July 1, 2024 • 18 mins
Clearly KC host Dr. Melissa Barnett OD explodes some myths with crosslinking expert Dr. William Trattler MD, of the Center for Excellence in Eye Care in Miami. He shares that patients with extremely thin corneas can be successfully crosslinked if the surgeon makes some adjustments in the treatment protocol. While most crosslinked patients will not need a second procedure, he observed that a repeat treatment can be safely performed if progression is suspected. Another myth debunked is that disease progression stops at age 40. Dr. Trattler reported seeing progression in older patients, often after years of no change, reinforcing the need for annual follow-up exams even after crosslinking or years of stability.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
Welcome to episode 27 of the Clearly KC podcast, featuring information about life with keratoconus.
I'm your host, Dr.
Melissa Barnett.
Today, it's a special treat.
.999We're joined by Dr.
William Trattler, MD, who is the Director of Cornea at the Center for Excellence in Eye Care in Miami, Florida.
(00:25):
He was part of the original FDA clinical trial for epithelium off corneal collagen crosslinking in 2008 and was one of the first doctors in the U.
S.
to perform epi on as part of the CXL USA clinical trial that started in 2010.
Today we are going to debunk several myths about crosslinking and keratoconus.
(00:50):
Welcome, Bill.
Thank you so much, Melissa.
I'm so honored to be here.
Thank Oh, I'm so happy that you're here and it was such a pleasure to see you not too long ago as well.
First let's begin with the consultation.
Say you have a patient in your chair who's newly diagnosed with keratoconus. 17 00:01:09,614.999 --> 00:01:16,180 How do you explain crosslinking to that patient and their family? Of course.
(01:16):
Obviously it depends on the age because we often have, parents bringing their children in, or it could be an older patient.
But basically it's a very simple concept that cross linking is an hour and 10 to hour and 20 minute treatment.
that strengthens the cornea.
you have a weak cornea.
The cornea is slowly outwards and instead of being round like a basketball, it's becoming steep like the tip of a football.
(01:37):
.999And what our goal is, is to perform this procedure to strengthen the cornea, stop it from getting worse. 24 00:01:42,884.999 --> 00:01:46,065 And slowly over time, most patients get improvements in the corneal shape.
Excellent.
What is the most common follow up question that a patient asks when you explain it? A few questions.
is there's a procedure hurt? And thankfully, the answer is no.
(01:58):
Obviously, we're using anesthesia.
So regardless of the technique, it's a very comfortable procedure for patients. 30 00:02:04,344.999 --> 00:02:06,595 They also want to know the longevity of the procedure. 31 00:02:06,904.999 --> 00:02:19,424.998 Will I need to have a second treatment in the future? Is it last for a few years? And I think the data supports that the success rate is between 97 percent to 99 percent of patients will need just one treatment over the first five to 10 years. 32 00:02:19,684.999 --> 00:02:22,614.999 But there is going to be a small percentage of patients that will need a second treatment. 33 00:02:22,884.999 --> 00:02:29,654.999 So I always advise them that it's really important to come back for annual follow ups even when they get treated with Yes, most definitely. 34 00:02:29,705.099 --> 00:02:31,65.099 Let's debunk some myths. 35 00:02:31,895.099 --> 00:02:36,405.099 Many people believe that older individuals with keratoconus do not progress. 36 00:02:36,565.099 --> 00:02:39,415.099 What is your experience? Yes. 37 00:02:39,415.099 --> 00:02:44,305.099 I remember hearing that concept, that somehow older patients were magically, strong. 38 00:02:44,305.099 --> 00:02:52,215.1005 I had a, optometry student from, Canada with me today, and he said, Oh, I thought that the cornea self crosslink is you get, over the 40. 39 00:02:52,555.1005 --> 00:02:53,225.1005 They don't progress. 40 00:02:53,225.1005 --> 00:02:54,625.1005 And that was his concept. 41 00:02:54,895.1005 --> 00:02:58,285.0005 If you think about it, the, cornea in a keratoconus patient is just weak. 42 00:02:58,285.0005 --> 00:03:00,655.0005 We know that it's weak from corneal strength testing. 43 00:03:00,775.0005 --> 00:03:02,485.0005 And so let's just take an easy example. 44 00:03:02,485.0005 --> 00:03:13,885.0005 If you have a patient that has more advanced keratoconus, they have steep corneas and very thin corneas, how is that cornea gonna be magically strengthened just as they get older? their cornea is always going to be weaker than a normal cornea. 45 00:03:14,85.0005 --> 00:03:14,899.9995 do you Yes. 46 00:03:15,150.0005 --> 00:03:15,980.0005 Yes, definitely. 47 00:03:16,955.0005 --> 00:03:24,485.0005 yeah, so it makes sense that patients that are more advanced that have steeper corneas to begin with are, less likely to be stable long term. 48 00:03:24,485.0005 --> 00:03:27,205.0005 There's just nothing that's going to naturally cross link their cornea. 49 00:03:27,405.0005 --> 00:03:37,25.0005 as we get a chance to have better technologies and we've been able to follow patients for years now, we can see patients who are in their 70s, and 80s that actually still progress if you follow them. 50 00:03:37,245.0005 --> 00:03:44,745.0005 And then by following that means you have mapping of their eye and you see them back one, two or three years later and compare their maps to the original maps to see if they're stable. 51 00:03:46,350.0005 --> 00:03:46,730.0005 Yes. 52 00:03:46,749.9995 --> 00:03:56,170.0005 I always remember the patient who already had cataract surgery and I was shocked to keratoconus after cataract surgery. 53 00:03:56,920.0005 --> 00:03:58,320.0005 It was just incredible. 54 00:04:00,340.0005 --> 00:04:02,270 Probably didn't have a topography it's interesting.
(04:02):
.9995I've seen patients that have obvious keratoconus on topography, but they can see 20, 20 without glasses when they're younger. 56 00:04:07,450.0005 --> 00:04:09,740.0005 So, it depends on the location of the cone. 57 00:04:09,970.0005 --> 00:04:15,770.0005 one of the most interesting cases for older patients progressing is this patient who was actually stable for a nine straight year. 58 00:04:15,770.0005 --> 00:04:17,270.0005 She had a history of previous LASIK. 59 00:04:17,560.0005 --> 00:04:20,270.0005 She had a pellucid pattern, and I saw her nine years in a row. 60 00:04:21,75.0005 --> 00:04:24,895.0005 I always told her there's an option to cross link, but she said, no, no, if I'm stable, I don't need to be cross linked. 61 00:04:25,125.0005 --> 00:04:27,165.0005 So for nine straight years, I Wow. 62 00:04:27,605.0005 --> 00:04:31,895.0005 but then from year nine to 10, she progressed she was worse. 63 00:04:32,215.0005 --> 00:04:35,925.0015 And then I said, okay, time to cross link, but it was 2021 COVID was going on. 64 00:04:35,925.0015 --> 00:04:36,915.0015 She said, I just want to wait. 65 00:04:36,915.0015 --> 00:04:38,65.0015 There's too much stuff going on. 66 00:04:38,355.0015 --> 00:04:41,635.002 And so she waited an additional year and a half and she progressed even further. 67 00:04:41,635.002 --> 00:04:55,585.001 So she ended up with a doctor shift in K max, after she'd been stable for nine years and she was in her sixties when she progressed and she didn't say that she was rubbing her eyes more, we talked a little bit about that, So that's the other thing is that the progression isn't linear. 68 00:04:55,835.002 --> 00:04:58,805.002 It can be stable and then get worse and then it gets stable, you're going to get worse. 69 00:04:58,815.001 --> 00:05:02,460.002 So that's why it's important to follow patients every Most definitely. 70 00:05:02,500.002 --> 00:05:05,320.002 So you mentioned a steep corneas and steep case. 71 00:05:05,770.002 --> 00:05:12,795.0015 What do you consider to be as steep corneal curvature? Oh, excellent question. 72 00:05:12,795.0015 --> 00:05:17,315.0015 I think when we get to 48 to 49, I think normal is in the 43 to 44 range. 73 00:05:17,315.0015 --> 00:05:20,225.0015 So as you get to 48 to 49, we're starting to get very suspicious. 74 00:05:20,235.0015 --> 00:05:21,855.0015 The patient may have early keratoconus. 75 00:05:22,795.0005 --> 00:05:33,825.0015 And then when we get into the high fifties we're getting to a steeper cornea, but then it's interesting because from the high fifties to the nineties or even a hundred, and they're just steep. 76 00:05:33,835.0015 --> 00:05:35,640.0015 You know what I mean? Like whether They're all safe. 77 00:05:36,235.0015 --> 00:05:39,725.0015 or 82 or a hundred, which is crazy that they can be a hundred. 78 00:05:39,935.0015 --> 00:05:40,675.002 They're just steep. 79 00:05:40,675.002 --> 00:05:46,185.0005 And we're trying to catch people in their high forties, low fifties, and even in the high fifties, we can catch them and cross. 80 00:05:46,415.0015 --> 00:05:48,275.0015 And then we could stop them from getting worse. 81 00:05:48,915.0015 --> 00:05:50,215.0015 Yes, I completely agree. 82 00:05:50,455.0015 --> 00:05:58,95.0015 It's just so interesting when you have the mindset, as I know you do, that every patient could possibly have keratoconus. 83 00:05:58,155.0015 --> 00:06:00,915.0015 So you want to rule it out, make sure that every patient does not. 84 00:06:00,965.0015 --> 00:06:03,915.0015 And just how prevalent keratoconus is. 85 00:06:03,985.0015 --> 00:06:06,535.0015 it's so incredibly prevalent in so many patients. 86 00:06:07,555.0015 --> 00:06:08,35.0015 Exactly. 87 00:06:08,75.0015 --> 00:06:11,275.0015 I had a good case where, my friend's son was about to go to college. 88 00:06:11,275.0015 --> 00:06:12,365.0005 He was heading off to Brown. 89 00:06:12,395.0015 --> 00:06:13,645.0005 I was super excited for him. 90 00:06:13,945.0015 --> 00:06:18,290.0015 He was, 18 years old and he came in with EKC and he had subepithelial infiltrates. 91 00:06:18,745.0015 --> 00:06:23,925.0015 And I was curious, let's take a look at his corneas because, he wasn't seeing well when we checked him and he actually had keratoconus. 92 00:06:23,925.0015 --> 00:06:24,810.0015 He had no Wow. 93 00:06:24,885.0015 --> 00:06:32,795.0025 he had keratoconus, he didn't have terrible vision, he's able to drive his car without glasses, but we weren't able to get him to see 2020 and we knew something that was going on. 94 00:06:32,795.0035 --> 00:06:35,535.0035 I thought it was maybe the EKC, but It was obviously keratoconus. 95 00:06:36,25.0035 --> 00:06:40,5.0035 So he went to his first semester and came back when he got cross linking over Christmas. 96 00:06:40,5.0035 --> 00:06:44,685.002 But, if he hadn't had the topography, he may have gone another couple of years before he got diagnosed. 97 00:06:45,310.003 --> 00:06:47,290.003 Especially in that age range. 98 00:06:47,290.003 --> 00:06:48,400.003 It's so prevalent. 99 00:06:49,430.003 --> 00:07:02,650.003 At the recent International Keratoconus Academy meeting, you and I discussed the misconception that there is a limit for corneal thickness with crosslinking, and I was fascinated by your response in our conversation. 100 00:07:03,100.003 --> 00:07:08,910.003 So please share your approach to thin corneas when crosslinking, Excellent. 101 00:07:09,10.003 --> 00:07:23,350.001 I think that, the concept of corneal thickness as being a risk factor issue was really related to the 2008 FDA clinical trial, where we had a strict limit of 300 microns as the minimum corneal thickness for them to be eligible for this procedure. 102 00:07:23,690.002 --> 00:07:32,20.102 And then once the epithelium was removed during the procedure itself, You had to swell the quantity to the 400 micron because that's what was the concept that you had to be 400 microns. 103 00:07:32,290.102 --> 00:07:34,110.102 But what was interesting is that the protocol. 104 00:07:34,545.102 --> 00:07:36,885.102 was to put drops in the cornea to swell it. 105 00:07:37,345.102 --> 00:07:44,915.102 But then once you were swollen and got to 400, you treat the eye for 30 minutes you're using a UV light and a lid speculum keeping the eye open. 106 00:07:45,145.102 --> 00:07:49,255.101 So there's some dehydration and you didn't have to check the again. 107 00:07:49,655.102 --> 00:07:53,495.102 So likely the corneal thickness went right back down to 300 by the end of the procedure. 108 00:07:53,875.102 --> 00:07:59,740.102 There have been many studies looking at the impact of cross linking on The endothelial cells, that was the big worry. 109 00:07:59,740.102 --> 00:08:04,460.102 Is it gonna damage the endothelial cells? But there's a study where they took, human donor corneas. 110 00:08:04,810.102 --> 00:08:14,400.102 They treated the corneas with riboflavin and they put the corneas upside down and it did crossing with the UV light, striking the endothelium side first and going through the, the opposite direction. 111 00:08:14,720.102 --> 00:08:18,800.102 And they show that there's no damage to the endothelial cells even after 30 minutes of treatment. 112 00:08:19,130.102 --> 00:08:19,370.102 So that. 113 00:08:20,115.102 --> 00:08:25,515.102 concept that the UV light would somehow damage the endothelial cells is probably not true. 114 00:08:25,905.102 --> 00:08:27,635.102 but we're still cautious. 115 00:08:27,635.102 --> 00:08:29,35.102 And so, Dr. 116 00:08:29,155.101 --> 00:08:33,685.002 Hafizi developed something called the sub, 400 micron protocol. 117 00:08:34,15.001 --> 00:08:35,865.0005 And basically it's just a graph you can use. 118 00:08:35,875.0015 --> 00:08:41,185.0015 So if you have a patient that's 280 microns or 260 microns, he has a time limit. 119 00:08:41,185.0015 --> 00:08:45,965.0015 So instead of using the UV light for 30 minutes, you could drop it to 25 minutes or 20 or 15 or 12. 120 00:08:46,215.0015 --> 00:08:46,735.0015 or 10. 121 00:08:47,155.0015 --> 00:08:51,645.0015 And, if it's a thinner cornea, maybe all they need is eight to 10 minutes of UV light exposure. 122 00:08:51,835.0015 --> 00:08:55,285.001 That's going to strengthen the cornea enough and they have a thinner cornea anyway. 123 00:08:55,485.001 --> 00:09:00,755.0005 There's less volume of cornea to cross link, but that's called the sub 400 micron protocol. 124 00:09:00,805.0005 --> 00:09:03,705.0005 We're able to treat very thin corneas safely. 125 00:09:03,895.0005 --> 00:09:05,685.0005 Cause the other option is a coronal transplant. 126 00:09:06,55.0005 --> 00:09:08,305.0005 If you don't do cross linking, yes, you can just do a transplant. 127 00:09:08,920.0005 --> 00:09:12,640.0005 But why not try the crossing? If it works, then you maybe could avoid a coronary transplant. 128 00:09:12,780.0005 --> 00:09:14,640.0005 and all the risks associated with that. 129 00:09:14,900.0005 --> 00:09:15,830.0005 Yeah, that's for sure. 130 00:09:15,880.0005 --> 00:09:24,190.0005 What are some of the thinnest corneas that you've crosslinked? I guess the other thing to think about is there are two types of thin corneas. 131 00:09:24,670.0005 --> 00:09:27,989.9995 Some patients with keratoconitis have just a small area that's very thin. 132 00:09:28,260.0005 --> 00:09:38,650.0005 So they've gotten very steep and you look in the zone and it's just a small one millimeter zone that's super thin, let's say below a 250 microns, but the rest of it's like the more 350 or something like that. 133 00:09:38,670.0005 --> 00:09:39,970.0005 and then others are globally thin. 134 00:09:40,20.0005 --> 00:09:42,770.0005 For some reason got really stretched out like ultra, ultra thin. 135 00:09:43,130.0005 --> 00:09:52,5.001 I treated a patient that, had a condition called brittle corneal syndrome, and she had 250 micron range across her whole cornea. 136 00:09:52,435.001 --> 00:09:55,385.0015 And so one of the things we did, there's a short in the treatment in time. 137 00:09:56,135.0015 --> 00:10:02,35.0005 other thing we do is we post the UV lights instead of leaving on continuously, which is the Dresden protocol. 138 00:10:02,235.0005 --> 00:10:03,464.9015 If you turn the light on. 139 00:10:03,815.0015 --> 00:10:06,365.0015 And then take the light away for 10 to 15 seconds. 140 00:10:06,615.0015 --> 00:10:08,365.0015 That oxygen should come back into the cornea. 141 00:10:08,775.0015 --> 00:10:11,835.001 There tends to be a little bit better reaction in the cornea. 142 00:10:11,835.001 --> 00:10:13,965.0015 There's more oxygen available for cross linking. 143 00:10:14,145.0015 --> 00:10:17,685.0005 It allows us to treat these sub 300 micron corneas safely. 144 00:10:17,685.0015 --> 00:10:27,255.0015 And thankfully to date, I've yet to see an issue with treating the sub 300 micron corneas, but obviously, nothing in the world's risk free, but overall our results have been quite good. 145 00:10:27,680.0015 --> 00:10:27,930.0015 Right. 146 00:10:27,930.0015 --> 00:10:30,570.0015 That's really excellent information to share. 147 00:10:30,820.0015 --> 00:10:33,540.0015 And that is great to hear. 148 00:10:33,590.0015 --> 00:10:38,130.0015 I can't even imagine 250 microns and talk across the entire cornea. 149 00:10:38,360.0015 --> 00:10:38,800.0015 Wow. 150 00:10:40,190.0015 --> 00:10:40,410.0015 Yeah. 151 00:10:40,440.0015 --> 00:10:42,730.0015 Well, this is a genetic condition for this particular patient. 152 00:10:43,50.0015 --> 00:10:48,150.0015 I guess the thing of it, what we're trying to do is we're trying to avoid a coronary transplant because coronary transplants do have risks. 153 00:10:48,210.0005 --> 00:10:55,490.0015 And also, you have a coronary transplant for keratoconus, the keratoconus can recur 20 years later, or even sometimes faster. 154 00:10:56,170.0015 --> 00:11:09,180.0015 when it recurs in a coronary transplant patient, sometimes they can be a little bit more difficult to treat because now it's the, host, corneal tissue that's near the limbus, it's going to be more difficult to perform cross linking or to stabilize the cornea in that situation. 155 00:11:09,180.0015 --> 00:11:16,800.0005 So you can do to avoid a transplant, because patients who have transplants often still need contact lenses and scleral lenses. 156 00:11:17,0.0005 --> 00:11:21,190.0015 So the patient can see well with the scleral lens, try to save that cornea and avoid the transplant. 157 00:11:22,100.0015 --> 00:11:24,190.0015 I have the same exact mindset. 158 00:11:25,800.0015 --> 00:11:53,330.0005 So moving on to the next topic, what other benefits do you see besides stabilization of the cornea when cross linking? Are there other benefits? Well, the main other benefit is that when you strengthen the cornea with cross linking, you typically, and I'd say it's about 85 percent in my experience, patients will experience reshaping of the cornea, where the steep part of the cornea becomes flatter and the flat part of the cornea becomes steeper, so the cornea is reshaping. 159 00:11:53,660.0015 --> 00:12:02,430.0015 And that results in, over time, some improvement in the quality of vision of the patient, less ghosting and often improvement in uncorrected or best corrected visual acuity. 160 00:12:02,810.0015 --> 00:12:08,890.0015 In fact, there's a current clinical trial ongoing right now called the, Epi on clinical trial, by the company Epi on. 161 00:12:09,170.0005 --> 00:12:14,90.0015 And basically the outcome is not looking at reshaping the cornea or improvement in the corneal shape. 162 00:12:14,280.0005 --> 00:12:16,619.9995 The outcome is improvement in vision. 163 00:12:17,310.0005 --> 00:12:23,50.0005 And that's because we do know that in patients that have cross linking, many patients, not all, but many will get some improvement in vision. 164 00:12:23,485.0005 --> 00:12:24,535.0005 It may not be in six months. 165 00:12:24,535.0005 --> 00:12:33,235.0005 It might not be in a year, but over three, five and seven years, as you watch them, they can get improvements in their vision, which is one of the most exciting things that I get to be associated with. 166 00:12:33,990.0005 --> 00:12:40,430.0005 It is incredibly exciting and just the potential for different options too. 167 00:12:40,510.0005 --> 00:12:49,999.9985 So maybe instead of a scleral lens, we could use a soft toric lens or glasses or, correct the vision in a slightly easier method as well. 168 00:12:50,549.9985 --> 00:12:52,959.9985 So there are so many additional benefits. 169 00:12:52,959.9985 --> 00:12:58,419.9975 It can also reduce the cost by having an easier option, Absolutely. 170 00:12:58,419.9985 --> 00:12:58,579.9985 Right. 171 00:12:58,579.9985 --> 00:13:01,769.9985 If the shape is better, they can wear glasses more easily. 172 00:13:01,769.9985 --> 00:13:05,220.1 And, patients can't wear scarlet contact lens is 24 7. 173 00:13:05,220.1 --> 00:13:06,260.1 They have to take them off. 174 00:13:06,660.1 --> 00:13:09,880.1 And if they can be more functional when they're wearing glasses, it's super helpful. 175 00:13:10,210.1 --> 00:13:12,440.1 And as you were mentioning, they also can be eligible for other things. 176 00:13:12,440.1 --> 00:13:15,20.1 One thing that they can become eligible for is an ICL. 177 00:13:15,310.099 --> 00:13:18,310.098 We've used the ICL, which is an implant that goes inside the eye. 178 00:13:18,310.099 --> 00:13:21,490.098 It's like a contact lens that goes inside the eye and corrects the vision. 179 00:13:21,850.099 --> 00:13:24,595.099 So that patients can wake up in the morning and see reasonably well. 180 00:13:24,595.099 --> 00:13:32,145.0985 They may still need a scleral lens to get their very best quality of vision, but it allows them to be a little bit more functional, if the shape has improved following cross linking. 181 00:13:32,365.0995 --> 00:13:53,835.0985 right? And I find that many of my patients, that's a very important factor to have decent uncorrected visual acuity by decent going around the house, doing day to day tasks, even being able to wear glasses to do some things, maybe not drive, but maybe some things like cooking is very helpful. 182 00:13:54,765.0995 --> 00:14:01,355.0995 When are we going to expect the results from this new trial? Well, I think there's a couple of clinical trials ongoing. 183 00:14:01,355.0995 --> 00:14:07,965.1005 I know Glockos has their Epion clinical trial ongoing, and I'm not sure the exact status, but hopefully we'll see the positive results from that study in the near future. 184 00:14:08,275.1005 --> 00:14:17,330.1005 And then the Epion clinical trial my understanding June 2024 is about 50 percent enrolled, and the goal is to be enrolled by the end of 2024. 185 00:14:17,670.1005 --> 00:14:18,800.1005 And it's placebo controlled. 186 00:14:18,800.1005 --> 00:14:34,870.0995 So 50 percent have treatment, 50 percent have the placebo, and then in the placebo group do get treated at the end of the one year follow up, but then hopefully those that did get, treated, that we would get the results from the placebo versus treatment group, that should occur like a year from now. 187 00:14:35,865.0995 --> 00:14:37,135.0995 we'll start to see more data coming through. 188 00:14:37,135.0995 --> 00:14:39,495.0995 So it's still a ways away, but it's getting exciting. 189 00:14:39,495.0995 --> 00:14:41,885.099 It's getting closer and Oh, it is getting closer and closer. 190 00:14:41,885.099 --> 00:14:45,225.0985 And it's exciting to have new techniques and new technology to. 191 00:14:45,845.0995 --> 00:14:48,635.0995 to really help our patients and have some great outcomes. 192 00:14:48,635.0995 --> 00:14:51,25.0995 And I know that you've been involved in many of them. 193 00:14:51,25.0995 --> 00:14:51,905.0995 So thank you. 194 00:14:52,905.0995 --> 00:15:02,215.0995 I'm putting you on the spot here, but what are some of your top clinical pearls or most valuable clinical advice? If keratoconus. 195 00:15:04,10.0995 --> 00:15:12,800.0995 Well, for, other doctors that are performing cross linking, I think the most important thing I find is that you want to identify the location of the cone. 196 00:15:13,90.0995 --> 00:15:28,720.0985 I use the Pentacam in our practice, and we look at the thinnest spot, area, and that's going to be our target when we cross link, because you don't want to cross link in the center of the cornea and keep it perfectly centered if the cone is displaced inferiorly, because you're going to miss the weak part of the cornea. 197 00:15:29,480.0985 --> 00:15:39,50.0995 we saw that a lot with our patients with a condition called Pellucid Marginal Degeneration, where when you treat the center and Pellucid, it's really far periphery towards the very, very bottom. 198 00:15:39,510.0995 --> 00:15:43,450.0995 You're going to get flattening in the middle, but this, the untreated part will start to get steeper. 199 00:15:43,820.0995 --> 00:15:46,985.0995 And so while, You might say, Oh my gosh, it looks like we're getting better. 200 00:15:46,985.0995 --> 00:15:49,315.0995 Then over time you realize that the patient's not doing better. 201 00:15:49,725.0995 --> 00:15:51,825.0995 So we learned back in, 2000. 202 00:15:52,280.0995 --> 00:15:55,760.0995 13 2014 that you really need to dissenter the treatment. 203 00:15:55,760.0995 --> 00:16:08,770.0995 And by that what you do is the patient's lying flat instead of looking directly up at the light, they're going to, we're going to request the patient look above and over the light so that the beam of light is beaming directly down in the bottom part of the cornea if that's where the thinnest spot is. 204 00:16:09,30.0995 --> 00:16:12,520.0995 and then the idea is to have the light treat that weaker area. 205 00:16:12,840.0995 --> 00:16:18,600.0995 Again, what happens is that weak area becomes stronger, that starts to flatten the other part that's not treated. 206 00:16:19,410.0995 --> 00:16:22,950.0995 starts to flex in the opposite direction and then you get the reshaping occurring. 207 00:16:23,320.0995 --> 00:16:24,730.0995 So that's what we find is very helpful. 208 00:16:24,850.0995 --> 00:16:32,260.0995 Obviously, some patients have central keratoconus and you'll treat them dead center, but for the other patients, you're going to want to locate the thinnest part of the cornea, the weakest part of the cornea. 209 00:16:32,430.0995 --> 00:16:35,530.0985 And that's the goal to center your leg treatment on that area. 210 00:16:35,910.0995 --> 00:16:43,340.099 That's an excellent clinical pearl, and it plays a role also when fitting scleral lenses in those types of patients. 211 00:16:43,340.099 --> 00:16:48,50.0995 So we use a slightly different design, than we would do if there's a cone that's right central. 212 00:16:49,920.0995 --> 00:16:53,700.099 Are there any other pearls you'd like to share with us? Oh, sure. 213 00:16:53,700.099 --> 00:16:54,830.0995 I guess the last pro is that. 214 00:16:55,580.0995 --> 00:16:59,480.0995 not the end of the day if your condition progresses after the first treatment. 215 00:16:59,480.0995 --> 00:17:12,750.0995 So let's say you have a patient has keratoconus, they undergo treatment, and then they come back a year and a half, two years later, and you realize that while the rate of change has slowed down, has a completely rested the progression of the keratoconus, you see a little bit of adrift. 216 00:17:13,70.0995 --> 00:17:16,820.0995 And so in those patients, they can safely undergo a second treatment. 217 00:17:16,820.0995 --> 00:17:21,270.0995 We've had excellent results where you see, the first treatment, they drifted a little bit, but they do the second one. 218 00:17:21,270.0995 --> 00:17:22,890.0995 Now they get the flattening and reshaping. 219 00:17:23,70.0995 --> 00:17:24,0.0995 So sometimes patients. 220 00:17:24,445.0995 --> 00:17:25,595.0995 need a second treatment. 221 00:17:25,825.0995 --> 00:17:34,715.0995 And it makes sense because we treat every single patient with a similar level of UV exposure, and the very weak corneas just might need a little bit extra, a little boost. 222 00:17:35,725.0995 --> 00:17:39,440.0005 The other pro dimension, though, is that when I think they may need a second treatment, I. 223 00:17:39,600.1005 --> 00:17:51,330.1 Having come back another month later, I put them on dry eye therapy and I repeat the testing because sometimes the reason they look a little worse on the topography is they have dry eye and it gives a false irregular shape. 224 00:17:51,330.1 --> 00:17:52,800.1005 It looks like maybe it's a little bit worse. 225 00:17:53,100.1005 --> 00:17:59,275.1005 I've found that many times the fact that the patient come from Delray Beach just, a week ago, I scheduled him for the second treatment. 226 00:17:59,275.1005 --> 00:18:00,875.1005 it's a long drive and they came in. 227 00:18:00,885.1005 --> 00:18:02,205.1005 They had gotten worse last time I saw them. 228 00:18:02,205.1005 --> 00:18:04,635.1005 And if they were further worse, they were all set. 229 00:18:04,635.1005 --> 00:18:09,885.1005 They were actually ready for their treatment, but they actually got better their original treatment was like three and a half years ago. 230 00:18:10,235.1005 --> 00:18:12,495.0995 And then I thought, Oh my gosh, it's getting a little bit worse. 231 00:18:12,815.0995 --> 00:18:15,675.0995 It turned out that it was just a funny reading, maybe from dryness or whatever. 232 00:18:15,675.0995 --> 00:18:17,415.0995 Now this time they look better again. 233 00:18:17,415.0995 --> 00:18:19,275.0995 So we did not have to do the second treatment. 234 00:18:19,325.1995 --> 00:18:23,255.1995 Well, these are all excellent clinical pearls that we can use in practice. 235 00:18:23,335.1995 --> 00:18:24,455.1995 Thank you so much. 236 00:18:24,745.1995 --> 00:18:28,235.1995 And thank you for inspiring us on the Clearly KC podcast. 237 00:18:28,625.1995 --> 00:18:33,495.1995 I am so appreciative of all your contributions to our field over all these years. 238 00:18:33,545.1995 --> 00:18:38,275.1995 And for all of our listeners, thank you so much for joining us on Clearly KC. 239 00:18:38,565.1995 --> 00:18:47,775.1995 Please listen to all of the episodes of the Clearly KC podcast on Podbean or your favorite podcast app to subscribe and get future episodes. 240 00:18:48,275.1995 --> 00:18:49,435.1995 For now, I'm Dr. 241 00:18:49,435.1995 --> 00:18:50,195.1995 Melissa Barnett. 242 00:18:50,465.1995 --> 00:18:52,785.1995 Please join us next time on Clearly Casey.
Welcome to episode 27 of the Clearly KC podcast, featuring information about life with keratoconus.
I'm your host, Dr.
Melissa Barnett.
Today, it's a special treat.
.999We're joined by Dr.
William Trattler, MD, who is the Director of Cornea at the Center for Excellence in Eye Care in Miami, Florida.
(00:25):
He was part of the original FDA clinical trial for epithelium off corneal collagen crosslinking in 2008 and was one of the first doctors in the U.
S.
to perform epi on as part of the CXL USA clinical trial that started in 2010.
Today we are going to debunk several myths about crosslinking and keratoconus.
(00:50):
Welcome, Bill.
Thank you so much, Melissa.
I'm so honored to be here.
Thank Oh, I'm so happy that you're here and it was such a pleasure to see you not too long ago as well.
First let's begin with the consultation.
Say you have a patient in your chair who's newly diagnosed with keratoconus. 17 00:01:09,614.999 --> 00:01:16,180 How do you explain crosslinking to that patient and their family? Of course.
(01:16):
Obviously it depends on the age because we often have, parents bringing their children in, or it could be an older patient.
But basically it's a very simple concept that cross linking is an hour and 10 to hour and 20 minute treatment.
that strengthens the cornea.
you have a weak cornea.
The cornea is slowly outwards and instead of being round like a basketball, it's becoming steep like the tip of a football.
(01:37):
.999And what our goal is, is to perform this procedure to strengthen the cornea, stop it from getting worse. 24 00:01:42,884.999 --> 00:01:46,065 And slowly over time, most patients get improvements in the corneal shape.
Excellent.
What is the most common follow up question that a patient asks when you explain it? A few questions.
is there's a procedure hurt? And thankfully, the answer is no.
(01:58):
Obviously, we're using anesthesia.
So regardless of the technique, it's a very comfortable procedure for patients. 30 00:02:04,344.999 --> 00:02:06,595 They also want to know the longevity of the procedure. 31 00:02:06,904.999 --> 00:02:19,424.998 Will I need to have a second treatment in the future? Is it last for a few years? And I think the data supports that the success rate is between 97 percent to 99 percent of patients will need just one treatment over the first five to 10 years. 32 00:02:19,684.999 --> 00:02:22,614.999 But there is going to be a small percentage of patients that will need a second treatment. 33 00:02:22,884.999 --> 00:02:29,654.999 So I always advise them that it's really important to come back for annual follow ups even when they get treated with Yes, most definitely. 34 00:02:29,705.099 --> 00:02:31,65.099 Let's debunk some myths. 35 00:02:31,895.099 --> 00:02:36,405.099 Many people believe that older individuals with keratoconus do not progress. 36 00:02:36,565.099 --> 00:02:39,415.099 What is your experience? Yes. 37 00:02:39,415.099 --> 00:02:44,305.099 I remember hearing that concept, that somehow older patients were magically, strong. 38 00:02:44,305.099 --> 00:02:52,215.1005 I had a, optometry student from, Canada with me today, and he said, Oh, I thought that the cornea self crosslink is you get, over the 40. 39 00:02:52,555.1005 --> 00:02:53,225.1005 They don't progress. 40 00:02:53,225.1005 --> 00:02:54,625.1005 And that was his concept. 41 00:02:54,895.1005 --> 00:02:58,285.0005 If you think about it, the, cornea in a keratoconus patient is just weak. 42 00:02:58,285.0005 --> 00:03:00,655.0005 We know that it's weak from corneal strength testing. 43 00:03:00,775.0005 --> 00:03:02,485.0005 And so let's just take an easy example. 44 00:03:02,485.0005 --> 00:03:13,885.0005 If you have a patient that has more advanced keratoconus, they have steep corneas and very thin corneas, how is that cornea gonna be magically strengthened just as they get older? their cornea is always going to be weaker than a normal cornea. 45 00:03:14,85.0005 --> 00:03:14,899.9995 do you Yes. 46 00:03:15,150.0005 --> 00:03:15,980.0005 Yes, definitely. 47 00:03:16,955.0005 --> 00:03:24,485.0005 yeah, so it makes sense that patients that are more advanced that have steeper corneas to begin with are, less likely to be stable long term. 48 00:03:24,485.0005 --> 00:03:27,205.0005 There's just nothing that's going to naturally cross link their cornea. 49 00:03:27,405.0005 --> 00:03:37,25.0005 as we get a chance to have better technologies and we've been able to follow patients for years now, we can see patients who are in their 70s, and 80s that actually still progress if you follow them. 50 00:03:37,245.0005 --> 00:03:44,745.0005 And then by following that means you have mapping of their eye and you see them back one, two or three years later and compare their maps to the original maps to see if they're stable. 51 00:03:46,350.0005 --> 00:03:46,730.0005 Yes. 52 00:03:46,749.9995 --> 00:03:56,170.0005 I always remember the patient who already had cataract surgery and I was shocked to keratoconus after cataract surgery. 53 00:03:56,920.0005 --> 00:03:58,320.0005 It was just incredible. 54 00:04:00,340.0005 --> 00:04:02,270 Probably didn't have a topography it's interesting.
(04:02):
.9995I've seen patients that have obvious keratoconus on topography, but they can see 20, 20 without glasses when they're younger. 56 00:04:07,450.0005 --> 00:04:09,740.0005 So, it depends on the location of the cone. 57 00:04:09,970.0005 --> 00:04:15,770.0005 one of the most interesting cases for older patients progressing is this patient who was actually stable for a nine straight year. 58 00:04:15,770.0005 --> 00:04:17,270.0005 She had a history of previous LASIK. 59 00:04:17,560.0005 --> 00:04:20,270.0005 She had a pellucid pattern, and I saw her nine years in a row. 60 00:04:21,75.0005 --> 00:04:24,895.0005 I always told her there's an option to cross link, but she said, no, no, if I'm stable, I don't need to be cross linked. 61 00:04:25,125.0005 --> 00:04:27,165.0005 So for nine straight years, I Wow. 62 00:04:27,605.0005 --> 00:04:31,895.0005 but then from year nine to 10, she progressed she was worse. 63 00:04:32,215.0005 --> 00:04:35,925.0015 And then I said, okay, time to cross link, but it was 2021 COVID was going on. 64 00:04:35,925.0015 --> 00:04:36,915.0015 She said, I just want to wait. 65 00:04:36,915.0015 --> 00:04:38,65.0015 There's too much stuff going on. 66 00:04:38,355.0015 --> 00:04:41,635.002 And so she waited an additional year and a half and she progressed even further. 67 00:04:41,635.002 --> 00:04:55,585.001 So she ended up with a doctor shift in K max, after she'd been stable for nine years and she was in her sixties when she progressed and she didn't say that she was rubbing her eyes more, we talked a little bit about that, So that's the other thing is that the progression isn't linear. 68 00:04:55,835.002 --> 00:04:58,805.002 It can be stable and then get worse and then it gets stable, you're going to get worse. 69 00:04:58,815.001 --> 00:05:02,460.002 So that's why it's important to follow patients every Most definitely. 70 00:05:02,500.002 --> 00:05:05,320.002 So you mentioned a steep corneas and steep case. 71 00:05:05,770.002 --> 00:05:12,795.0015 What do you consider to be as steep corneal curvature? Oh, excellent question. 72 00:05:12,795.0015 --> 00:05:17,315.0015 I think when we get to 48 to 49, I think normal is in the 43 to 44 range. 73 00:05:17,315.0015 --> 00:05:20,225.0015 So as you get to 48 to 49, we're starting to get very suspicious. 74 00:05:20,235.0015 --> 00:05:21,855.0015 The patient may have early keratoconus. 75 00:05:22,795.0005 --> 00:05:33,825.0015 And then when we get into the high fifties we're getting to a steeper cornea, but then it's interesting because from the high fifties to the nineties or even a hundred, and they're just steep. 76 00:05:33,835.0015 --> 00:05:35,640.0015 You know what I mean? Like whether They're all safe. 77 00:05:36,235.0015 --> 00:05:39,725.0015 or 82 or a hundred, which is crazy that they can be a hundred. 78 00:05:39,935.0015 --> 00:05:40,675.002 They're just steep. 79 00:05:40,675.002 --> 00:05:46,185.0005 And we're trying to catch people in their high forties, low fifties, and even in the high fifties, we can catch them and cross. 80 00:05:46,415.0015 --> 00:05:48,275.0015 And then we could stop them from getting worse. 81 00:05:48,915.0015 --> 00:05:50,215.0015 Yes, I completely agree. 82 00:05:50,455.0015 --> 00:05:58,95.0015 It's just so interesting when you have the mindset, as I know you do, that every patient could possibly have keratoconus. 83 00:05:58,155.0015 --> 00:06:00,915.0015 So you want to rule it out, make sure that every patient does not. 84 00:06:00,965.0015 --> 00:06:03,915.0015 And just how prevalent keratoconus is. 85 00:06:03,985.0015 --> 00:06:06,535.0015 it's so incredibly prevalent in so many patients. 86 00:06:07,555.0015 --> 00:06:08,35.0015 Exactly. 87 00:06:08,75.0015 --> 00:06:11,275.0015 I had a good case where, my friend's son was about to go to college. 88 00:06:11,275.0015 --> 00:06:12,365.0005 He was heading off to Brown. 89 00:06:12,395.0015 --> 00:06:13,645.0005 I was super excited for him. 90 00:06:13,945.0015 --> 00:06:18,290.0015 He was, 18 years old and he came in with EKC and he had subepithelial infiltrates. 91 00:06:18,745.0015 --> 00:06:23,925.0015 And I was curious, let's take a look at his corneas because, he wasn't seeing well when we checked him and he actually had keratoconus. 92 00:06:23,925.0015 --> 00:06:24,810.0015 He had no Wow. 93 00:06:24,885.0015 --> 00:06:32,795.0025 he had keratoconus, he didn't have terrible vision, he's able to drive his car without glasses, but we weren't able to get him to see 2020 and we knew something that was going on. 94 00:06:32,795.0035 --> 00:06:35,535.0035 I thought it was maybe the EKC, but It was obviously keratoconus. 95 00:06:36,25.0035 --> 00:06:40,5.0035 So he went to his first semester and came back when he got cross linking over Christmas. 96 00:06:40,5.0035 --> 00:06:44,685.002 But, if he hadn't had the topography, he may have gone another couple of years before he got diagnosed. 97 00:06:45,310.003 --> 00:06:47,290.003 Especially in that age range. 98 00:06:47,290.003 --> 00:06:48,400.003 It's so prevalent. 99 00:06:49,430.003 --> 00:07:02,650.003 At the recent International Keratoconus Academy meeting, you and I discussed the misconception that there is a limit for corneal thickness with crosslinking, and I was fascinated by your response in our conversation. 100 00:07:03,100.003 --> 00:07:08,910.003 So please share your approach to thin corneas when crosslinking, Excellent. 101 00:07:09,10.003 --> 00:07:23,350.001 I think that, the concept of corneal thickness as being a risk factor issue was really related to the 2008 FDA clinical trial, where we had a strict limit of 300 microns as the minimum corneal thickness for them to be eligible for this procedure. 102 00:07:23,690.002 --> 00:07:32,20.102 And then once the epithelium was removed during the procedure itself, You had to swell the quantity to the 400 micron because that's what was the concept that you had to be 400 microns. 103 00:07:32,290.102 --> 00:07:34,110.102 But what was interesting is that the protocol. 104 00:07:34,545.102 --> 00:07:36,885.102 was to put drops in the cornea to swell it. 105 00:07:37,345.102 --> 00:07:44,915.102 But then once you were swollen and got to 400, you treat the eye for 30 minutes you're using a UV light and a lid speculum keeping the eye open. 106 00:07:45,145.102 --> 00:07:49,255.101 So there's some dehydration and you didn't have to check the again. 107 00:07:49,655.102 --> 00:07:53,495.102 So likely the corneal thickness went right back down to 300 by the end of the procedure. 108 00:07:53,875.102 --> 00:07:59,740.102 There have been many studies looking at the impact of cross linking on The endothelial cells, that was the big worry. 109 00:07:59,740.102 --> 00:08:04,460.102 Is it gonna damage the endothelial cells? But there's a study where they took, human donor corneas. 110 00:08:04,810.102 --> 00:08:14,400.102 They treated the corneas with riboflavin and they put the corneas upside down and it did crossing with the UV light, striking the endothelium side first and going through the, the opposite direction. 111 00:08:14,720.102 --> 00:08:18,800.102 And they show that there's no damage to the endothelial cells even after 30 minutes of treatment. 112 00:08:19,130.102 --> 00:08:19,370.102 So that. 113 00:08:20,115.102 --> 00:08:25,515.102 concept that the UV light would somehow damage the endothelial cells is probably not true. 114 00:08:25,905.102 --> 00:08:27,635.102 but we're still cautious. 115 00:08:27,635.102 --> 00:08:29,35.102 And so, Dr. 116 00:08:29,155.101 --> 00:08:33,685.002 Hafizi developed something called the sub, 400 micron protocol. 117 00:08:34,15.001 --> 00:08:35,865.0005 And basically it's just a graph you can use. 118 00:08:35,875.0015 --> 00:08:41,185.0015 So if you have a patient that's 280 microns or 260 microns, he has a time limit. 119 00:08:41,185.0015 --> 00:08:45,965.0015 So instead of using the UV light for 30 minutes, you could drop it to 25 minutes or 20 or 15 or 12. 120 00:08:46,215.0015 --> 00:08:46,735.0015 or 10. 121 00:08:47,155.0015 --> 00:08:51,645.0015 And, if it's a thinner cornea, maybe all they need is eight to 10 minutes of UV light exposure. 122 00:08:51,835.0015 --> 00:08:55,285.001 That's going to strengthen the cornea enough and they have a thinner cornea anyway. 123 00:08:55,485.001 --> 00:09:00,755.0005 There's less volume of cornea to cross link, but that's called the sub 400 micron protocol. 124 00:09:00,805.0005 --> 00:09:03,705.0005 We're able to treat very thin corneas safely. 125 00:09:03,895.0005 --> 00:09:05,685.0005 Cause the other option is a coronal transplant. 126 00:09:06,55.0005 --> 00:09:08,305.0005 If you don't do cross linking, yes, you can just do a transplant. 127 00:09:08,920.0005 --> 00:09:12,640.0005 But why not try the crossing? If it works, then you maybe could avoid a coronary transplant. 128 00:09:12,780.0005 --> 00:09:14,640.0005 and all the risks associated with that. 129 00:09:14,900.0005 --> 00:09:15,830.0005 Yeah, that's for sure. 130 00:09:15,880.0005 --> 00:09:24,190.0005 What are some of the thinnest corneas that you've crosslinked? I guess the other thing to think about is there are two types of thin corneas. 131 00:09:24,670.0005 --> 00:09:27,989.9995 Some patients with keratoconitis have just a small area that's very thin. 132 00:09:28,260.0005 --> 00:09:38,650.0005 So they've gotten very steep and you look in the zone and it's just a small one millimeter zone that's super thin, let's say below a 250 microns, but the rest of it's like the more 350 or something like that. 133 00:09:38,670.0005 --> 00:09:39,970.0005 and then others are globally thin. 134 00:09:40,20.0005 --> 00:09:42,770.0005 For some reason got really stretched out like ultra, ultra thin. 135 00:09:43,130.0005 --> 00:09:52,5.001 I treated a patient that, had a condition called brittle corneal syndrome, and she had 250 micron range across her whole cornea. 136 00:09:52,435.001 --> 00:09:55,385.0015 And so one of the things we did, there's a short in the treatment in time. 137 00:09:56,135.0015 --> 00:10:02,35.0005 other thing we do is we post the UV lights instead of leaving on continuously, which is the Dresden protocol. 138 00:10:02,235.0005 --> 00:10:03,464.9015 If you turn the light on. 139 00:10:03,815.0015 --> 00:10:06,365.0015 And then take the light away for 10 to 15 seconds. 140 00:10:06,615.0015 --> 00:10:08,365.0015 That oxygen should come back into the cornea. 141 00:10:08,775.0015 --> 00:10:11,835.001 There tends to be a little bit better reaction in the cornea. 142 00:10:11,835.001 --> 00:10:13,965.0015 There's more oxygen available for cross linking. 143 00:10:14,145.0015 --> 00:10:17,685.0005 It allows us to treat these sub 300 micron corneas safely. 144 00:10:17,685.0015 --> 00:10:27,255.0015 And thankfully to date, I've yet to see an issue with treating the sub 300 micron corneas, but obviously, nothing in the world's risk free, but overall our results have been quite good. 145 00:10:27,680.0015 --> 00:10:27,930.0015 Right. 146 00:10:27,930.0015 --> 00:10:30,570.0015 That's really excellent information to share. 147 00:10:30,820.0015 --> 00:10:33,540.0015 And that is great to hear. 148 00:10:33,590.0015 --> 00:10:38,130.0015 I can't even imagine 250 microns and talk across the entire cornea. 149 00:10:38,360.0015 --> 00:10:38,800.0015 Wow. 150 00:10:40,190.0015 --> 00:10:40,410.0015 Yeah. 151 00:10:40,440.0015 --> 00:10:42,730.0015 Well, this is a genetic condition for this particular patient. 152 00:10:43,50.0015 --> 00:10:48,150.0015 I guess the thing of it, what we're trying to do is we're trying to avoid a coronary transplant because coronary transplants do have risks. 153 00:10:48,210.0005 --> 00:10:55,490.0015 And also, you have a coronary transplant for keratoconus, the keratoconus can recur 20 years later, or even sometimes faster. 154 00:10:56,170.0015 --> 00:11:09,180.0015 when it recurs in a coronary transplant patient, sometimes they can be a little bit more difficult to treat because now it's the, host, corneal tissue that's near the limbus, it's going to be more difficult to perform cross linking or to stabilize the cornea in that situation. 155 00:11:09,180.0015 --> 00:11:16,800.0005 So you can do to avoid a transplant, because patients who have transplants often still need contact lenses and scleral lenses. 156 00:11:17,0.0005 --> 00:11:21,190.0015 So the patient can see well with the scleral lens, try to save that cornea and avoid the transplant. 157 00:11:22,100.0015 --> 00:11:24,190.0015 I have the same exact mindset. 158 00:11:25,800.0015 --> 00:11:53,330.0005 So moving on to the next topic, what other benefits do you see besides stabilization of the cornea when cross linking? Are there other benefits? Well, the main other benefit is that when you strengthen the cornea with cross linking, you typically, and I'd say it's about 85 percent in my experience, patients will experience reshaping of the cornea, where the steep part of the cornea becomes flatter and the flat part of the cornea becomes steeper, so the cornea is reshaping. 159 00:11:53,660.0015 --> 00:12:02,430.0015 And that results in, over time, some improvement in the quality of vision of the patient, less ghosting and often improvement in uncorrected or best corrected visual acuity. 160 00:12:02,810.0015 --> 00:12:08,890.0015 In fact, there's a current clinical trial ongoing right now called the, Epi on clinical trial, by the company Epi on. 161 00:12:09,170.0005 --> 00:12:14,90.0015 And basically the outcome is not looking at reshaping the cornea or improvement in the corneal shape. 162 00:12:14,280.0005 --> 00:12:16,619.9995 The outcome is improvement in vision. 163 00:12:17,310.0005 --> 00:12:23,50.0005 And that's because we do know that in patients that have cross linking, many patients, not all, but many will get some improvement in vision. 164 00:12:23,485.0005 --> 00:12:24,535.0005 It may not be in six months. 165 00:12:24,535.0005 --> 00:12:33,235.0005 It might not be in a year, but over three, five and seven years, as you watch them, they can get improvements in their vision, which is one of the most exciting things that I get to be associated with. 166 00:12:33,990.0005 --> 00:12:40,430.0005 It is incredibly exciting and just the potential for different options too. 167 00:12:40,510.0005 --> 00:12:49,999.9985 So maybe instead of a scleral lens, we could use a soft toric lens or glasses or, correct the vision in a slightly easier method as well. 168 00:12:50,549.9985 --> 00:12:52,959.9985 So there are so many additional benefits. 169 00:12:52,959.9985 --> 00:12:58,419.9975 It can also reduce the cost by having an easier option, Absolutely. 170 00:12:58,419.9985 --> 00:12:58,579.9985 Right. 171 00:12:58,579.9985 --> 00:13:01,769.9985 If the shape is better, they can wear glasses more easily. 172 00:13:01,769.9985 --> 00:13:05,220.1 And, patients can't wear scarlet contact lens is 24 7. 173 00:13:05,220.1 --> 00:13:06,260.1 They have to take them off. 174 00:13:06,660.1 --> 00:13:09,880.1 And if they can be more functional when they're wearing glasses, it's super helpful. 175 00:13:10,210.1 --> 00:13:12,440.1 And as you were mentioning, they also can be eligible for other things. 176 00:13:12,440.1 --> 00:13:15,20.1 One thing that they can become eligible for is an ICL. 177 00:13:15,310.099 --> 00:13:18,310.098 We've used the ICL, which is an implant that goes inside the eye. 178 00:13:18,310.099 --> 00:13:21,490.098 It's like a contact lens that goes inside the eye and corrects the vision. 179 00:13:21,850.099 --> 00:13:24,595.099 So that patients can wake up in the morning and see reasonably well. 180 00:13:24,595.099 --> 00:13:32,145.0985 They may still need a scleral lens to get their very best quality of vision, but it allows them to be a little bit more functional, if the shape has improved following cross linking. 181 00:13:32,365.0995 --> 00:13:53,835.0985 right? And I find that many of my patients, that's a very important factor to have decent uncorrected visual acuity by decent going around the house, doing day to day tasks, even being able to wear glasses to do some things, maybe not drive, but maybe some things like cooking is very helpful. 182 00:13:54,765.0995 --> 00:14:01,355.0995 When are we going to expect the results from this new trial? Well, I think there's a couple of clinical trials ongoing. 183 00:14:01,355.0995 --> 00:14:07,965.1005 I know Glockos has their Epion clinical trial ongoing, and I'm not sure the exact status, but hopefully we'll see the positive results from that study in the near future. 184 00:14:08,275.1005 --> 00:14:17,330.1005 And then the Epion clinical trial my understanding June 2024 is about 50 percent enrolled, and the goal is to be enrolled by the end of 2024. 185 00:14:17,670.1005 --> 00:14:18,800.1005 And it's placebo controlled. 186 00:14:18,800.1005 --> 00:14:34,870.0995 So 50 percent have treatment, 50 percent have the placebo, and then in the placebo group do get treated at the end of the one year follow up, but then hopefully those that did get, treated, that we would get the results from the placebo versus treatment group, that should occur like a year from now. 187 00:14:35,865.0995 --> 00:14:37,135.0995 we'll start to see more data coming through. 188 00:14:37,135.0995 --> 00:14:39,495.0995 So it's still a ways away, but it's getting exciting. 189 00:14:39,495.0995 --> 00:14:41,885.099 It's getting closer and Oh, it is getting closer and closer. 190 00:14:41,885.099 --> 00:14:45,225.0985 And it's exciting to have new techniques and new technology to. 191 00:14:45,845.0995 --> 00:14:48,635.0995 to really help our patients and have some great outcomes. 192 00:14:48,635.0995 --> 00:14:51,25.0995 And I know that you've been involved in many of them. 193 00:14:51,25.0995 --> 00:14:51,905.0995 So thank you. 194 00:14:52,905.0995 --> 00:15:02,215.0995 I'm putting you on the spot here, but what are some of your top clinical pearls or most valuable clinical advice? If keratoconus. 195 00:15:04,10.0995 --> 00:15:12,800.0995 Well, for, other doctors that are performing cross linking, I think the most important thing I find is that you want to identify the location of the cone. 196 00:15:13,90.0995 --> 00:15:28,720.0985 I use the Pentacam in our practice, and we look at the thinnest spot, area, and that's going to be our target when we cross link, because you don't want to cross link in the center of the cornea and keep it perfectly centered if the cone is displaced inferiorly, because you're going to miss the weak part of the cornea. 197 00:15:29,480.0985 --> 00:15:39,50.0995 we saw that a lot with our patients with a condition called Pellucid Marginal Degeneration, where when you treat the center and Pellucid, it's really far periphery towards the very, very bottom. 198 00:15:39,510.0995 --> 00:15:43,450.0995 You're going to get flattening in the middle, but this, the untreated part will start to get steeper. 199 00:15:43,820.0995 --> 00:15:46,985.0995 And so while, You might say, Oh my gosh, it looks like we're getting better. 200 00:15:46,985.0995 --> 00:15:49,315.0995 Then over time you realize that the patient's not doing better. 201 00:15:49,725.0995 --> 00:15:51,825.0995 So we learned back in, 2000. 202 00:15:52,280.0995 --> 00:15:55,760.0995 13 2014 that you really need to dissenter the treatment. 203 00:15:55,760.0995 --> 00:16:08,770.0995 And by that what you do is the patient's lying flat instead of looking directly up at the light, they're going to, we're going to request the patient look above and over the light so that the beam of light is beaming directly down in the bottom part of the cornea if that's where the thinnest spot is. 204 00:16:09,30.0995 --> 00:16:12,520.0995 and then the idea is to have the light treat that weaker area. 205 00:16:12,840.0995 --> 00:16:18,600.0995 Again, what happens is that weak area becomes stronger, that starts to flatten the other part that's not treated. 206 00:16:19,410.0995 --> 00:16:22,950.0995 starts to flex in the opposite direction and then you get the reshaping occurring. 207 00:16:23,320.0995 --> 00:16:24,730.0995 So that's what we find is very helpful. 208 00:16:24,850.0995 --> 00:16:32,260.0995 Obviously, some patients have central keratoconus and you'll treat them dead center, but for the other patients, you're going to want to locate the thinnest part of the cornea, the weakest part of the cornea. 209 00:16:32,430.0995 --> 00:16:35,530.0985 And that's the goal to center your leg treatment on that area. 210 00:16:35,910.0995 --> 00:16:43,340.099 That's an excellent clinical pearl, and it plays a role also when fitting scleral lenses in those types of patients. 211 00:16:43,340.099 --> 00:16:48,50.0995 So we use a slightly different design, than we would do if there's a cone that's right central. 212 00:16:49,920.0995 --> 00:16:53,700.099 Are there any other pearls you'd like to share with us? Oh, sure. 213 00:16:53,700.099 --> 00:16:54,830.0995 I guess the last pro is that. 214 00:16:55,580.0995 --> 00:16:59,480.0995 not the end of the day if your condition progresses after the first treatment. 215 00:16:59,480.0995 --> 00:17:12,750.0995 So let's say you have a patient has keratoconus, they undergo treatment, and then they come back a year and a half, two years later, and you realize that while the rate of change has slowed down, has a completely rested the progression of the keratoconus, you see a little bit of adrift. 216 00:17:13,70.0995 --> 00:17:16,820.0995 And so in those patients, they can safely undergo a second treatment. 217 00:17:16,820.0995 --> 00:17:21,270.0995 We've had excellent results where you see, the first treatment, they drifted a little bit, but they do the second one. 218 00:17:21,270.0995 --> 00:17:22,890.0995 Now they get the flattening and reshaping. 219 00:17:23,70.0995 --> 00:17:24,0.0995 So sometimes patients. 220 00:17:24,445.0995 --> 00:17:25,595.0995 need a second treatment. 221 00:17:25,825.0995 --> 00:17:34,715.0995 And it makes sense because we treat every single patient with a similar level of UV exposure, and the very weak corneas just might need a little bit extra, a little boost. 222 00:17:35,725.0995 --> 00:17:39,440.0005 The other pro dimension, though, is that when I think they may need a second treatment, I. 223 00:17:39,600.1005 --> 00:17:51,330.1 Having come back another month later, I put them on dry eye therapy and I repeat the testing because sometimes the reason they look a little worse on the topography is they have dry eye and it gives a false irregular shape. 224 00:17:51,330.1 --> 00:17:52,800.1005 It looks like maybe it's a little bit worse. 225 00:17:53,100.1005 --> 00:17:59,275.1005 I've found that many times the fact that the patient come from Delray Beach just, a week ago, I scheduled him for the second treatment. 226 00:17:59,275.1005 --> 00:18:00,875.1005 it's a long drive and they came in. 227 00:18:00,885.1005 --> 00:18:02,205.1005 They had gotten worse last time I saw them. 228 00:18:02,205.1005 --> 00:18:04,635.1005 And if they were further worse, they were all set. 229 00:18:04,635.1005 --> 00:18:09,885.1005 They were actually ready for their treatment, but they actually got better their original treatment was like three and a half years ago. 230 00:18:10,235.1005 --> 00:18:12,495.0995 And then I thought, Oh my gosh, it's getting a little bit worse. 231 00:18:12,815.0995 --> 00:18:15,675.0995 It turned out that it was just a funny reading, maybe from dryness or whatever. 232 00:18:15,675.0995 --> 00:18:17,415.0995 Now this time they look better again. 233 00:18:17,415.0995 --> 00:18:19,275.0995 So we did not have to do the second treatment. 234 00:18:19,325.1995 --> 00:18:23,255.1995 Well, these are all excellent clinical pearls that we can use in practice. 235 00:18:23,335.1995 --> 00:18:24,455.1995 Thank you so much. 236 00:18:24,745.1995 --> 00:18:28,235.1995 And thank you for inspiring us on the Clearly KC podcast. 237 00:18:28,625.1995 --> 00:18:33,495.1995 I am so appreciative of all your contributions to our field over all these years. 238 00:18:33,545.1995 --> 00:18:38,275.1995 And for all of our listeners, thank you so much for joining us on Clearly KC. 239 00:18:38,565.1995 --> 00:18:47,775.1995 Please listen to all of the episodes of the Clearly KC podcast on Podbean or your favorite podcast app to subscribe and get future episodes. 240 00:18:48,275.1995 --> 00:18:49,435.1995 For now, I'm Dr. 241 00:18:49,435.1995 --> 00:18:50,195.1995 Melissa Barnett. 242 00:18:50,465.1995 --> 00:18:52,785.1995 Please join us next time on Clearly Casey.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!