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Accelerated CXL Protocol, New Imaging Aid Keratoconus Care

The advent of corneal collagen crosslinking (CXL) using ultraviolet A (UV-A) redefined the progressive keratoconus (KC) treatment paradigm from one of management to one of active, non-invasive intervention. Accelerated CXL, one variation of the Dresden protocol, uses higher levels of UV light over shorter durations of time, in effect administering the same UV dosage as conventional CXL treatments while providing for reduced procedure time.

A new study in the journal Cornea looked at the impact of accelerated CXL, mediated by exposure to a UV-A irradiance of 18 (mW/cm2) for a period of five minutes, on progressive keratoconus. The study examined the effects of the CXL protocol through follow-up visits over the course of up to 21.7 months.

Sjögren’s Markers May Signal Conjunctival Damage

There may be a connection between serologic markers and conjunctival damage in patients with Sjögren’s syndrome, reports a study in Cornea. Researchers evaluated 64 patients diagnosed with primary Sjögren’s according to the 2012 Sjögren’s International Collaborative Clinical Alliance (SICCA) criteria. Serum anti-Ro/SSA, anti-La/SSB, rheumatoid factor (RF), antinuclear antibody (ANA) levels, Ocular Surface Disease Index (OSDI), Schirmer I test values, tear breakup time and SICCA ocular staining score (OSS) were determined. A strong correlation between serum RF and ANA levels and conjunctival staining scores and the total OSS was identified, suggesting conjunctival damage. Further study is needed to investigate the OSDI and SICCA OSS at multiple time points after treatment. More

Corneal Sensitivity Indicates Dry Eye Severity

Dry eye patients exhibit varied but diminished corneal sensitivity (CoS), suggesting there are different states of ocular surface compensation for the disease. Researchers measured the CoS and evaluated the tear films of forty-six patients with DES four times over the course of three months, and observed a statistically significant change in sensitivity values, especially with more severe disease. More

New Tear-Infused Contact Lenses Released

A new tear-infused lens material technology from Johnson & Johnson Vision Care is designed to help wearers tolerate their lenses longer. The Acuvue Oasys Brand Contact Lenses 1-Day with HydraLuxe mimic the body’s natural mucins to lubricate and moisturize the eye, improving comfort, J&J says. More

Check out more articles from the October issue of RCCL here!

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20 Pearls on Corneal Infection Care

As the number of contact lens wearers worldwide continues to increase, so too does the number of patients presenting with complex, sometimes treatment-resistant corneal infections. To help, the October issue of Review of Cornea & Contact Lenses is devoted to broadening your knowledge of the management of different corneal infections. Below are 20 pearls shared by several experts in the field. For more detail, click through to read the original articles for each.

Signs and symptoms of bacterial keratitis typically commence within 24 hours of infection; watch for photophobia, decreased visual acuity, redness, discharge, eyelid swelling and pain of varying degrees. More
2. Though controversial, adjunctive topical steroids can aid bacterial keratitis treatment. After 24 to 48 hours of antibiotic therapy, adding a topical steroid BID to QID can help speed resolution and possbily reduce corneal scarring. More
3. Because early Acanthamoeba keratitis often presents with a dendritiform or a nonspecific keratitis, two-thirds of these patients are misdiagnosed as having HSV keratitis. Pain out of proportion to clinical findings—a classic Acanthamoeba indication—can differentiate between the two. More

4. For suspected or confirmed cases of Pseudomonas, gatifloxacin and ciprofloxacin provide better coverage than other FQs. Concomitant use of tobramycin or bacitracin/polymyxin B provides an even broader spectrum of coverage and further limits resistant bacteria. More
5. In suspected infectious keratitis, obtain corneal scrapings for Gram stain and cultures with blood agar, chocolate agar, Sabouraud dextrose agar and thioglyoclate broth. Note, however, once the infection has advanced deeper into the stroma, a corneal biopsy may be necessary to confirm the diagnosis. More

Stains and cultures are best pursued if the ulcer is large; is centrally located; involves the mid or deep stroma; is an infection that has been unresponsive to initial treatment; or has atypical features that may indicate fungal, amoebic or mycobacterial keratitis. More
7. The clinical picture of herpetic uveitis can be quite variable: look for fine or granulomatous keratic precipitates that may be distributed diffusely, in Arlt’s triangle or in a linear pattern. Concomitant corneal edema, IOP spikes or sectorial iris atrophy may also appear. More
8. Treatment of isolated viral uveitis should include both oral antivirals at the correct treatment dosage for the suspected etiology, and a topical, and in some cases, oral corticosteroid to enhance penetration of medication into the anterior chamber. More
9. When evaluating a patient for a bacterial infection, recording a thorough contact lens history, including nature and duration of symptoms, presence of discharge and changes in vision, can help pinpoint severity as well as identify more rapidly evolving infections. More
10. Herpes viruses can remain dormant within the host and reactivate later; as such, these eyes must be treated over both the acute and chronic phase of the disease to prevent inflammation, scarring and a possible need for retransplantation. More
11. Treatment should be tailored to the causal organism; however, in the case of a rapidly progressive disease process, patients cannot afford to wait until Gram stain results return. In these cases, consider first-line empiric treatment, which provides broad coverage against both Gram-positive and Gram-negative organisms. More

When differentiating between Gram-positive and Gram-negative ulcers, consider the color: Gram-positive organisms will present with a well-demarcated yellow and gray-white area of infiltration directly beneath the epithelial defect, while gram-negative infections are more diffuse in presentation with a “soupy” or “wet” appearance. More
13. Culture specimens should be obtained from the conjunctiva and lid margins of infected eyes, as well as from the leading edge and base of the corneal ulcer using a calcium alginate swap moistened with thioglycolate or trypticase soy broth. More
14. In herpes zoster, dosing 400mg of acyclovir BID can reduce the rate of recurrent stromal disease—the manifestation most likely to lead to corneal transplant; however, long-term use can lead to acyclovir resistance, so only use the drug in cases that absolutely require it. More
15. In cases of a corneal ulcer with corneal performation, consider amniotic membrane transplantation, which promotes re-epithelialization and inhibits inflammation. Use bandage contact lenses, autologous serum eye drops, punctal plugs or tarsorrhaphy to assist with healing. More
16. Mild cases of adenovirus are self-limiting and can be treated using supportive means like chilled artificial tears, cool compresses and topical antihistamines; moderate to severe cases involving subepithelial infiltrates and symptomatic pseudomembrane formation should be managed using topical steroids. More
17. Consider older, less frequently used drugs such as bacitracin, gentamycin and sulfacetamide for treatment-resistant corneal ulcers. For Gram-positive resistant bacteria, topical, fortified vancomycin can be used as a last resort. Be sure to tailor therapy as necessary using culture and sensitivity. More
18. Fungal infections often have impressive anterior chamber inflammation with endothelial plaque and hypopyon. Despite this inflammation, they often have less lid edema and hyperemia than classically seen with bacterial infections. More

19. Therapeutic PK can be used as a last resort in cases of corneal perforation or progressive corneal and scleral melt. Success of the graft is typically higher when the infection is localized and inflammation is controlled prior to surgery. More

Early detection of adenovirus is imperative for successful management; look for symptoms including unilateral tearing, redness, photophobia and eyelid edema, as well as conjunctival chemosis, follicular conjunctivitis and preauricular lymphadenopathy. More

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