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Topical anti-inflammatories may be effective in keratoconus
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BALTIMORE – An inflammatory component of keratoconus may be exacerbated by contact lens wear, according to a presenter here at a symposium on evidence-based medicine.
While the etiology of keratoconus remains unclear, Albert Jun, MD, PhD, reviewed new research indicating that an inflammatory component can be measured in altered concentrations of inflammatory molecules such as IL 6, IL 10, TNF-alpha and matrix metalloproteinases. This evidence may support the study of topical anti-inflammatory drops for treating and preventing disease advancement, he said at the symposium, which was jointly sponsored by Wilmer Eye Institute and the Maryland Optometric Association.
Ashley Behrens, MD, presented data indicating that surgical intervention such as intrastromal corneal rings or ultraviolet light cross linking in unscarred corneas may stabilize corneal curvature and best corrected visual acuity in keratoconic patients. The panel discussion debated if cross linking should be considered earlier, before any scar formation.
It is well known that keratoconic patients are not candidates for laser ablative procedures due to an increased risk of corneal ectasia. Are we able to predict, however, which “seemingly normal” patients may become ectatic? Andrew Morgenstern, OD, and J. Christopher Freeman, OD, debated this topic using evidence-based medicine from six published studies. While it quickly became apparent that certain groups are at a higher risk, research has yet to predict with certainty when ectasia can be foreseen after uncomplicated ablative procedures.
Jeremy Goldman, OD, presented a review of the Collaborative Longitudinal Evaluation of Keratoconus (CLEK) study and its impact on modern gas-permeable fitting techniques. The audience response system tested attendees’ understanding of the First Definite Apical Clearance (FDACL) fitting philosophy studied, which was recommended in the CLEK publications. While no causal relationship was found between a steep or flat fit and retardation of disease severity, the audience survey found that 76% still design their lenses with apical touch.
Research in nutraceuticals
Discussions reviewing the use of nutraceuticals shed light on the overwhelming lack of evidence for compounds such as bilberry for improvement of night vision and retinitis pigmentosa. In contrast, many practitioners commonly recommend either flaxseed or fish oil for symptomatic relief of dry eye.
Studies of these supplements have shown that omega-3 fatty acids have anti-inflammatory properties that act on various cytokines and TNF-alpha. The possibility for an inflammatory component in the etiology of keratoconus sparked discussion of the potential role of these over-the-counter supplements for the retardation and inhibition of keratoconus development.
Low vision/occupational therapy
When refractive, pharmaceutical and surgical methods fail, many patients are in need of low vision rehabilitation and occupational therapy.
Judith Goldstein, OD, advised primary care doctors to avoid prescribing for such patients during a comprehensive exam. Schedule follow-up visits for specialty low vision examinations, clarifying goals for successful rehabilitation and developing a plan tailored for the patient’s daily needs, she said.
Dr. Goldstein also presented encouraging results of the Low Vision Intervention Trial (LOVIT), which concluded that patients suffering from macular disease who received orientation and mobility as well as low vision therapy showed statistically significantly higher improvement in daily functioning and reduced mental depression.
For more information:
- Rich Zimbalist, OD, can be reached at rich.zimbalist@gmail.com.
- Elliott H. Myrowitz, OD, MPH, is an assistant professor and chief of optometric services at the Wilmer Eye Institute, Johns Hopkins University School of Medicine and Johns Hopkins Hospital. He can be reached at (410) 583-2800; e-mail: emyrowitz@jhmi.