March 1, 2019 Conference
AM - Cornea
Professional Practice Gaps: We obtained feedback from NEOS members, reviewed evaluations from prior NEOS meetings, and discussed with the Program Committee to identify potential practice gaps that include an update on medical therapy for infectious, inflammatory, and neoplastic disease of the cornea.
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically designed to fill the identified practice gaps in our membership's current and potential scope of professional activities in a way that focuses on education, while managing commercial support and maintaining independence from promotional activities and commercial proprietary interests. This program seeks to:
- Present an overview of infectious keratitis and outline strategies for proper diagnosis and effective treatment.
- Review current trends in the management of ocular surface tumors.
- Identify causes and therapies for ocular surface disease.
Prompt diagnosis of the etiology of infectious keratitis is essential to achieving optimum outcomes. Diagnosis is achieved most commonly through clinical observation, staining and culture. Advanced modalities such as confocal microscopy, polymerase chain reaction and genetic analysis can also have a role. We will review the context in which these options can be used in a general ophthalmology practice.
Ocular herpetic simplex and herpetic zoster keratitis is a common infectious cause of corneal blindness in the US. After primary infection occurs, significant ocular damage can occur when the virus reactivates. Treatment is tailored to clinical presentation and host comorbidity. Various ocular presentations and treatment options will be reviewed.
Michael E. Zegans
Fungal keratitis is a severe infection of the cornea that is more common in regions close to the equator. The microbiology of fungal keratitis varies by region as well, with filamentous fungi such as Fusarium and Aspergillus species being more common in tropical regions and yeast such as Candida albicans being more common in climates that are more temperate. Since the slit lamp cannot reliably differentiate fungal and bacterial keratitis, obtaining corneal cultures is the critical first step in initiating appropriate treatment of fungal keratitis. Fungal keratitis can also occur in outbreaks as demonstrated by the Fusarium spp. outbreak associated with Moisture Loc contact lens solution. Natamycin remains the antifungal, which is FDA, approved for the ocular surface. The recent Mycotic Ulcer Treatment Trial (MUTT) concluded that natamycin was superior to topical voriconzaole and found modest if any benefits to the addition of oral voriconazole while demonstrating an increase in drug related side effects. Fungal keratitis may often progress to corneal perforation or the need for a therapeutic corneal transplant. Furthermore, there are reports of increased risk of Candida interface infection in endothelial keratoplasty. Thus, fungal keratitis remains a complex and evolving challenge.
Ocular surface squamous neoplasia is the most common ocular surface neoplasia. It is characterized by a gelatinous, papillary, leukoplakic or opalescent features. While often easy to diagnose clinically, it may have subtle features and more challenging to identify in cases of co-existent ocular surface diseases. Wide excision with cryotherapy is the gold standard, but medical therapy has the advantage of treating the entire ocular surface, both obvious and subclinical disease. Newer methods of topical chemotherapy such as 5 fluorouracil, interferon, and mitomycin have gained increased popularity and will be discussed. High resolution optical coherence tomography is very helpful in the diagnosis and management of this disease and will also be presented.
Limbal stem cell deficiency (LSCD) leads to corneal neovascularization, pannus, corneal scar, and persistent corneal epithelial defects and ulceration. LSCD can be caused by inherited conditions such as aniridia, or acquired through trauma, such as after chemical injury, or severe autoimmune diseases, including mucous membrane pemphigoid and Stevens-Johnson syndrome/toxic epidermal necrolysis. LSCD can also occur in the setting of apparently minor injury if the injury is prolonged, for example, long-term contact lens wear. The objectives of this presentation are to review the clinical and adjunctive findings in LSCD, including a review of current concepts in imaging of LSCD.
Jia Yin, Ula Jurkunas, Reza Dana, Lynette Johns
Limbal stem cell transplant with cultivated autologous limbal epithelial (stem) cells (CALEC) is technology aimed at restoring vision for patients whose cornea has been compromised by limbal stem cell deficiency (LSCD). The CALEC study is a collaboration between Harvard Department of Ophthalmology, Dana-Farber Cancer Institute, the Jaeb Center, and the National Eye Institute. The research team has established a consistent manufacturing process to produce GMP-compatible cultivated autologous limbal stem cell product. We have received Investigational New Drug Application approval from the FDA to perform a clinical trial on CALEC transplantation at the Massachusetts Eye and Ear Infirmary. This is a single-center study to assess safety and feasibility of CALEC products and to compare their efficacy to the Conjunctival Limbal Autografts in 24 patients with unilateral LSCD. This is the first ex vivo limbal stem cell transplantation in the U.S. and will pave the way for the development of cell manufacturing technology based on rigorously vetted processes and will bring the novelty of a well-controlled stem cell-based clinical trial to the forefront of regenerative medicine.
Conjunctivitis is an umbrella term that implies inflammation of the conjunctiva. It is characterized by the combination of conjunctival injection (vascular dilation) and cellular infiltration and exudation. This inflammation can have many origins: infectious, toxic, pharmacological, mechanical, anatomical and allergic. This presentation will focus on infectious causes of conjunctivitis and will include diagnostic tips that will help in determining the underlying etiology of inflammation and hopefully lead to a quicker and more targeted treatment plan.
Pigmented lesions on the ocular surface can be benign or life threating. Common lesions include complexion associated melanosis, nevus, primary acquired melanosis, and the dreaded conjunctival melanoma. We will discuss the clinical features of each, how to best diagnose the pigmented lesion, and the management of each. This talk will focus on when to watch and when to worry.
PM Subspecialty Session: Trends in Refractive Surgery: From Baby Boomer to Millennial
Professional Practice Gaps: Feedback from NEOS members and Program committee review identified that given the new and evolving technologies in cornea and lens-based refractive surgery, it is critical for the refractive surgeon to have a sound understanding of the role of new options, particularly in the setting of longstanding-standard of care techniques. Refractive surgeons not only must evaluate the options but continue to understand how to grow and maintain their refractive practice.
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically
designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
1. Discussing the up-to-date refractive technologies in different generations.
2. Considering ways to approach and market your refractive practice.
3. Discussing ways of approaching the refractive patient with new technologies or unexpected outcomes.
Gregory J. McCormick
Helen K. Wu
Richard C. Rodman