-
FALL 2016 | itech 1
Corneal collagen cross-linking
is a treatment for keratoco-
nus that was approved in the
United States in April 2016.
The procedure has long been avail-
able in Europe, and Avedros approval
of Photrexa brings it to many more
patients in need.
-
tion of keratoconus.
Understanding keratoconusKeratoconus is a progressive, degen-
eration of the cornea which often be-
gins in teenagers and slowly pro-
gresses at a variable rate for the rest
of the patients life. It is estimated
that the incidence of keratoconus
in the United States is about one in
2,000 patients, but that number may
be much higher if calculated using
modern screening strategies. In some
countries, keratoconus is much more
common, affecting as many as one pa-
tient in 500.
Because the cornea is the primary
focusing lens of the eye, even mild
cases of keratoconus have an effect on
the quality of the patients vision. The
most common early symptom of kera-
toconus is blurred vision caused by
astigmatism. Keratoconus is almost
always bilateral, but it can be more
advanced in one eye than the other.
correct the vision; however, the
amount and axis of the astigmatism
in keratoconus changes frequently,
and in many patients glasses no lon-
ger provide clear vision and contact
lenses are often required. Because the
astigmatism is asymmetrical, rigid
gas permeable contact lenses usually
provide the best vision.
Most patients can function for
years with contact lenses, and in
fewer than 10 percent of patients the
degeneration becomes severe requir-
ing corneal transplantation. Figure 1
shows a side view of a cornea with a
cone-shaped protrusion indicating ad-
vanced keratoconus.
Diagnosing and treating keratoconusFrequent changes in a patients pre-
scription may be an early sign of kera-
made with corneal topography.
The corneal topographic map
shows the shape of the cornea, much
like a topographic map of the Earth
in which red and yellow colors indi-
cate a steep curve (mountains), and
curve (oceans and plains). Typically,
The recently approved procedure will help many with this progressive diseaseBy James J. Salz, MD
Corneal collagen cross-linking for keratoconus
Fall 2016SUPPLEMENT TO Ophthamology Times and Optometry Times
Building the Ophthalmic Tech'sCommunity of Practice
1 FIGURE 1 Cornea with advanced keratoconus
CROSS-LINKING CONTINUED ON PAGE 4
James J. Salz, MD is clinical professor
of ophthalmology at the University of
Southern California Roski Eye Insti-
tute. [email protected]
http://www.ubm.com/mailto:[email protected]://optometrytimes.modernmedicine.com/tag/itech
-
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4 itech | FALL 2016
Prof. Theo Seiler learned about colla-
gen cross-linking during a visit to his
dentist. The dentist was performing
a procedure to strengthen Dr. Seilers
gums. The gums were painted with
were strengthened when they were
exposed to ultraviolet light for several
minutes.
Intrigued by this process, Profes-
sor Seiler performed experiments
on rabbit corneas and found that the
treated corneas were more rigid after
cross-linking than the control cor-
neas. He then began a study on pa-
tients with keratoconus and published
the preliminary results in 2003.1
cornea in the horizontal plane, and
-
gether by attaching the elements at-
the inferior part of the cornea in kera-
toconus becomes steeper, so the map
shows a red spot in the lower por-
tion of the cornea (Figure 2 top). As
the cone progresses, the steep area
becomes steeper and larger, and the
astigmatism increases (Figure 2 bot-
tom right). The area of the cone also
becomes thinner than the surround-
ing area.
The pathology of keratoconus is
due to an often inherited weakness
of a portion of the millions of colla-
!
of the cornea. Until recently, kerato-
conus was treated with glasses, con-
tact lenses, and, in a small percentage
of patients, with corneal transplant
(penetrating keratoplasty) surgery
when the keratoconus progressed to
the point that contact lenses were no
longer adequate.
Now, a procedure called corneal
cross-linking can halt progression in
most patients and even cause some
regression of keratoconus. This pro-
cedure will dramatically reduce the
number of patients who will require
corneal transplants during their life-
times and provide patients with many
alternatives for vision improvement.
Corneal collagen cross-linking therapy""-
bers leads to a bulging of the cor-
nea (ectasia). More than 15 years ago,
Cross-linkingContinued from page 1
CORNEA
Investigations are
underway with
cross-linking without
removing the
epithelium, the epi-on
procedure
FIGURE 2
Top: Corneal maps of inferior steepening typical of early keratoconus in both eyes.
Bottom: Left, cornea suitable for crosslinking. Right, central cone too steep for crosslinking.
FIGURE 3
6FKHPDWLFGLDJUDPRIKRUL]RQWDOFROODJHQEHUVZLWKYHUWLFDOFURVVOLQNV(Image courtesy of Eyemaginations)
2
3
-
FALL 2016 | itech 5
keratoconus was published in 2003
by Drs. Wollensak, Spoerl, and Seiler2
in 23 eyes of 22 patients with follow-
up from three months to four years.
In all treated eyes, the progression
of keratoconus was halted. In 16 eyes
(70 percent), regression with a re-
duction of the maximal keratometry
readings by 2.01 D and of the refrac-
tive error by 1.14 D was found.
Since that initial report, other
!
collagen cross-linking is effective in
stabilizing most corneas with kerato-
conus and in many cases reducing the
magnitude of the cone as evidenced
by a decrease in the steepest K read-
ing and a reduction of myopia and/or
"-
-
bers are then stronger, and the num-
ber of crosslinks increase following
cross-linking.
Cross-linking is indicated when
it can be demonstrated that the cor-
neal ectasia is progressing over time.
This can be shown either with in-
creasing astigmatism and/or an in-
crease in the keratometry (K) read-
ings by manual K readings or through
the topography map. The usual cri-
teria are an increase in the subjec-
tive amount of astigmatism of 1.00 D
or more through refraction, or more
commonly, objectively with manual K
readings or on the map, with exams
one year apart. Corneal thickness
should be at least 400 m in the thin-
nest portion of the cornea. In younger
*"!
physicians are advocating for treat-
ment at the time of initial diagnosis
because these patients are likely to
progress over their lifetimes.
The most common method of cor-
!-
ally remove the corneal epithelium
in the epi-off procedure (Figure 4),
-
vin drops for about 30 minutes. Once
-
side the anterior chamber, visible as
-
-
9
-
CORNEA
6 itech | FALL 2016
astigmatism.
Wollensak3 provided a long-
term follow-up review of cross-link-
ing using the Dresden protocol. The
"
Dresden clinical study have shown
that in 60 treated eyes, the progres-
sion of keratoconus was halted in all
60 eyes. In 31 of the eyes, there also
"
?
In another long-term study of 40
eyes in 32 patients, Haehemi4 con-
-
sults, treatment of progressive ker-
atoconus with corneal cross-linking
can stop disease progression, with-
out raising any concern for safety,
and can eliminate the need for kera-
toplasty.
Because cross-linking usually in-
volves removal of the epithelium and
""
bandage contact lens, complications
are always possible, just like those
that might be expected from a pho-
torefractive keratectomy (PRK) or
prolonged wearing of soft contact
lenses.
Dr. Seilers group performed a
PubMed search of reported compli-
cations of corneal crosslinking.5 The
researchers reported the published
complication rates of the procedure
ranged from 1 percent to 10 percent,
depending on the stage of keratoco-
nus. Early postoperative complica-
tions were transient stromal haze,
!!-
pensation, delayed epithelial healing,
and infectious keratitis.
Stromal opacity (Figure 7) can be
a delayed postoperative event. In an-
Q
linking appears to have a very high
"!-
tions.
Wrapping upCorneal collagen cross-linking is a
major advance in medicine and for the
!-
tunity to stabilize and at times par-
tially reverse the progressive changes
usually observed over their lifetime.
Because keratoconus is a worldwide
problem affecting thousands of pa-
tients, the necessity of corneal trans-
plants and frequent changes in the
prescription for glasses and contact
lenses will be dramatically reduced.
For further reading, Randleman et
al have published an extensive review
article with 170 references on corneal
cross-linking.6
References
1. Rush SW,Rush RB. Epithelium-off versus
transepithelialcornealcollagencrosslinkingfor
progressivecornealectasia: a randomized and
controlled trial. Br J Ophthalmol.2016 Jul 7. pii:
bjophthalmol-2016-308914. doi: 10.1136/bjophthal-
mol-2016-308914. [Epub ahead of print]
2. Wollensak G,Spoerl E,Seiler T. Riboflavin/
ultraviolet-a-inducedcollagencrosslinkingfor the
treatment ofkeratoconus. Am J Ophthalmol.2003
May;135(5):620-7.
3. Wollensak G. Crosslinkingtreatment of progres-
sivekeratoconus: new hope. Curr Opin Ophthal-
mol.2006 Aug;17(4):356-60.
4. Hashemi H,Seyedian MA,Miraftab M,Fotouhi
A,Asgari S. Corneal collagen cross-linking with
riboflavin and ultraviolet a irradiation for kerato-
conus: long-term results. Ophthalmology.2013
Aug;120(8):1515-20.
5. Seiler TG, Schmidinger G,Fischinger I,Koller
T,Seiler T. Complications of corneal cross-linking.
Ophthalmologe. 2013 Jul;110(7):639-44.
6. Randleman JB, Khandelwal SS, Hafezi F.
Corneal cross-linking. Surv Ophthalmol. 2015 Nov-
Dec;60(6):509-23.
Cross-linkingContinued from page 5
7 FIGURE 7 Corneal haze as a complication of cross-linking.
This procedure will dramatically reduce the
number of patients who will require corneal
transplants during their lifetime and provide
patients with many alternatives for vision
improvement
-
FALL 2016 | itech 7
Super optician to the rescue!A Post-It note leads me on a quest to make it right for the patient
Tami L. Hagemeyer, ABOC, is responsible for optometric and medi-
cal eye care at Premier Vision Group in Bowling Green, OH.
After three glorious vacation
days, days I spent catch-
ing up with my family and
getting some much-needed
!"
ciate time off as much as anyone, but
after a few days away to recharge I
"!"
its cheerful photos and framed moti-
vational messages designed to keep
me in my imagined happy place. It is
almost always a pleasure to return to
my little home-away-from-home" in
"
Almost always.
Post-Its everywhereThis return would have been per-
fect if it werent for the dreaded Post-
It notes! These Post-It notes are be-
coming the bane of my professional
existence and wreaking havoc in my
"
found stuck everywhereon my com-
puter screen, on my keyboard, and
this week a Post-It had been placed on
one of my beloved motivational mes-
sage frames.
After a few deep breaths, I began
perusing through the seven or eight
Post-Its when one note caught my at-
tention. It was from the optometrist,
and said: Mr. Smith stopped in today
and is noticing blurred vision with his
new sunglasses. I re-checked his re-
fraction, and the problem does not
seem to be with his new prescription.
I did, however, notice his sun frame
has quite a curve on it, would you
please check the base curve?
He went on to explain the lensom-
pupillary distance. He wrote, I told
!!
-
itech | FALL 2016
tical dilemma.
I admit I had thoughts of return-
ing his new sunglasses to our lab for
a lens evaluation when our patient
dropped in. It seems he was curious
about the situation and wondered if
I had any new thoughts. I spoke with
complete candor when I told him that
I was currently working on a solution
but hadnt found it yet.
I asked him to put the new sun-
glasses on and describe exactly what
he was experiencing. He said his vi-
sion seemed blurred, and it was im-
possible for him to read the docu-
ments on our wall approximately 15
feet away. He then put on the new
dress glasses and read the documents
with complete clarity. I asked to see
his previous/original sunglasses.
When he retrieved them from his
car, to my surprise the lenses had the
same base curve as his dress glasses,
which was approximately 6.25 BC OU.
That seemed a little strange because
"!-
cant wrap. When looking directly at
my patient, I realized the frame had
a natural wrap from the bridge. The
new lenses, however, had a base curve
"?9!
style. It was becoming clear to me
what the possible problem might be.
Making it right for the patientI removed both lenses from the new
sunglass frame and let them rest
for about 10 minutes. Then, using my
lens clock, I checked the base curve
again. After rest, the lenses were both
at approximately 7.50 BC. I have a
TAMI IN THE TRENCHES | One tech's take on the day-to-day job
shown by the doctor in my ability as
the answer for the patient. The second
thing the note meant is that I had some
serious detective work to do.
Figuring it out, step by stepI began by reviewing the patients
comparing it with any changes made
by the doctor. The changes were mini-
!
was an addition of prism in each eye.
I also noted the chief complaint dur-
ing his most recent comprehensive
eye examination of his distance vision
seeming slightly weaker than during
his previous examinations.
It was interesting that my patient
had also purchased dress glasses that
were dispensed without any complica-
tion, which was an indication to me that
the new prescription was, as the doctor
thought, probably not the cause.
The plot thickened as I realized
the patient had purchased the exact
frame with the exact style, material,
and lens tint the year before, so he
clearly had been comfortable with the
base curve of the frame and lenses.
I continued by checking the pupil-
lary distance, which had not changed
from the previous year. Every mea-
!!-
prit could possibly be the position of
the frame on his face together with
the new prisms; the placement of the
lenses may hold the answer to our op-
Post-It questContinued from page 7
!!"
for occasional lens size corrections. I
began by re-edging the lensesmin-
imal edging was necessary because
I didnt want the lenses too small for
the frames. I re-mounted them in the
frame. Much to my relief, the lenses
seemed better to my patient. His vi-
sual acuity was improved, and he was
able to read some of the wall docu-
ments. Following adjustments to the
wrap of the frame, our patient began
to feel more comfortable with his new
sunglasses. However, in the end I had
to return the sunglasses to my lab
because the lenses did not maintain
their base curve, which did not opti-
mize my patients new prescription.
When his sunglasses arrived fol-
lowing their re-make, I allowed extra
time during dispensing to talk with
my patient. We discussed the events
that had transpired and the many
steps we had gone through to ensure
I made certain he understood that
his visual comfort was our top prior-
ity. After careful alignment, his visual
acuity seemed perfect.
"
that although he had to make several
"
second, and the extra attention as-
sured him that he is a valued patient.
Although my patient had to wait an
additional three days to receive his
new sunglasses, I had been able to re-
making a return visit probable.
I dont think of myself as a super
!
!-
mas. I also take great pleasure in de-
veloping an understanding of trust
with the doctortogether we recog-
nize each individual patient and his
importance to our practices contin-
ued growth.
Although my patient had to wait an additional three
days to receive his new sunglasses, I had been able
WRUHVWRUHKLVFRQGHQFHLQRXUSUDFWLFHPDNLQJD
return visit for his eyewear probable
-
FALL 2016 | itech 9
ETHICS
The ethics of care for technicians8QGHUVWDQGKRZDXWRQRP\MXVWLFHEHQHFHQFHDQGnon-malfeasance come into play
I have often wondered why there
are a limited number of ethics
classes available for technical
staff to take
While the doctors have the Hippo-
cratic oath that binds them to their
areas of practice, where is the oath
that the technical staff takes to en-
sure we are all working under the
same premise?
We know that our role is to ensure
that the patient is protected, physi-
cally cared for, and that all caregiv-
ers are responsible to ensure that
we always do the right thing when
it comes to their care. But where do
these tenets come from and what do
they actually mean to us?
'HQLQJHWKLFVAccording to the Oxford Dictionary,
ethics are the moral principles that
govern a person's or groups behav-
ior. Ethics deal with right and wrong
types of behaviorwhat we ought
to do. Ethics are a set of moral prin-
ciples and the code of behavior that
governs an individuals actions with
other individuals in a society. We
need to be aware that ethics can, and
do, differ among cultures.
Laws are not ethics. Laws are so-
-
ments for violations; ethics do not
have established punishments.
Every day, we are put in the posi-
tion to determine what is right and
wrong about a given situation or our
behavior.
Medical ethics are simply ethics as
they are applied to medicine.
Tom L. Beauchamp and James F.
Childress, authors of Principles of Bio-
medical Ethics, determined that med-
ical ethics work with the principles
"!{
non-malfeasance.
AutonomyAutonomy addresses respect that a
patient has the ability to make deci-
sions for his own care. This respect
works with the belief that the patient
has the capacity, and the right, to
think, decide, and act on his own be-
half regarding his care.
The patient needs to be able to
make a rational, informed, and un-
coerced decision. In order to do this,
he must be given the information to
make that decision and have the abil-
ity to ask questions of the doctor to
make sure he has all the information
he needs. Note that the patient must
be able to ask questions of the doctor,
not the technician or nurse.
The concept of autonomy leads to
informed consent. This means that a
patient cannot have any medical in-
tervention for diagnostic, investiga-
tional, or palliative purposes without
granting permission. The patient must
"
the intervention. Informed consent
encompasses more than asking a pa-
tient to sign a written consent form.
"
communication between the patient
and the responsible physician who is
providing the care that results in the
patient's authorization and/or agree-
!!-
tervention.
For example, if your patient is
scheduling surgery, the doctor should
discuss the procedure, the hoped-
for outcome, and any potential risks.
Informed consent is a conversation
which takes place before the form is
signed. Be sure the form is signed in
"!-
tient. You cant be sure that your pa-
By Dianna E. Graves, COMT, BS, Ed
Dianna Graves is clini-
cal services manager at
St. Paul Eye Clinic PA, in
Woodbury, MN. TECH ETHICS CONTINUED ON PAGE 10
-
10 itech | FALL 2016
ETHICS| Do the right thing with patient care
sion must be made on the facts on pa-
tients medical conditions, not on race,
ability to pay, creed, religion, or per-
sonality. The patient with a lacerated
eyelid is going to be seen before all
the other patients, regardless of their
appointment times.
%HQHFHQFH!
""
help prevent harm, to remove harm,
or to improve the situation of others.
It requires that any intervention that
is given will be given with the intent
of doing good for the patient.
Non-malfeasanceNon-malfeasance requires that any
procedure done to a patient does not
harm the patient involved or others in
society. From this the concept of do
no harm arises.
Non-malfeasance protects the pa-
tient from physicians who provide in-
effective treatments to a patient even
if the patient asks for that treatment.
More ethical considerationsTwo other areas also address ethics
attitude.
One of these areas
-
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/EWZ^KEKE>/EKZzW,KEz>hKwww.EYLEA4U.com/IT
d^zEtzE/EYLEA4Uz>
2015, Regeneron Pharmaceuticals, Inc., All rights reserved 10/2015
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EYLEA and EYLEA4U are registered trademarks of Regeneron Pharmaceuticals, Inc.
http://www.EYLEA4U.com/IT
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