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. drjjsalz@gmail.com

http://www.ubm.com/mailto:drjjsalz@gmail.comhttp://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.

tamihagemeyer@gmail.com

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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