EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Thursday, January 23, 2020


EyeWorld/ASCRS reporting live from Hawaiian Eye 2020 in Kauai, Hawaii, Thursday, January 23, 2020
Thursday’s programming at the Hawaiian Eye meeting featured presentations on a variety of cornea topics.
Medical cornea cases

In a Thursday morning session, presentations included a variety of medical cornea cases with panelists sharing their own cases and commenting on how they might handle some of the issues that popped up.

The first case presented was that of a 45-year-old woman with myopia who had uncomplicated LASIK and came in saying that she couldn’t see. She was postop day 1 and 20/70 in both eyes.

Douglas Katsev, MD, Santa Barbara, California, said that the patient was treated aggressively with steroids.

The patient had diffuse lamellar keratitis, and the treatment plan included increased steroid use and a wash out performed at 3 days postop. Postop 3 weeks, the patient was overcorrected by 2 D but correctable to 20/20, he said.

Marguerite McDonald, MD, Lynbrook, New York, asked about the time of day when this patient was operated on. She said if it’s the first patient of the day, there could be something on the equipment, and it could be something that gets washed off during the day. In fact, it was Dr. Katsev’s first patient of the day, but he never figured out the exact cause of this problem.

The panel offered several pearls for diffuse lamellar keratitis management: recognize early, increase steroids quickly, consider oral prednisone, and lift the flap but not before day 3.

The second case discussed was a 60-year-old man who had a 2-year history of redness, irritation, and occasional mucus formation in the right eye. The patient was also myopic and wore 2-week disposable contact lenses; he said he was good with his hygiene. He had been treated with loteprednol on and off, which helped, and had also been on multiple trials of topical antibiotics.

Ashley Brissette, MD, New York, New York, said that when she notices an asymmetric issue between two eyes, she will often ask the patient about his/her sleep position, because if they are sleeping on one side, this could be having an impact.

If it’s unilateral, Preeya Gupta, MD, Durham, North Carolina, said that she also thinks of patients picking at their eyes and things like a foreign body or a lacrimal issue.

The issue with this patient was a contact lens left in the eye, which Dr. Gupta discovered in the superior fornix. She described a double lid eversion with sweeping as a key technique. She said she has a high suspicion in contact lens wearers that something could be left behind. Key features to look for are unilateral disease, mucus discharge, chronic symptoms, and variable response to medications.

Kenneth Beckman, MD, Columbus, Ohio, indicated that he will also do these without anesthesia, if possible, because the patient will have immediate relief if you get it out.

Another case looked at a 48-year-old man with a long history of ocular burning, itchy, tearing, and repeated episodes of styes and lid bumps. Dr. McDonald described this case, indicating that the patient came in with 4+ MGD and lid neovascularization, 3+ cuff shaped collarettes, loose lids that were easily everted, a decreased tear lake in both eyes, and 3+ papillary changes.

She pulled a lash and examined it under the microscope and found that that patient had Demodex. Having an infestation that is causing disease increases with age and is about 100% in the very elderly, she said.

Dr. McDonald’s treatment plan for this patient included microblepharoexfoliation in-office treatment with tea tree oil foaming gel cleanser, loteprednol etabonate drops, doxycycline, and lifitegrast. The patient did very well with this treatment, she added.

In another case presentation, Dr. Brissette shared specifics from a 24-year-old patient she had with chronic conjunctivitis who had already sought multiple opinions. The patient had tried multiple drops, she said, as well as antibiotics and steroids. The patient also had eczema.

This was ultimately the issue: the patient was on dupilumab, which Dr. Brissette said can be used to treat eczema and other conditions. Up to 30% of patients on dupilumab experience eye symptoms, like conjunctivitis and keratitis, she said.

Dr. Brissette said that you should start the patient on aggressive dry eye therapies, but if there is no resolution, stop dupilumab.

With this issue, usually the first treatment is not enough, Dr. Beckman said, adding that patients are usually unwilling to stop the medication because of its effectiveness. He said that it is key to work with dermatologists and see these patients before they start this medication. Dr. Beckman likes to start the patients on lifitegrast before starting the dupilumab.

Editors’ note: The panelists have financial interests with a variety of ophthalmic companies.

Debates in cornea

Another Thursday morning session featured speakers on either side of several debates in cornea. On the topic of neurotrophic keratopathy, John Sheppard, MD, Norfolk, Virginia, and John Hovanesian, MD, Laguna Hills, California, debated on whether medical or surgical therapy is better.

Dr. Sheppard stressed that medical therapy is the best option. He stressed that medical treatments can be preventive, supportive, for comorbidity control, or disease modifying.

He highlighted prevention, with surgical vigilance, herpetic vigilance, and HSV and VZV exposure transmission vigilance. In terms of surgical vigilance, he mentioned more torics and fewer LRIs, more lamellar corneal transplants and fewer PKs, more PRKs and SMILEs and fewer LASIK cases, and less mitomycin C and fewer preservatives. For herpetic vigilance, Dr. Sheppard mentioned both the zoster vaccination and aggressive, appropriate anti-viral therapy. He also highlighted the importance of HSV and VZV exposure transmission vigilance, especially for those who are immunosuppressed or immunocompromised and for newborns and the elderly.

He also mentioned several disease modifying treatments including nerve growth factor, amniotic membranes, and neurostimulation.

Arguing for surgical intervention, Dr. Hovanesian mentioned the many etiologies of neurotrophic keratopathy, noting that many people will have a lid dysfunction.

He mentioned a number of surgical treatments including cyanoacrylate tarsorrhaphy, Botox tarsorrhaphy, and a pedicle conjunctival flap. He also argued that using amniotic membrane can technically be considered surgical and added that this can address many non-healing defects.

The most effective medical therapy, Dr. Hovanesian said, is to stop all unnecessary medications. He suggested identifying lid disease and fixing it first to solve non-healing corneal epithelial defects. He also said to partner with a capable oculoplastics specialist; adopt simple techniques you can do in the office; and reserve biologics for cases where they are needed.

Editors’ note: Drs. Sheppard and Hovanesian have financial interests with a variety of ophthalmic companies.

EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators.

Medical editors: Eric Donnenfeld, MD, chief medical editor; Rosa Braga-Mele, MD, cataract editor; Clara Chan, MD, cornea editor; Nathan Radcliffe, MD, glaucoma editor; Vance Thompson, MD, refractive editor

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