This month’s issue showcases recent strides in cornea care, a somewhat sleepy category that doesn’t always get the attention it deserves. Among the other topics covered in this issue, dry AMD stands out as another perhaps overlooked area where optometrists can really shine if we put our minds to it.
Keratoconus is such a difficult condition because of its progressive nature, effects on vision and higher failure rates after transplants. Having new, more patient-friendly treatment options is greatly needed.
Imagine being able to treat keratoconus topically or crosslink the eye with just a scleral lens. Both concepts are in clinical trials. The first, a drug called IVMed-80 (iVeena), showed in its Phase II data a 1.8D mean reduction in K readings compared to placebo, an 11.3 letter improvement in BCVA over baseline and no treatment-related adverse events. The second concept, a scleral lens known as CXLens (TecLen), includes a built-in transducer that allows energy emission to crosslink the cornea. Riboflavin would be placed in the bowl of the lens and procedure would be completed in the optometrist’s office.
Although a very sound and comprehensive clinical study known as SCUT showed that using topical steroids in bacterial keratitis did not show greater vision loss, and actually improved outcomes in more severe cases, there are safeguards to keep in mind. First, be sure the patient has bacterial keratitis—avoid if there is a chance it could be fungal or HSV. Second, steroids are not recommended within 48 hours (preferably 72) if the infection may be caused by Pseudomonas (e.g., in contact lens wearers). Next, confirm the antibiotic you are using is working by clinical improvement, re-epithelialization or culture results that confirm the pathogen is susceptible to the antibiotic.
Limbal stem cell deficiency, (LSCD), although rare, can be somewhat easy to overlook. Damage to the limbal stem cells or to their microenvironment leads to LSCD. As a result, the corneal epithelium is replaced with conjunctival epithelial cells. A good history that identifies a previous trauma—such as a chemical burn, contact lens overwear, Stevens-Johnson Syndrome or aniridia—will help in the diagnosis.
Presentations vary but LSCD typical manifests superiorly with corneal staining and sometimes haze, epithelial irregularity, poor healing and recurrent erosion. Treatments range from biologics like amniotic membrane (Prokera, BioTissue; Apollo, Atlas Ocular) and autologous serum (Vital Tears) to cytokine extract drops (Regener-Eyes), lubricants and inflammation control. Scleral lenses can be effective. In severe cases, a limbal stem cell transplant can deliver unbelievable results.
Shifting gears from cornea, I can’t state enough how much I feel optometry needs to be the primary provider of dry AMD management. Optometrists see 85% of all comprehensive eye exams in the United States, and patients frequently ask us what options exist for this devastating condition. Five potential treatments are going through FDA trials for geographic atrophy, but much can also be done now.
Early detection can help a patient begin carotenoid supplementation. The most illuminating diagnostic for early AMD, with over 90% sensitivity and specificity, is dark adaptometry, which can now be performed with a device that resembles a virtual reality headset (AdaptDx Pro, Maculogix) and doesn’t require a separate room. If the patient has progressed to intermediate stage AMD (i.e., a least one large drusen), AREDS2 formulations are proven to slow progression.
To monitor the disease, at-home testing (Notal Vision) can help encourage patient buy-in due to its convenience. Don’t forget to recommend high quality sunglasses, as well as a healthy diet and avoidance of smoking. Dry AMD treatments involving the complement system could be on their way, but now is the time to be active in management, as this condition is more common than glaucoma and DR combined.
It’s an exciting time to be in practice with so many new tools in the development pipeline, but waiting for FDA approvals before you begin managing these conditions will leave you behind, as there are many treatment and management options available today.
Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chairman of the affiliated New Technologies & Treatments conferences. A fixture in optometric clinical education, he provides consulting services to a wide array of ophthalmic clients. Dr. Karpecki’s full disclosure list can be found here.