA approved products: Oralair (5 kinds of northern 2. Pitt AD, Smith AF, Lindsell L, Voon LW, Rose PW, Bron AJ. Eco-
grass pollen), Grastek (timothy grass pollen), Ragwitek nomic and quality-of-life impact of seasonal allergic conjunctivitis
(short ragweed), and Odactra (house dust mites) in Oxfordshire. Ophthalmic Epidemiol. 2004; 11:17e33.
■■ Topical cetirizine 3. Fukuda K, Ishida W, Harada Y, et al. Efficacy of oral immuno-
■■ Newer targets to block inflammatory cascade: spleen therapy with a rice-based edible vaccine containing hypoallergenic
tyrosine kinase (Syk), aldehyde-trap, toll-like receptor 2 Japanese cedar pollen allergens for treatment of established aller-
■■ New application of existing drug: tacrolimus gic conjunctivitis in mice. Allergol Int. Epub ahead of print 2017
■■ Oral administration of staple foods engineered to express Jul 1. doi: 10.1016/j.alit.2017.06.006.
allergens for oral immunotherapy (transgenic rice seeds
that express cedar pollen)
Stevens-Johnson Syndrome: A Chronic Problem

Wuqaas M Munir MD
I. Background C. Functional deficits and effect on activities of daily

living
A. Classification and overlap of Stevens-Johnson
syndrome (SJS) and toxic epidermal necrolysis D. Chronic ocular therapy
(TEN)
1. Role of systemic therapies
B. Pathogenesis and differential diagnosis of severe
2. Topical supportive therapy
immunologic dermatobullous conditions
a. Lubrication
C. Incidence and associations of SJS/TEN with
ocular involvement b. Autologous serum
II. Acute SJS/TEN c. Topical immunotherapy
A. Systemic manifestations d. Scleral contact lenses
B. Ocular manifestations and key examination find- 3. Surgical therapy
ings
a. Punctal occlusion
1. Inflammation and epithelial sloughing
b. Tarsorraphy
2. Membrane formation
c. Amniotic membrane transplantation
3. Symblepharon
d. Epithelial or stem cell transplantation
4. Corneal complications
e. Fornix reconstruction
C. Acute ocular therapy
f. Keratoplasty
1. Role of systemic therapies (limited)
g. Keratoprosthesis
2. Topical supportive therapy
3. Topical immunotherapy Selected Readings
4. Surgical therapy 1. Saeed HN, Chodosh J. Ocular manifestations of Stevens-Johnson
syndrome and their management. Curr Opin Ophthalmol. 2016;
a. Amniotic membrane transplantation: 27:522-529.
Techniques
2. Rojas MVD, Dart JKG, Saw VPJ. The natural history of Stevens-
b. Membrane lysis Johnson syndrome: patterns of chronic ocular disease and the role
of systemic immunosuppressive therapy. Br J Ophthalmol. 2007;
III. Chronic SJS/TEN 91:1048-1053.
A. Systemic manifestations 3. Schneider JA, Cohen PR. Stevens-Johnson syndrome and toxic
epidermal necrolysis: a concise review with a comprehensive sum-
B. Ocular manifestations and key examination
mary of therapeutic interventions emphasizing supportive mea-
findings sures. Adv Ther. 2017; 34(6):1235-1244.
1. Conjunctival cicatricial changes 4. Kohanim S, Palioura S, Saeed HN, et al. Acute and chronic oph-
2. Poor tear film thalmic involvement in Stevens-Johnson syndrome / toxic epider-
mal necrolysis: a comprehensive review and guide to therapy. II.
3. Inhibited eyelid function and eyelid malposition Ophthalmic disease. Ocul Surf. 2016; 14:168-188.
4. Motility restriction
5. Limbal stem cell deficiency
6. Corneal complications
Revisiting a Dry Topic:

Is Anything New with Sjögren Syndrome?
Stephen C Pflugfelder MD
I. Risk Factors 3. Tung CI, Perin AF, Gumus K, Pflugfelder SC. Tear meniscus
dimensions in tear dysfunction and their correlation with clinical
A. High interferon (IFN) activity correlates with parameters. Am J Ophthalmol. 2014; 157(2):301-310.e301.
severity of ocular surface disease.
4. Pflugfelder SC, De Paiva CS, Moore QL, et al. Aqueous tear defi-
B. Intestinal dysbiosis is associated with more severe ciency increases conjunctival interferon-gamma (IFN-gamma)
ocular and systemic disease severity. expression and goblet cell loss. Invest Ophthalmol Vis Sci. 2015;
56(12):7545-7550.
II. Ocular Surface Disease Profile
5. Alex A, Edwards A, Hays JD, et al. Factors predicting the ocular
A. Greatest perturbation of tear function and ocular surface response to desiccating environmental stress. Invest Oph-
surface health among dry eye conditions thalmol Vis Sci. 2013; 54(5):3325-3332.
B. Heightened response to desiccating environmental 6. Moore QL, De Paiva CS, Pflugfelder SC. Effects of dry eye thera-
challenge pies on environmentally induced ocular surface disease. Am J
Ophthalmol. 2015; 160(1):135-142.
C. Severe conjunctival goblet cell loss that may create
7. Galletti JG, Guzman M, Giordano MN. Mucosal immune toler-
a vicious immune cycle with:
ance at the ocular surface in health and disease. Immunology
1. Loss of immune tolerance 2017; 150(4):397-407.
2. Greater IFN-γ production 8. Vishwanath S, Everett S, Shen L, Malyavantham K, Suresh L,

Ambrus JL Jr. Xerophthalmia of Sjogren’s syndrome diagnosed
III. Diagnosis with anti-salivary gland protein 1 antibodies. Case Rep Ophthal-
mol. 2014; 5(2):186-189.
Antibodies to salivary gland protein 1 (SP1) and
parotid secretory protein (PSP) may identify patients 9. Tananuvat N, Daniell M, Sullivan LJ, et al. Controlled study of
who are Sjögren-specific antibody A and B negative. the use of autologous serum in dry eye patients. Cornea 2001;
20(8):802-806.
IV. Therapy
10. Noble BA, Loh RS, MacLennan S, et al. Comparison of autolo-
A. Increase conjunctival goblet cell number / secretion gous serum eye drops with conventional therapy in a randomised
controlled crossover trial for ocular surface disease. Br J Ophthal-
1. Blood products (serum / plasma rich in growth mol. 2004; 88(5):647-652.
factors)
11. Azari AA, Rapuano CJ. Autologous serum eye drops for the
2. Nasal stimulation of goblet cells treatment of ocular surface disease. Eye Contact Lens. 2015;
41(3):133-140.
B. Protect the cornea from desiccation with scleral
contact lenses 12. Gumus K, Pflugfelder SC. Intranasal tear neurostimulation: an
emerging concept in the treatment of dry eye. Int Ophthalmol
Clin. 2017; 57(2):101-108.
Selected Readings
13. Romero-Rangel T, Stavrou P, Cotter J, Rosenthal P, Baltatzis S,
1. Hall JC, Baer AN, Shah AA, et al. Molecular subsetting of inter- Foster CS. Gas-permeable scleral contact lens therapy in ocular
feron pathways in Sjogren’s syndrome. Arthritis Rheumatol. surface disease. Am J Ophthalmol. 2000; 130(1):25-32.
2015; 67(9):2437-2446.
14. Weber SL, de Souza RB, Gomes JA, Hofling-Lima AL. The use
2. de Paiva CS, Jones DB, Stern ME, et al. Altered mucosal microbi- of the esclera scleral contact lens in the treatment of moderate to
ome diversity and disease severity in Sjogren syndrome. Sci Rep. severe dry eye disease. Am J Ophthalmol. 2016; 163:167-173.
2016; 6:23561. e161.
Sclera on Fire: What Labs Do I

Really Need to Check?
Donald U Stone MD
I. Infectious Scleritis V. Summary of Diagnostic Approach

A. Take a history: Postsurgical, traumatic A. Thorough history
1. Fungal (cultures and stains) B. Test for systemic infections
2. Bacterial (cultures and stains) 1. Treponemal (syphilis) test: treponemal antibod-
ies, rapid plasma reagin
B. Systemic infections, via local or hematogenous
spread 2. Tuberculosis
1. Tuberculosis (systemic tests, ± local culture or a. PPD or serum QuantiFERON test
biopsy)
b. Chest imaging
2. Viral: herpes family
C. Test for systemic autoimmune conditions
3. Lyme borreliosis (serum titers)
1. Rheumatoid factor, cyclic citrullinated proteins
4. Brucellosis (serum titers, culture) (CCP)
II. Noninfectious Scleritis 2. Anti-neutrophil cytoplasmic antibodies
(P-ANCA and C-ANCA)
A. Rheumatoid arthritis
3. Antinuclear antibodies
B. Systemic vasculitis
4. HLA B27
1. Antineutrophil cytoplasmic antibody associated
5. Renal function (creatinine) and urinalysis
2. Systemic lupus erythematosus
6. Complete blood count, erythrocyte sedimenta-
3. Behçets
tion rate, C-reactive protein are nonspecific.
C. Sarcoidosis
7. Other tests based on suspicion
D. HLA B-27 associated
D. Pregnancy test before imaging or systemic therapy!
1. Ankylosing spondylitis Urine or serum beta-HCG
2. Psoriatic arthritis
Selected Readings
3. Inflammatory bowel disease
1. Daniel Diaz J, Sobol EK, Gritz DC. Treatment and management
E. Relapsing polychondritis of scleral disorders. Surv Ophthalmol. 2016; 61(6):702-717.
F. Bisphosponate associated 2. Galor A, Thorne JE. Scleritis and peripheral ulcerative keratitis.
Rheum Dis Clin North Am. 2007; 33(4):835-854.
III. Surgically Induced Necrotizing Scleritis
3. Jabs DA, Busingye J. Approach to the diagnosis of the uveitides.
IV. Masquerade – Neoplasia Am J Ophthalmol. 2013; 156(2):228-236.
A. Choroidal tumor (melanoma)
B. Conjunctival tumor (squamous or melanocytic)
C. Lymphoma
Case: Not Just Another Red Eye

Superior Limbic Keratoconjunctivitis
Christopher J Rapuano MD
I. Introduction VI. Treatment

Superior limbic keratoconjunctivitis (SLK) is an A. Preservative-free artificial tear drops every 2 hours.
uncommon, usually bilateral, chronic, relapsing, Consider temporary or permanent punctal occlu-
inflammatory reaction that may be associated with sion.
thyroid dysfunction (~30%). It is often found in con-
B. Cyclosporine 0.05% to 2% b.i.d. to q.i.d. may be
junction with dry eye syndrome and usually affects
helpful. Lifitegrast 5% b.i.d. may also be beneficial.
middle-aged females (3-5:1 female-to-male ratio).
Occasionally serum tears can be helpful.
II. Etiology
C. Acetylcysteine (eg, Mucomyst) 10% drops q.i.d. for
Unknown, but most likely related to mechanical treatment of corneal filaments
trauma involving the superior palpebral and lax bul-
D. Topical antihistamine / mast cell stabilizers (eg,
bar conjunctiva
azelastine, epinastine, ketotifen, nedocromil,
III. Symptoms olopatadine, bepotastine, alcaftadine) q.d. to b.i.d.
may be helpful.
A. Foreign-body sensation, burning, photophobia,
pain, red eye, excessive blinking E. Application of silver nitrate 0.5% solution to supe-
rior bulbar and palpebral conjunctiva for 15 to 30
B. May have exacerbations and remissions
seconds
IV. Signs
F. Localized cautery to superior conjunctiva
A. Hyperemia, thickening, redundance, and laxity of
G. Double freeze-thaw cryotherapy
superior bulbar conjunctiva
H. Surgical resection with or without amniotic mem-
B. Lack of luster and positive staining of superior bul-
brane graft of superior bulbar conjunctiva
bar conjunctiva with fluorescein, lissamine green,
and rose bengal dyes VII. Prognosis
C. Fine, velvety, superior tarsal papillae Good for improvement in symptoms; fair for complete
resolution of symptoms. May be recalcitrant to treat-
D. Superior corneal filaments, punctate erosions, and
ment.
occasionally pannus
V. Workup
Selected Readings
A. History; ask about thyroid disease. 1. Ahn JM, Choi CY, Seo KY. Surgical approach with high-fre-
B. Slitlamp examination with special attention to the quency radiowave electrosurgery for superior limbic keratocon-
superior bulbar and palpebral conjunctiva junctivitis. Cornea 2014; 33(2):210-214.
2. Gris O, Plazas A, Lerma E, Güell JL, Pelegrín L, Elíes D. Conjunc-
C. Fluorescein, lissamine green, or rose bengal stain-
tival resection with and without amniotic membrane graft for the
ing of superior bulbar conjunctiva treatment of superior limbic keratoconjunctivitis. Cornea 2010;
D. Dry eye testing 29(9):1025-1030.
E. Thyroid function testing 3. Fraunfelder FW. Liquid nitrogen cryotherapy of superior limbic
keratoconjunctivitis. Am J Ophthalmol. 2009; 147(2):234-238.
2017 Subspecialty Day | Cornea Financial Disclosure 51
Financial Disclosure
The American Academy of Ophthalmology has a profound duty Financial Relationship Disclosure
to its members, the larger medical community and the public
For purposes of this disclosure, a known financial relationship
to ensure the integrity of all of its scientific, educational, advo-
is defined as any financial gain or expectancy of financial gain
cacy and consumer information activities and materials. Thus
brought to the Contributor or the Contributor’s immediate fam-
each Academy Trustee, Secretary, committee Chair, committee
ily (defined as spouse, domestic partner, parent, child or spouse
member, taskforce chair, taskforce member, councilor, and
of child, or sibling or spouse of sibling of the Contributor) by:
representative to other organizations (“Academy Leader”), as
well as the Academy staff and those responsible for organizing ■■ Direct or indirect compensation;
and presenting CME activities, must disclose interactions with ■■ Ownership of stock in the producing company;
Companies and manage conflicts of interest or the appearance ■■ Stock options and/or warrants in the producing company,
of conflicts of interest that affect this integrity. Where such even if they have not been exercised or they are not cur-
conflicts or perceived conflicts exist, they must be appropriately rently exercisable;
and fully disclosed and resolved. ■■ Financial support or funding to the investigator, includ-
All contributors to Academy educational and leadership ing research support from government agencies (e.g.,
activities must disclose all financial relationships (defined NIH), device manufacturers, and/or pharmaceutical
below) to the Academy annually. The ACCME requires the companies; or
Academy to disclose the following to participants prior to the ■■ Involvement with any for-profit corporation that is likely
activity: to become involved in activities directly impacting the
Academy where the Contributor or the Contributor’s
■■ All financial relationships with Commercial Companies
family is a director or recipient
that contributors and their immediate family have had
within the previous 12 months. A commercial company is
any entity producing, marketing, re-selling or distributing Description of Financial Interests
health care goods or services consumed by, or used on,
Category Code Description
patients.
■■ Meeting presenters, authors, contributors or reviewers Consultant / Advisor C Consultant fee, paid advisory
who report they have no known financial relationships to boards or fees for attending a
disclose. meeting
The Academy will request disclosure information from Employee E Employed by a commercial
meeting presenters, authors, contributors or reviewers, com- company
mittee members, Board of Trustees, and others involved in
Lecture Fees L Lecture and speakers bureau
Academy leadership activities (“Contributors”) annually.
fees (honoraria), travel fees or
Disclosure information will be kept on file and used during
reimbursements when speaking
the calendar year in which it was collected for all Academy
at the invitation of a commer-
activities. Updates to the disclosure information file should be
cial company
made whenever there is a change. At the time of submission of a
Journal article or materials for an educational activity or nomi- Equity Owner O Equity ownership/stock options
nation to a leadership position, each Contributor should specifi- (publicly or privately traded
cally review his/her statement on file and notify the Academy of firms, excluding mutual funds)
any changes to his/her financial disclosures. These requirements
Patents / Royalty P Patents and/or royalties that
apply to relationships that are in place at the time of or were in
might be viewed as creating a
place 12 months preceding the presentation, publication sub-
potential conflict of interest
mission, or nomination to a leadership position. Any financial
relationship that may constitute a conflict of interest will be Grant Support S Grant support from all sources
resolved prior to the delivery of the activity.
Visit www.aao.org/about/policies for the Academy’s policy
on identifying and resolving conflicts of interest.
52 Financial Disclosure 2017 Subspecialty Day | Cornea
Faculty Financial Disclosure
Control of Content
The American Academy of Ophthalmology considers presenting authors, not co-authors, to be in control of the educational content.
It is Academy policy and traditional scientific publishing and professional courtesy to acknowledge all people contributing to the
research, regardless of CME control of the live presentation of that content. This acknowledgement is made in a similar way in other
Academy CME activities. Though they are acknowledged, co-authors do not have control of the CME content and their disclosures
are not published or resolved.
Mohamed F Abou Shousha MD David F Chang MD Anat Galor MD

University of Miami: P Carl Zeiss Inc.: C Allergan: C
Eyenovia: O Shire: C
Anthony J Aldave MD Iantech: C,O
5AM Ventures: C Icon Bioscience: O Darren G Gregory MD
Avellino Laboratories: C,L iDrops: C,O None
ClearView Healthcare Partners: C Ivantis: C,O
Gore: C Johnson & Johnson Vision: C Hans E Grossniklaus MD
National Eye Institute: S Mynosys: O,C National Cancer Institute: S
Noveome Biotherapeutics: C PowerVision Inc.: C,O National Eye Institute: S
Shire: C RX Sight: O,C
Sun Ophthalmics: C Slack, Incorporated: P Sadeer B Hannush MD
Versant Ventures: O None
Eduardo C Alfonso MD
Alcon Laboratories Inc.: C Mazen Y Choulakian MD Deborah S Jacobs MD
Bio-Tissue Inc.: C None Boston Foundation for Sight, 501(c)3: E
TecLens: C
Zaina N Al-Mohtaseb MD Victoria M Cohen FRCOphth
Alcon: C None Bennie H Jeng MD
Allergan: C CoDa Therapeutics: C
Denise de Freitas MD EyeGate Pharmaceuticals Inc.: O
Renato Ambrósio Jr MD None Jade Therapeutics: C
Alcon Laboratories Inc.: C Kedrion: C
Allergan: L Deepinder K Dhaliwal MD Santen Inc.: C
Carl Zeiss Inc.: L Bausch+Lomb: C
Mediphacos: L Imprimis: S Carol L Karp MD
Oculus Inc.: C Novabay: C,S None
Ocular Therapeutix: L
Michael W Belin MD Sightlife: L William Barry Lee MD
Oculus Inc.: C Staar Surgical: L Bausch+Lomb: L
Elsevier: P
Winston D Chamberlain MD PhD William J Dupps MD PhD Shire: C
None Avedro: C
Cleveland Clinic Innovations: P Jennifer Y Li MD
National Eye Institute: S None
Marjan Farid MD Thomas M Lietman MD

Abbott: C None
Alcon Laboratories Inc.: C
Allergan: C
Shire: C
Disclosures current as of 10/6/17

Check the Mobile Meeting Guide for the most up-to-date financial disclosures.
2017 Subspecialty Day | Cornea Financial Disclosure 53
Marian Sue Macsai-Kaplan MD Afshan A Nanji MD Carol L Shields MD

Allergan Inc.: L None None
Bausch+Lomb Surgical: L
PRN Physician Recommended Stephen C Pflugfelder MD Arun D Singh MD
Nutriceuticals: C Allergan: C Aura Biosciences: C
Senju: C Castle Biosciences: C
Parag A Majmudar MD Shire: C,S Iconic Inc.: C
Alcon Laboratories Inc.: C Isoaid LLC: C
Allergan Inc.: C Francis W Price Jr MD
Bausch+Lomb: C Alcon Laboratories Inc.: C Donald Stone MD
CXL Ophthalmics LLC: O Avedro Inc.: L None
Rapid Pathogen Screening: O Calhoun Vision Inc.: O
Shire: C Haag-Streit: C Donald Tan MD FRCS FRCOphth
Sun Pharma: C Interactive Medical Publishing: O Carl Zeiss Meditec: L
ReVital Vision: O Eye Lens: C
Mark J Mannis MD Strathspey Crown LLC: O Network Medical: P
None Sun Ophthalmics: C Santen Inc.: L,C
TearLab: O
Todd P Margolis MD PhD Mark A Terry MD
None Christopher J Rapuano MD Bausch+Lomb Surgical: P,S
Allergan: C Envisia: C
Shahzad I Mian MD Bio-Tissue Inc.: C,L Moria: S
None Novartis, Alcon Pharmaceuticals: C
Rapid Pathogen Screening: O Elmer Y Tu MD
Darby D Miller MD Shire: C,L AbbVie: C
None Sun Ophthalmics: C Eversight: S
TearLab: C Eye Bank Association of America: S
Wuqaas M Munir MD
None Jennifer R Rose-Nussbaumer
MD
None
Disclosures current as of 10/6/17

Check the Mobile Meeting Guide for the most up-to-date financial disclosures.
54 Index 2017 Subspecialty Day | Cornea
Presenter Index
Abou Shousha*, Mohamed 29

Aldave*, Anthony 15
Alfonso*, Eduardo 3
Ambrósio*, Renato 30
Belin*, Michael 36
Chamberlain, Winston 10
Chang*, David 27
Choulakian, Mazen 42
Cohen, Victoria 24
de Freitas, Denise 4
Dhaliwal*, Deepinder 45
Dupps*, William 40
Farid*, Marjan 12
Galor*, Anat 44
Gregory, Darren 25
Grossniklaus*, Hans 20
Hannush, Sadeer 35
Jacobs*, Deborah 37
Lee*, William 38
Lietman, Thomas 2
Macsai-Kaplan*, Marian Sue 16
Majmudar*, Parag 28
Mannis, Mark 9
Margolis, Todd 6
Mian, Shahzad 1
Miller, Darby 18
Munir, Wuqaas 47
Nanji, Afshan 23
Pflugfelder*, Stephen 48
Price*, Francis 34
Rapuano*, Christopher 50
Rose-Nussbaumer, Jennifer 7
Shields, Carol 22
Singh*, Arun 26
Stone, Donald 49
Tan*, Donald 13
Terry*, Mark 17
Tu*, Elmer 43

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Cornea 2017

Keeping the Old,

In conjunction with the Cornea Society

Ernest N Morial Convention Center

Supported in part by an unrestricted

2017 Cornea Planning Group 2012 Anthony J Aldave MD R Michael Siatkowski MD

2017 Cornea Subspecialty Day Planning Group

Bennie H Jeng MD Carol L Karp MD Jennifer Y Li MD

2017 Subspecialty Day R Michael Siatkowski MD AAO Staff

Francis S Mah MD (Cornea) Nicholas J Volpe MD

Cornea 2017 Contents

Program Planning Group ii

Faculty Listing viii

How to Use the Audience Interaction Application xii

Program Schedule xiii

Section I: Corneal Infections—Old Bugs, New Drugs 1

Section II: Keratoplasty—Are We Doing the Right Thing? 10

Advocating for Patients 18

Section III: Conjunctival Tumors—What’s Old, What’s New? 20

Section IV: Anterior Segment Imaging—What’s Recent, What’s Decent? 27

Section V: Keratoconus, A Steep Learning Curve—The Newest in Diagnosis and Management 36

Section VI: Inflammatory Conditions of the Anterior Segment—It’s Burning Me Up! 44

Faculty Financial Disclosure 51

Academy’s CME Mission Statement Scientific Integrity and Disclosure of Financial

Mohamed F Abou Shousha MD Renato Ambrósio Jr MD Mazen Y Choulakian MD

Anthony J Aldave MD Michael W Belin MD Victoria M Cohen FRCOphth

Eduardo C Alfonso MD Winston D Chamberlain MD PhD Denise de Freitas MD

Zaina N Al-Mohtaseb MD David F Chang MD Deepinder K Dhaliwal MD

William J Dupps MD PhD Hans E Grossniklaus MD Carol L Karp MD

Marjan Farid MD Sadeer B Hannush MD William Barry Lee MD

Anat Galor MD Deborah S Jacobs MD Jennifer Y Li MD

Darren G Gregory MD Bennie H Jeng MD Thomas M Lietman MD

Marian Sue Macsai-Kaplan MD Shahzad I Mian MD Stephen C Pflugfelder MD

Parag A Majmudar MD Darby D Miller MD Francis W Price Jr MD

Mark J Mannis MD Wuqaas M Munir MD Christopher J Rapuano MD

Todd P Margolis MD PhD Afshan A Nanji MD Jennifer R Rose-Nussbaumer

Carol L Shields MD Donald Stone MD Mark A Terry MD

Arun D Singh MD Donald Tan MD FRCS FRCOphth Elmer Y Tu MD

Ask a Question Live During the Meeting

To ask a question during the meeting, follow the directions below.

■ Select “Program Handouts & Evaluations”

■ Filter by Meeting—Cornea Meeting

■ Select Current Session

■ Select “Ask the presenter a question (live)” Link

■ Click Submit Question

Cornea 2017: Keeping the Old,

Section I: Corneal Infections—Old Bugs, New Drugs

Section II: Keratoplasty—Are We Doing the Right Thing?

Section III: Conjunctival Tumors—What’s Old, What’s New?

Section IV: Anterior Segment Imaging—What’s Recent, What’s Decent?

Section V: Keratoconus, A Steep Learning Curve—The Newest in Diagnosis and Management

Section VI: Inflammatory Conditions of the Anterior Segment—It’s Burning Me Up!

’Roid Rage: The Controversy over Steroids

I. History of the Controversy C. Secondary outcomes

Fungal Keratitis: Detecting and Disabling

Detection Surgical Interventions

Acanthamoeba Keratitis: Embracing the Challenge

Viral Keratitis: What’s New that We Can Do?

Herpes Simplex Virus (HSV) Varicella Zoster Virus (VZV)

Cut It Out! Nonmedical Approaches to

I. Corneal Crosslinking (CXL) for Infectious Keratitis B. Outcomes

Table 1. Relevant Randomized Clinical Trials Assessing Corneal Crosslinking

Trial Question N Finding Comment

7. Sarnicola E, Sarnicola C, Sabatino F, Tosi GM, Perri P, Sarnicola

Case: The Most Unusual Keratitis

●● Pruritis, photophobia, tearing

●● Conjunctival injection Figure 2.