No financial disclosures or conflicts of interest as it pertains to this presentation.

Transcription

1 No financial disclosures or conflicts of interest as it pertains to this presentation. Alan N. Carlson, M.D. Professor of Ophthalmology Chief, Corneal and Refractive Surgery Duke Eye Center April 26, 2014 JCAHPO /ASCRS What about eye rubbing? KC more likely to be allergic Allergic patients rub their eyes Therefore, KC patients are more likely to demonstrate allergic eye rubbing Connecting the Dots: 15 distinguishing features between allergic and KC eye rubbing buries her fist in her eyes better than sex I feel like I want to press so hard that someday I will touch my brain Follow up visit: Since you called it to my attention, I am now aware of my eye rubbing. (unaware, habitual) I asked my family, friends, coworkers about eye rubbing and they observed behavior that I was unaware. My mom reminded me that I used to be a horrible eye rubber. (reformed) OK, yes, I rub. I suppose you going to ask me if I also wet my bed. (embarrassed) Honestly, I can t find any history or pattern of eye rubbing. 1

2 Connecting the Dots: Asymmetric KC: Over 80% of patients prefer to sleep on the side that is worse. Pattern of pillow pressure also seen with post-lasik Keratoectasia Face down sleeping position common. Position impacted by OSA and Rx. Connecting the Dots: This is also a component link to FES And also ANC Sign Does mechanical injury help explain why only 7% of KC patients have a positive family history? Is corneal crosslinking less likely to be the optimal solution if it is merely making the cornea more resistant to trauma? Contact Lens & Anterior Eye xxx (2012) xxx xxx Contents lists available at SciVerse ScienceDirect Contact Lens & Anterior Eye Review: The role of heat in rubbing and massage-related corneal deformation Charles W. McMonnies a,, Donald R. Korb b,c, Caroline A. Blackie b,c a School of Optometry and Vision Science, University of New South Wales, Kensington 2052, Australia b Korb Associates, 400 Commonwealth Ave., Unit 2, Boston, MA 02215, United States c Tear Science, Inc., Morrisville, NC, United States a r t i c l e i n f o Keywords: Warm compresses Ocular massage Corneal deformation a b s t r a c t Purpose: To examine the role of elevated corneal temperature in the development of rubbing/massage-related corneal deformation and the possibility that warm compresses in the management of meibomian gland dysfunction or chalazion could contribute to such adverse responses. Methods: With reference to reports of corneal deformation associated with meibomian gland dysfunction, chalazion, dacryocystoceles and post-trabeculectomy, the mechanisms for increased corneal temperature due to ocular massage, especially when combined with warm compresses are examined. Results: Several mechanisms for rubbing/massage to elevate corneal temperature have been described, apart from the application of warm compresses or other forms of heat. Conclusions: Raised corneal temperature helps to explain corneal deformation which develops in asso-ciation with rubbing or massage in conditions such as keratoconus, chalazion, post-trabeculectomy, post-laser assisted in situ keratomileusis, post-graft and dacryocystoceles. When combined with warm compresses or other methods of heat delivery to the eye, the elevation of corneal temperature appears to explain how meibomian gland dysfunction treatment involving warm compresses and massage could induce rubbing-related deformation. Patients whose management involves iatrogenic ocular massage appear to require screening for risk of corneal deformation. Risk may be increased for patients with a concurrent habit of rubbing their eyes abnormally in response to allergic itch for example. It appears to be possible to modify ocular massage techniques to reduce the risk of corneal deformation. Careful tutoring and followup using corneal topography appears to be required when massage is prescribed, especially when used in conjunction with heat application. 2

3 3

4 RIGHT LEFT Right sided paralysis: Study Range Mean Other Details Sample Lass et al / Most common indication for PK in a patient age y.o. was KC. Making these patients y.o. now Where are they now? Yeung et al / Lim & Vogt Weed et al Ertan ) & Muftuoglu / Zadnik et al / Owens & Gamble 37 +/ Lass 10% > 50yo 417 Pobelle et al 7.4% > 50yo 121 Moodaley et al Majority < 40yo 337 Yildiz et al 40% > 50yo 697 Practitioner Mean Age Between 10 oldest nonkc vs KC pts LO 20.4 p< JK 21.0 p< JM 7.6 p< GB 20.9 p< PS 25.1 p<0.001 GW 14.2 p<0.001 NC 2.8 p>0.317 DK 4.6 p<0.046 JL 20.3 p<0.001 KR 14.7 p<0.001 Means 15.2 p<0.001 Maybe KC is not a disease isolated to the Cornea. Data from CL fitting optometrists in community-based private practice. Zero KC Pts >90yo and even when adjusting for sample size, the number of Pts > 80yo was less than 1/6 what was anticipated. 4

5 Beardsley and Foulks: Association of KC and MVP Overall prevalence = 38% Heterogeneous population PK 44% Beardsley TC, Foulks GN. An association of keratoconus and mitral valve prolapse. Ophthalmology 1982;89:35-7 In the past, MVP has been grossly overdiagnosed - up to 35% of patients in some reports were said to have MVP. However, careful studies have now shown that the actual incidence is roughly 2% to 3% of the general population. It seems likely, however, that many physicians still greatly over-diagnose this condition. Patients undergoing penetrating keratoplasty for KC were found to be significantly heavier (14.4kg on average) than controls who were non-kc patients requiring keratoplasty for corneal scarring. The average body mass index was high for both groups, but 52.8% of the KC group fulfilled the criteria of severe obesity, compared with 23.5% of the controls. Kristinsson JK, Carlson AN, Kim T. Keratoconus and obesity-a connection: Invest Ophthalmol Vis Sci 2003; 44: E-Abstract 812. Patients undergoing PK for KC are 8.6 times more likely to develop OSA-HS or considered high risk for developing it in the future. Gupta PK, Stinnett SS, Carlson AN. Prevalence of sleep apnea in patients with keratoconus. Cornea

6 HTN Pulmonary HTN Cardiac arrhythmias Cardiovascular disease Gastroesophageal reflux Obesity Keratoconus FES OSA Obesity Floppy Cornea Floppy Eyelid Floppy Soft Palate Floppy Belly Is my patient contributing to the progression of their KC with eye rubbing or pressure during sleep? How does this impact my consideration of CCCxl? Where are my elderly KC patients? Is there a reason to obtain a formal sleep study to establish whether or not they have OSA? Eye Rubbing Sleep position FES and KC Sleep position Eyelash misdirection Weight Gain MVP OSA Recurrent KC post-pk Post-LASIK Kerato-ectasia?Cross-Linking Where are the elderly KC patients? 6