October 2015




Third in a series of 5 presentations

Hot off the press: Best in cornea


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View Dr. Jengs presentation at Clinical.EWrePlay.org.

View Dr. Jengs presentation at Clinical.EWrePlay.org.

Bennie H. Jeng, MD, highlighted the best cornea papers at the Hot Off the Press session at the 2015 ASCRS•ASOA Symposium & Congress. The papers were chosen from the Best Paper of Session winners. Here are the abstracts from the studies, with Dr. Jengs comments regarding selection.

Comparison of efficacy and convenience of warm compresses and eyelid hygiene to thermal pulsation treatment for meibomian gland dysfunction

Jack V. Greiner, DO, PhD

Purpose: To evaluate the efficacy, convenience, and cost of long-term use of twice daily warm compresses and eyelid hygiene as compared to a single, in-office thermal pulsation treatment (LipiFlow, TearScience, Morrisville, N.C.), which applies simultaneous heat and pressure to the eyelids, in patients with meibomian gland dysfunction (MGD) and dry eye.

Methods: In a prospective, multicenter, open-label, randomized clinical trial, 99 subjects (197 eyes) received a single 12-minute thermal pulsation treatment and 98 subjects (196 eyes) received twice daily warm compresses (EyeGiene System, Eyedetec Medical, Danville, Calif.) and eyelid hygiene (OCuSOFT Lid Scrub, Rosenberg, Texas) for 3 mo. Subjects had MGD based on meibomian gland (MG) secretions and dry eye symptoms based on OSDI questionnaire. Changes in MG secretions and dry eye symptoms scores from baseline to 3 mo. were compared between groups (n=196 and 188 eyes). Compliance with use and cost of treatment were evaluated. Subjects receiving single thermal pulsation treatment were followed to 12 mo. (n=188 eyes).

Results: The thermal pulsation group had significantly greater mean improvement than the compress and hygiene group from baseline to 3 mo. in MG secretions (6.23.7 to 17.810.6 vs. 6.33.6 to 10.8 8.0; p<0.0001) and dry eye symptoms (45.621.1 to 21.6 19.8 vs. 51.823.1 to 33.525.5; p=0.0068). Over 3 mo., 15% of subjects used compresses and hygiene <7 times/week despite 14/week instructions. Costs of compresses and hygiene for twice-daily use over 1 year vs. thermal pulsation treatment were similar. The thermal pulsation group had sustained mean efficacy at 12 mo. in MG secretions (17.39.1) and dry eye symptoms (21.621.3).

Conclusion: Compared to twice daily warm compresses and eyelid hygiene over 3 months, a single thermal pulsation treatment is significantly more effective in improving MG secretions and dry eye symptoms, shows sustained efficacy over 1 year at a similar cost, and is more convenient without the need for daily patient compliance.

Dr. Jeng: Conventional treatment of meibomian gland dysfunction includes the use of warm compresses and eyelid scrubs. One of the biggest drawbacks of this therapy, even if it works, is compliance. In this paper, the authors described their results when comparing eyelid hygiene to a single in-office thermal pulsation therapy. This is an important study as it not only demonstrates the short-term effects of treatment with thermal pulsation therapy compared to eyelid hygiene, but it also shows the lasting effects of the treatment out to 12 months. Combined with the lack of worry about compliance, thermal pulsation therapy seems to be very effective. However, there is a cost differential between the two treatments that is not addressed in this study.

Primary pterygia excision performed via Anduze technique with mitomycin-C 0.02% applied to subconjunctival space: Review

William B. Trattler, MD

Purpose: To evaluate pterygium excision performed by the Anduze bare scleral approach with 0.02% mitomycin-C (MMC) injected into the subconjunctival space, and quantify risks and benefits.

Methods: Patients underwent primary pterygium surgery with injection of less than 0.01 mL of 0.02% MMC into the subconjunctival space at the completion of the excision.

Results: Ongoing study, results of 112 eyes (112 patients) presented, results will be updated. Three-month and one-year postoperative follow-up demonstrated a 0.018% (2/112) recurrence rate. There were no vision threatening complications to report, and adverse effects were mild 0.098% (11/112). The postoperative complications were easily resolved with topical therapy with the most common complication being pyogenic granuloma.

Conclusion: The results of this clinical review demonstrate that the Anduze bare scleral approach is an effective surgical technique for pterygium excision. Injection with 0.1 mL of MMC directly into the subconjunctival space provides superior results with minimal risk to the patient.

Dr. Jeng: Although conjunctival autograft is frequently considered the gold standard method of performing pterygium excision, many other surgical techniques exist, and some techniques involve the use of adjunctive medications. In this paper, the authors presented their patients who underwent primary pterygia excision with 0.02% mitomycin-C, without the use of cautery, sutures, or glue. Although their recurrence rate is low, as is their complication rate, more extended follow-up is necessary for study of this technique. In addition, although there were no cases of scleral melting in this series, there have been reports of this complication after use of mitomycin-C, and as such, caution should be exhibited when interpreting the results of this study.

Corneal CXL: Epi-on versus pocket technique

Christoph Kranemann, MD, Alberto J. Aguayo Bonniard, MD

Purpose: To compare the efficacy and safety of epi-on corneal crosslinking with crosslinking using a corneal pocket.

Methods: Patients with progressive keratoconus or pellucid marginal degeneration were randomized to either technique and followed for a minimum of 18 months. The study was unmasked. A total of 24 patients were randomized14 to epi-on and 10 to pocket crosslinking. Sequential topographies and wavefronts were taken preoperatively and postoperatively q 3 monthly. Anterior and posterior topographies were obtained and a pachymetry map taken. Accelerated crosslinking was conducted and corneal pockets were created at 110-micron depth with a femtosecond corneal laser. Any surgical and postoperative complications were recorded.

Results: All patients with epi-on treatments improved topographically and refractively within 24 hours. The pocket patients only improved after a minimum of 6 weeks. All refractive and topographic gains regressed in the epi-on group by the 18-month mark. The pocket group improved up to the 12-month mark and remained stable at 18 months. Mean topography improved from 53.4+/2.1 D in the epi-on group to 51.5+/1.9 vs. 52.9+/1.85 D in the pocket group to 51.8+/2.2 at 3 months NS. At 18 months the mean topography had regressed to 53.6+/2.5 in the epi-on group vs. 50.8 +/2 in the pocket group P 0.03. There were no complications in either group.

Conclusion: Epi-on corneal crosslinking appears to have a faster recovery but a limited long-term effect in the treatment protocol used. Pocket crosslinking appeared to be more effective in the medium term.

Dr. Jeng: Corneal collagen crosslinking (CXL) has continued to gain popularity as an effective modality to halt the progression of corneal ectasia. However, there is debate about whether using an epithelium-on protocol versus epithelium-off protocol is better. In this paper, the authors described the use of CXL using a technique called corneal pocket crosslinking. In this procedure, a femtosecond laser was used to create a lamellar pocket where riboflavin can be injected. This procedure allows better delivery of the drug to the corneal stroma without the disadvantages of scraping the corneal epithelium. When compared to transepithelial CXL, the corneal pocket technique demonstrated more sustained effect at 18 months. Because this was a small study, more data is warranted, but this does seem to be a promising new technique that harnesses the advantages of both epithelium-on and epithelium-off CXL.

Editors note: Dr. Jeng is professor and chair, Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore. He has no financial interests related to this article.

Contact information

Jeng: bjeng@som.umaryland.edu

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