• Identifying the Pre-Ectatic Cornea


    “While we still have much to learn, we understand corneal ectasias better than ever before”—and we have the ability to identify corneal ectasias “better than ever and at earlier stages than ever before,” said J. Bradley Randleman, MD, on Friday at Refractive Surgery Subspecialty Day. However, he noted, we’ve also learned that doing so takes great effort and acumen on the part of the physician and continuing technological advances. “There simply are no shortcuts.”

    Steps forward. Recent progress includes the advent of corneal epithelial thickness mapping, the understanding that corneal ectasia is what Dr. Randleman termed a “focally focal disease process. We know that indirectly when we look at corneal topography: The more steepening you have in one area, the more flattening you have in another.” Finally, there is growing recognition that inflammatory factors are involved, he said. With regard to the latter, he cited recent work on the focal reduction of lysyl oxidase.

    Missteps. “We’re all human; we want a roadmap that tells us exactly what to do,” Dr. Randleman said. That has led to an overemphasis on machine-derived metrics and overreliance on indices rather than detailed image analysis, among other missteps.

    Next steps. These will include genetic testing, biochemical analysis, and the possibility of point-of-care diagnosis, Dr. Randleman said. On the technology front, he cited the use of combined screening methods (e.g., Scheimpflug and epithelial mapping) as well as developments in speckle interferometry, Brillouin microscopy, and optical coherence tomography (OCT) elastography.

    Screening recommendations. How should patients be screened? At present, Dr. Randleman said, “We should use multiple complementary [screening] technologies. We should use all data available, not just—or even primarily—the metrics that the machine gives us, and we should evaluate all corneal surfaces.”

    In the future, he said, “Hopefully, we’ll be able to incorporate genetic testing, point-of-care inflammatory evaluations, and direct focal biomechanical measurements.” —Jean Shaw

    Financial disclosures. None.

    Read more news from AAO 2019 and the Subspecialty Day meetings.