Cornea
July 2023

by Liz Hillman
Editorial Co-Director

In a symposium at the 2023 ASCRS Annual Meeting, six cases with irregular corneas were presented and the panel was challenged to answer what would they do. Here’s an overview of those cases.

Case 1: Young patient for LASIK eval with borderline topo irregularity

William Trattler, MD, presented this case, featuring a 30-year-old male seeking refractive surgery whose Pentacam (Oculus) imaging showed inferior steepening. His corneas had thicknesses of 540 and 550 microns, and he was a mild myope (OD: –3.75+0.25×032, OS: –3.5 sphere) who corrected to 20/20. Dr. Trattler also presented that the patient had Belin/Ambrosio Enhanced Ectasia Display (BAD) scores of 1.44 and 1.26. Dr. Trattler said that even though there is inferior steeping, the BAD scores are in the normal range.

From there, Dr. Trattler presented the patient’s epithelial thickness maps, which showed epithelial hyperplasia, confirmed by a second map from a second device that measures epithelial thickness. “This patient has steepening not due to an abnormal stromal shape, but due to epithelial hyperplasia,” Dr. Trattler said, noting that research by Dan Reinstein, MD, has shown that corneal refractive surgery is safe in these cases. Neda Shamie, MD, said she would want to optimize the ocular surface and make sure the patient was out of contact lenses long enough to confirm that it wasn’t transient epithelial hyperplasia and after that would be comfortable with a corneal-based procedure. Sumit “Sam” Garg, MD, suggested doing genetic testing for keratoconus might be helpful.

Case 2: Young patient for LASIK evaluation with high score on genetic testing but normal topography

Nir Sorkin, MD, shared this case of a 25-year-old female with no family history of keratoconus who was interested in refractive surgery. Her manifest refraction was –3.25/–0.5×180 correcting to 20/20 in the right eye and 3.5/–0.5×180 correcting to 20/20 in the left. Her slit lamp exam was unremarkable and Pentacam images, BAD score, pachymetry, and epithelial maps were normal. However, genetic testing showed she was at high risk for keratoconus.

“She’s the ideal LASIK candidate, but she’s had genetic testing, high scoring,” Dr. Sorkin said.

Dr. Trattler said that, while he’s a fan of genetic testing, he thinks topography and tomography are more important preoperative tests in determining candidacy for laser vision correction. “I would offer laser vision correction but would tell the patient that we’re going to follow you every year with topography, and if we see findings that are suspicious for ectasia, we’ll do crosslinking,” he said, noting that an ICL could also be considered.

Kenneth Beckman, MD, noted the scale on the topography. He said if the scale was a half a diopter it could show irregularities on the topography. Marcony Santhiago, MD, PhD, said that the genetic test could be a false positive.

Case 3: Patient with post-refractive ectasia (unstable) for cataract evaluation

Neda Shamie, MD, shared the case of a 56-year-old referred for cataract consultation who had prior LASIK that she was happy with until a few years ago when she began to need glasses again. The patient’s manifest refraction was –0.75–3.25×003, correcting to 20/30, in her right eye and –0.75–2.25×007, correcting to 20/40, in her left.

“This patient has cataracts, but when a patient has LASIK and you see a lot of astigmatism in their refractive error, that’s a red flag,” Dr. Shamie said, bringing up that her topography showed ectasia.

In counseling a patient like this, Dr. Beckman said he’d want to see old refraction and old topographies, if possible, to confirm stability. It would help address if you’re doing the cornea or the lens first, he said. Dr. Shamie said they had previous data that showed progression. She said the plan was to crosslink first, then wait to allow stabilization to obtain measurements for cataract surgery.

Case 4: Older patient with stable keratoconus for cataract eval

This case of a high myope with stable keratoconus (OD: –11–1.00×080, OS: –12–2.75 x123) was presented by Audrey Talley Rostov, MD. In cases like this, she tends to use the Barrett True K formula for IOL calculations, but she mentioned the Kane formula as well.

Dr. Rostov asked the panel if they would consider a toric IOL in this patient. Dr. Garg said he’d want to know if they had good vision in glasses in the past; if not, he would steer away from a toric. Contact lenses are an option as well, but Dr. Rostov said many of her older patients want to get away from contact lens use.

Dr. Rostov ended up implanting a toric IOL, using the femtosecond laser for axis alignment. She said that keratoconus patients receiving toric IOLs aren’t necessarily expecting perfection, but IOL alignment is important, and she avoids multifocal and EDOF IOLs. Dr. Garg said that it’s not just about nailing the cylinder in these cases, it’s about nailing the sphere and trying to avoid ending up hyperopic.

Case 5: Young patient with keratoconus wants refractive options

“Combined procedures have been shown to have a greater effect in the treatment and improvement of visual acuity and quality in patients with keratoconus.”

Karolinne Rocha, MD, PhD

A 28-year-old male firefighter with a history of congenital anterior polar cataracts, keratoconus (right eye more advanced), and a history of contact lens intolerance wanted to know what his refractive surgery options were. Karolinne Rocha, MD, PhD, presented the case, sharing that his uncorrected visual acuity in his right eye was count fingers (MRx –3.5–4.5×070, correctable to 20/60). His K max was 54 D and progressed to 58 D 6 months later.

Dr. Rocha said she decided to do a combined Intacs (CorneaGen) and crosslinking procedure. Even though the magnitude of his astigmatism was still high after Intacs, she said with glasses he could see 20/30. A couple of years later he returned with his cataract worse and visually significant, and Dr. Rocha said she used the Kane Keratoconus formula to calculate for a toric IOL. Using a monofocal T9 (6.00) toric IOL, there was still residual cylinder, but Dr. Garg said that these patients are often accepting of some residual astigmatism. His final refraction, according to Dr. Rocha, was +0.75+2.5×165 20/25.

“Combined procedures have been shown to have a greater effect in the treatment and improvement of visual acuity and quality in patients with keratoconus. Concurrent or sequential procedures are great alternatives to patient intolerance to contacts,” she said.

Case 6: Patients in their 40s with keratoconus want to know if they’re a good candidate for crosslinking

Ramy Riad Fikry, MD, PhD, shared two cases where patients in their 40s were seeking a second opinion on whether they should have crosslinking. One was a 40-year-old man who didn’t have a family history of keratoconus and learned of his diagnosis when he was seeking out refractive surgery. The patient was followed up with after his initial second opinion consultation after 6 months, showing a stable condition in both eyes. Dr. Fikry said he tested the patient’s corneal biomechanics and other metrics that would detect changes before loss of lines, finding the patient was stable without the need for further intervention. The second case, however, showed significant progression and proceeded with crosslinking treatment.

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About the physicians

Kenneth Beckman, MD
Comprehensive EyeCare of Central Ohio
Westerville, Ohio

Ramy Riad Fikry, MD, PhD
Cairo University
Cairo, Egypt

Sumit “Sam” Garg, MD
Professor of Ophthalmology
Gavin Herbert Eye Institute
University of California, Irvine
Irvine, California

Karolinne Rocha, MD, PhD
Associate Professor of Ophthalmology
Medical University of South Carolina
Charleston, South Carolina

Audrey Talley Rostov, MD
Northwest Eye Surgeons
Seattle, Washington

Marcony Santhiago, MD, PhD
Professor of Ophthalmology
University of Sao Paulo
Sao Paulo, Brazil

Neda Shamie, MD
Maloney-Shamie Vision Institute
Los Angeles, California

Nir Sorkin, MD
Tel Aviv University
Tel Aviv, Israel

William Trattler, MD
Center for Excellence in Eye Care
Miami, Florida

Relevant disclosures

Beckman: None
Fikry: None
Garg: None
Rocha: None
Rostov: None
Santhiago: None
Shamie: Alcon, Bausch + Lomb, CorneaGen, Glaukos, RxSight, Johnson & Johnson
Sorkin: None
Trattler: Alcon, Allergan, ArcScan, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, Oculus, STAAR Surgical

Contact

Beckman: kenbeckman22@aol.com
Fikry: ramyriadfikry@kasralainy.edu.eg
Garg: gargs@uci.edu
Rocha: karolinnemaia@gmail.com
Rostov: atalleyrostov@nweyes.com
Santhiago: marconysanthiago@hotmail.com
Shamie: ns@maloneyshamie.com
Sorkin: nir.sorkin@gmail.com
Trattler: wtrattler@gmail.com