Following in the footsteps of several other organizations that were to have meetings this spring but could not, due to the COVID-19 pandemic, the American Society of Cataract and Refractive Surgery, referred to most often as ASCRS, went virtual for its annual meeting. The meeting occurred May 16 and May 17 and offered a virtual exhibit hall, along with more than 30 CME and non-CME sessions via intimate videoconferences.

Here’s a look at some of the lectures presented during the Keratoconus Essentials and Corneal Essentials tracks:

Keratoconus Essentials

Topography and tomography enable the early diagnosis of keratoconus (KC), Kenneth A. Beckman, MD, explained during his “Diagnosis of Keratoconus: Topography and Tomography Pearls,” lecture, which opened the track.

Specifically, the imaging displays localized areas of steepening, regular astigmatism, asymmetric, mustache, sagging, skewed or truncated bowtie, skewed radial axis and asymmetry between the two eyes, posterior elevation of the cornea, crab claw appearance, or a bell shape — all classic signs of KC, he said.

“We tend to see the cones developing as early as the early teens, but it could be even younger, so I think [it’s important] to look for scissoring, failure to correct [with spectacles], and big changes in astigmatism or anything unusual like that to get patients evaluated with imaging,” Dr. Beckman explained.

Intacs (CorneaGen) are devices that provide structural support to the cornea and aid in biomechanical remodeling, said W. Barry Lee, MD, during his lecture “Intacs for Keratoconus.” He added that a combined technique with Intacs may benefit patients by providing some additional visual effect.

“. . . That’s where things like cross-linking with Intacs, cross-linking with conductive keratoplasty and Intacs, and Intacs with cross-linking and an implantable collamer lens to correct myopia might be the way to go,” he offered. “Or even doing topography-guided photorefractive keratectomy (PRK) down the road.”

Patients who undergo PRK after first going through cross-linking can achieve improvements in vision, said William Trattler, MD, in his lecture, “Laser Vision Correction in Patients with Keratoconus.”

“…The more time you wait, the better the [corneal] shape will often be. So, I typically recommend my patients wait one year, two years, three years and four or five is even better,” he explained. “It all depends on the patient, their hobbies or activities, and how much improvement we get as well… But the more a patient waits, the more potential improvement they can achieve.”

As there is a large overlap in visual complaints (e.g. glare and reading difficulty) related to corneal ectasia, KC and cataracts, and each cause requires different intervention, determining the true cause of these visual complaints is important. This is where an RGP lens comes in, reminded Brandon D. Ayres, MD, during his lecture, “Cataract Surgery Considerations in Keratoconus.”

“Make sure the patient is out of their contact lens, and then use an RGP lens, which separates the cornea issue from the cataract,” he said. “If the patient’s vision improves, you can be pretty well be assured that the cornea is to blame, and it’s not a lens issue.”

He added that many advocate for CXL in KC patients who have cataracts because the corneal flattening that results from the procedure may lead to a better refractive result post-cataract surgery.

In terms of IOL selection, Dr. Ayres said that in cases of astigmatism in relatively mild-to-moderate KC patients, a toric IOL can be used, though these patients should be made aware that if their astigmatism is higher than the IOL can correct, the procedure will be astigmatism-reducing, not eliminating.

Patients who undergo cross-linking (CXL) should have ongoing follow-up, especially in the first two years, noted Kathryn M. Hatch, MD, ABO, in her lecture, “Crosslinking: Current State of the Art.”

“Once they seem stable, they can continue to be followed yearly and be co-managed with referring optometrists or ophthalmologist, assuming that they have the appropriate diagnostic testing, including tomography,” she explained.

Additionally, Dr. Hatch pointed out that all 50 states now have more than six plans that cover the FDA-approved epi-off procedure and that Avedro’s ARCH Program (See https://bit.ly/2LXmAYl ) can assist with coverage for patients, including those who have state insurance.

Cornea Essentials

Given that adenovirus-caused epidemic keratoconjunctivitis looks an awful lot like conjunctivitis, which can be a symptom of COVID-19, Karolinne M. Rocha, MD, PhD, ABO, said ophthalmologists should consider testing red eye patients for the coronavirus, during a Q & A session after her lecture “Coronavirus/Adenovirus.”

“...We don’t know if we’re going to see a second peak of COVID, especially during the winter time, [so] it’s definitely something we need to consider,” she explained. “I think testing is important, so we can make the diagnosis, that patient can stay home, and we can avoid that transmission.”

Dr. Rocha added that telehealth visits for patients reporting red eye may also be a good idea to limit the possible spread of COVID-19, while recommending patients who report fever and cough contact their primary eyecare provider.

During her lecture on “Corneal Lumps and Bumps,” Clara C. Chan, FRCS, MD, went into detail about how superficial keratectomy can eliminate Salzmann’s Nodular Degeneration.

“When we do a keratectomy, we do it under a topical anesthetic, just kind of getting the edge off and then peeling the lesion,” she explained. “You want a dry surface to start, get that scrape away from the actual lump itself, just so you can get the edge. You can see the nice, smooth basement membrane, so then you know that you’ve gotten rid of everything that’s abnormal…”

As dry eye disease is significantly underdiagnosed in the pre-operative cataract patient and it can negatively impact IOL measurements, leading to an unsatisfactory refractive outcome, ophthalmologists should make screening for the ocular surface disease a priority before the procedure, said Preeya K. Gupta, MD, in her lecture, “Treating Ocular Surface Disease Before Cataract Surgery.”

“Ocular surface disease is very common in patients presenting for cataract evaluation, and we must treat it prior to surgery, especially in patients with high visual expectations,” she explained. “And we should know that biometry and keratometry readings do change after treating ocular surface disease, so I’d encourage everybody to screen their patients.” CP