Cornea Society NewsA Cornea Soc i e t y Pub l i ca t ion

J anua r y 2012

Vo l 8 , No . 1

(fDMAEK) yielded greater endothelialcell loss than manual DMEK prepara-tion or DSAEK procedures. Conversely,femtosecond lasers may aid in morepredictable big bubble formation inDMAEK.

Prosthetic lenses show promise

In patients with severe ocular surfacedisease, a prosthetic rehabilitation ofthe ocular surface ecosystem (PROSE)offers “improved visual acuity and visu-al function,” said Kristen Hawthorne,MD. At 6 months, patients with neu-rotrophic keratitis, exposure, Stevens-Johnson syndrome, and graft-vs.-hostdisease were likely to still be wearingthe device. A lower success rate wasseen in patients with a self-reporteddiagnosis of anxiety, depression, orfatigue. The scleral lens she describedhas a Dk of about 88, “which is aroundwhat typical gas permeable contactlenses are,” she said. “It’s not the pieceof plastic that matters, it’s the fit.”

Two other presentations on theBoston Type 1 KPro found it to be aviable option outside the U.S. to man-age repeat graft failure and chemicalinjuries. Gamma irradiated, femtosec-ond pre-cut corneal lenticules withoutviable endothelium may be a goodalternative to fresh corneal tissue inKPro procedures.

CDS projections

A greater restriction on donor age andendothelial cell density would decreaseavailability and increase cost, saidKevin Ross, MPH. A 2-year retrospectiveanalysis of 10,310 donor corneas (from9,365 donors) evaluated the impact ofendothelial cell density and donor age

Cornea Society/EBAA Fall EducationalSymposium lives up to name

T he 2011 Cornea Society/EBAAFall Educational Symposium,moderated by Sadeer B.Hannush, MD, and Stephen C.

Kaufman, MD, offered a full day’sworth of science on advances inendothelial, lamellar, and penetratingkeratoplasty procedures; keratoprothe-ses; and more.

The opening paper of the sessionset the tone for the high caliber scien-tific discussions that would follow.Mark A. Terry, MD, found the amountof time donor tissue is stored before useimpacts neither the cell count nor com-plication rates, and commented the“upper limit of how long we can waitbefore using the tissue is unknown.”

Those results may have an impact

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outside the U.S. as well, where donorgrafts may be 4-5 days old before use,he added. Although time-to-use wasnot measured in a different retrospec-tive study in India on pediatric DSEKgraft survival, at the end of 1 year 86%of pediatric grafts survived, accordingto Jatin Ashar, MD.

Moving to surgical techniques,Massimo Busin, MD, said ultra-thinDescemet’s stripping automatedendothelial keratoplasty (UT-DSAEK)may be the “ideal graft for EK proce-dures,” as it offers the rapid visualrecovery of DMEK but is easier to per-form. In 152 surgeries with 1-, 3-, 6-,and 12-month follow-up, BCVA of20/20 was achieved in 41%; 82% were20/25 or better at 6 months, he said.“The fastest and best recoveries were inphakic patients,” he said. His two-stepprocedure involves one pass with a300-micron head and the second witha 50-micron head.

As a proponent of DMEK, FrancisW. Price Jr., MD, spoke about using aroughened bimanual aspiration hand-piece to “polish” the peripheralrecipient bed to reduce the rate ofair reinjection after DMEK.

“Without polishing, air reinjectionwas necessary in 46 of 100 eyes,” hesaid. “With polishing, the air reinjec-tion rate was significantly lower ateight of 32 eyes (25%).” In phakicpatients he recommended injectingearlier than in pseudophakes.

DMEK/DMAEK procedures willcontinue to gain converts because oftheir potentially better visual out-comes, said Winston Chamberlain,MD. However, using a femtosecondlaser to prepare donor corneas

Andrea Ang, MD, accepts the BestPaper Award from David Glasser,MD, Marian Macsai, MD, and MontyMontoya

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President’s Message

Dear Colleagues,This New Year, I am honored to receive the torch of the presidency of The Cornea Society

from David Glasser, whose leadership undoubtedly leaves big shoes to fill. During his term,David has worked tirelessly to lead The Society to new heights, and it has been a great privi-lege for all of us on the Board who have benefited from his insightful guidance and experi-ence. David will of course be our immediate past president, and it will be reassuring to havehim continue to guide the Board and The Society.

The transition of the presidency sets a new milestone for The Society as we endeavor toserve the global community of corneal surgeons around the world, and one of my goals willbe to help The Cornea Society, with its current linkages to the Asia Cornea Society andEuCornea, become more international. In my role as president of the Asia Cornea Society, Ienvisage even stronger relationships between the societies, especially as our Board continuesto have strong international representation from the Americas, Europe, and Asia. One idea weare exploring is to create a global list of corneal fellowship and training programs, which would be on our website, so thatyoung members and ophthalmologists wishing to pursue our specialty would have access to the wealth of training initia-tives currently around the world. Recognition must also be given to Michael Belin’s outstanding efforts in pursuing inter-national relations, evident in the burgeoning calendar of The Cornea Society’s participation in various international andregional ophthalmic meetings in the coming year. We would also like to welcome our newly elected Board members,Anthony Aldave, Natalie Ashfari, Kathy Colby, and Sonia Yoo, who will bring fresh ideas and initiatives.

Led by our new Scientific Program Chair, Barry Lee, you can count on the scientific programs at ASCRS Cornea Day2012 and AAO Cornea Subspecialty Day 2012 to be even more stimulating. They will continue to provide scientific con-tent to meet the educational needs of the comprehensive as well as the corneal fraternity. In addition, with our new VP ofInternational Relations, Terry Kim, we hope to further engage industry partners to continue their strong support of TheSociety.

Our members continue to be the heartbeat of The Society and the nuclei of our endeavors. In order to have our fin-gers on the pulse of our members, Gail Reggio, our executive director, initiated two focus group meetings during theASCRS Symposium & Congress in San Diego in March 2011, to obtain feedback on The Society’s programs and services.Five task forces have since been created to address the objectives identified from the focus group meetings, namely aMembership Task Force chaired by Michael Belin; a Vision Mission Branding Task Force chaired by Marian Macsai; aMeetings/Education Task Force chaired by Chris Rapuano; a Young Physicians Task Force chaired by Barry Lee; and aCommunication Task Force chaired by Penny Asbell. These various task forces have since been hard at work and made sig-nificant recommendations that I am convinced will result in a new vibrancy and enable The Society to be even moreresponsive to the immediate needs of our members.

This year also marks the transition for the editorship of our Cornea journal, as Doyle Stulting, who has tirelessly guid-ed the journal to unprecedented growth for 9 years, passes on the baton to Alan Sugar, our incoming editor, whose distin-guished career and vast experience will unquestionably bring the journal to the next level. Our sincere thanks must alsogo to Ed Holland and Sadeer Hannush for their great contributions over the last few years and especially to Mark Mannis,our immediate past president, as they rotate off the Board.

Finally, I would like to express my appreciation to The Cornea Society Board of Directors for their patience and sup-port. It is indeed gratifying to see The Cornea Society prosper and grow from strength to strength, and 2012 will undoubt-edly bring new challenges and successes as we continue to strive toward our mission to promote education and research inthe corneal field around the world.

Sincerely,Donald T.H. Tan, FRCSPresident

Cornea Society News – published quarterly by The Cornea Society2

The Cornea Society January 2012

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Cornea Society News – published quarterly by The Cornea Society

restrictions, presuming a $2,000 pro-cessing fee was in place.

“According to the Cornea DonorStudy guidelines, 100% of the tissuewould be available with a 70-year-olddonor that had 2,000 cells,” he said.But if surgeons demanded 2,300 cells,only 87.5% of the available tissue in70-year-olds would be viable (at a costof $2,285); at 2,800 cells only 36.9% ofthe donor tissue would be available

3

Cornea continued from page 1

from 70-year-olds, and the “break even”point would be $5,427, Mr. Ross said.The costs continue to escalate if donorage is dropped to 65 or 60 years old andcell counts increase, he said.

Awards

Throughout the day, several awardswere presented. S. Arthur Boruchoff,MD, was this year’s recipient of theClaes H. Dohlman, MD, PhD, Award,given to an individual who has fosteredteaching corneal fellows. Dr. Dohlman,who accepted on Dr. Boruchoff’s behalf,said Dr. Boruchoff has been “tremen-dous and selfless” with his time overthe course of his career. Friends for thepast 50 years, Dr. Dohlman said it washe who should be honored that “such astellar educator” was named this year’srecipient. “Art is a great teacher—betterthan anyone else,” he said.

The best paper to be published inCornea by an author under the age of 40is awarded the Troutman Prize Lecture.This year’s recipient, Daniel Bohringer,MD, and colleagues wrote about long-term graft survival in penetrating ker-atoplasty. They found the incidence oflate endothelial failure was 8% inpatients with keratoconus and 33% inthose with bullous keratopathy.

Richard Troutman, MD, who estab-lished the award in 2008, was on handto deliver the award personally.

“Nothing in this world happensalone,” he said. “We are all in thistogether.”

The EBAA’s highest honor, the R.Townley Paton Award Lecture, wasbestowed upon Alan Sugar, MD, theincoming editor of Cornea. He spokeabout the 5-year results from theCornea Donor Study, finding endothe-lial cell density “was not predictive ofearly graft failure. But at 6 months,recipients with less than 1,700 had amuch higher rejection rate—13%—when compared to those with cellcounts between 1,700 and 2,499 (3%)and those with more than 2,500 (2%).So it’s what happens initially that is apredictive factor.”

Lastly, the Best Paper Award wasgiven to Andrea Ang, MD, who dis-cussed the incidence, characteristics,and outcomes in ocular surface trans-plantation. “Younger patients shouldbe treated more aggressively to preventrejection,” she said. “Close monitoring,early recognition, and aggressive treat-ment—even when it’s a low-graderejection—is crucial.”

Looking at the latest in cornea

Keratoprostheses, keratitis, and keratoplasties just some of the highlights covered at AAO’s CorneaSubspecialty Day

T he American Academy ofOphthalmology’s 2011 CorneaSubspecialty Day, sponsored byThe Cornea Society, featured a

variety of cutting-edge cornea-focusedpresentations.

Presenters covered a host of topics,including ocular surface disease, infec-tious keratitis, and corneal transplanta-tion, including lamellar keratoplasty,penetrating keratoplasty (PK), and pedi-atric keratoplasty.

One highlight was “A BiosyntheticAlternative to Human Donor Tissue,”presented by Per Fagerholm, MD, pro-fessor of ophthalmology, LinkopingUniversity, Linkoping, Sweden. Dr.Fagerholm presented on the results of aphase I study in 10 humans using mate-rial made from human recombinantcollagen type III that is crosslinkedusing water-soluble carbodiimide. Thisbiosynthetic alternative is used tomimic the corneal stroma’s extracellularmatrix.

The 10 patients, all of whom hadanterior lamellar keratoplasty per-formed, were compared against a con-trol group that underwent PK withhuman donor corneas.

At 3 years post-op, patients withthe biosynthetic material had peripheralhost-implant interface haze and focalareas of haze in the midperipheral cen-tral cornea, the latter of which mayhave been due to disruption of re-epithelialization. Although Dr.Fagerholm said the best corrected visualacuity was not impressive (although itimproved with contact lens insertion),the overall trial results were solid.

“The phase I trial demonstratedsafety and long-term stability,” he said.

The next steps are to improve thematerial and surgical technique evenfurther and expand the study, Dr.Fagerholm said.

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Richard Troutman, MD, and DavidGlasser, MD, present the TroutmanAward to Daniel Bohringer, MD

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Cornea Society News – published quarterly by The Cornea Society4

Keratoprostheses

Other presentations focused on kerato-prostheses such as the Boston KPro(recently renamed the prostheticreplacement of the ocular surfaceecosystem, or PROSE). Although U.S.-based clinicians think of the Bostondevice when they hear the word KPro,there are other KPros to consider world-wide, such as the osteo-odonto-kerato-prosthesis, said Christopher Liu,FRCOphth, Sussex Eye Hospital,Brighton, U.K. The device uses apatient’s tooth root and alveolar boneto support an optical cylinder, said Dr.Liu. The device was developed about 40years ago but is only now gaining moreattention. Sixty cases with the OOKPhave been completed in Brighton since1996, Dr. Liu said. The OOKP is not aseasily reversible as the PROSE device,but it has strong results, he said.

Keratitis

Another hot topic in cornea is the useof steroids to treat bacterial keratitis.Thomas M. Lietman, MD, Universityof California, San Francisco, reported onthe results of a clinical trial publishedonline in October on the Archives ofOphthalmology website. The study’s pri-mary outcome was best spectacle cor-rected visual acuity (BSCVA) at 3months. Five hundred patients wereultimately enrolled. The study com-pared the use of prednisolone sodiumphosphate 1.0% to placebo as adjunc-tive therapy for bacterial corneal ulcers.“Eligible patients had a culture-positivebacterial corneal ulcer and received top-ical moxifloxacin for at least 48 hoursbefore randomization,” according to thestudy abstract. Investigators found thatadding a steroid did not improve BSCVAat the 3-month mark, Dr. Lietman said.

Keratoplasty

As more surgeons decide to performDescemet’s stripping endothelial kerato-plasty, they should consider some help-ful pearls, said Friedrich E. Kruse, MD,professor of ophthalmology, Universityof Erlangen, Germany. Surgeons should

carefully select patients and donors,select the type of insertion techniquethey will use, and consider convertingto Descemet’s membrane endothelialkeratoplasty (DMEK) or ultrathinDescemet’s stripping automatedendothelial keratoplasty. If performingDMEK, surgeons should control graftorientation, graft insertion, and donorunfolding and attachment, Dr. Krusesaid.

Corneal neovascularization

Corneal neovascularization is oftenassociated with corneal scarring, thesecond most frequent cause of blindnessglobally, said Reza Dana, MD, professorand director of Cornea & RefractiveSurgery, Massachusetts Eye and EarInfirmary; Department ofOphthalmology, Harvard MedicalSchool; and senior scientist and W.Clement Stone Scholar, Schepens EyeResearch Institute, Boston. For this rea-son—and because corneal neovascular-ization can amplify other cornealpathologies—it is important to under-stand causes and therapies for it, Dr.Dana told attendees.

Common causes of corneal neovas-cularization include infections, chemi-cal burns, penetrating trauma, degener-ations, autoimmune disorders, meibo-mian gland dysfunction, and cornealtransplants, Dr. Dana said.

“Management approaches shouldoptimize the treatment of underlyingetiology or the offending agent,” Dr.Dana said. Depending on the cause, thismay include pterygium surgery, amniot-ic membrane grafting, limbal stem cellgrafting, laser treatment, photodynamictherapy, diathermy, or—the most com-mon treatment approach—pharmaco-logic measures. Dr. Dana and fellowinvestigators have been looking at localocular delivery using the anti-vascularendothelial growth factors bevacizumab(Avastin, Genentech, South SanFrancisco) and ranibizumab (Lucentis,Genentech) to treat corneal neovascu-larization.

Future therapies

Toward the end of Cornea SubspecialtyDay, Shigeru Kinoshita, MD, professorof ophthalmology, Kyoto PrefecturalUniversity of Medicine, Kyoto, Japan,focused on three types of therapies indevelopment to treat corneal endothe-lial disease. They are cultivated cornealendothelial cell sheet transplantation,cultivated corneal endothelial cell injec-tion therapy, and eye drops. Dr.Kinoshita and fellow investigators haveused cell sheet transplantations in pri-mates with advanced corneal endothe-lial dysfunction; the transplantationswere moderately successful. Cell injec-tion therapy along with a Rho-kinase(ROCK) inhibitor in a group of rabbitsand monkeys led to better endothelialcell adhesion, high cell density, andnormal-looking morphology. The use ofeye drops, which Dr. Kinoshitadescribed as still “a dream,” involvesthe use of ROCK inhibitor eye drops.Experimental use of drops in rabbitsand monkeys led to the regeneration ofa corneal endothelial monolayer andhigh endothelial cell density.

Editors’ note: Dr. Dana has financial interests with Alcon (Fort Worth, Texas),Allergan (Irvine, Calif.), Bausch + Lomb(Rochester, N.Y.), and other ophthalmiccompanies. Dr. Kinoshita has financialinterests with Abbott Medical Optics(AMO, Santa Ana, Calif.), Alcon, Hoya(Chino Hills, Calif.), and other ophthalmiccompanies. Dr. Kruse has financial interests with CellSeed (Tokyo) and Santen(Emeryville, Calif.). Drs. Fagerholm,Lietman, and Liu have no financial inter-ests to report.

Contact information

Dana: Reza_Dana@meei.harvard.eduFagerholm: perfa@inr.liu.seKinoshita: shigeruk@ophth.kpu-m.ac.jpKruse: Friedrich.Kruse@augen.imed.uni-erlangen.deLietman: Tom.lietman@ucsf.eduLiu: cscliu@aol.com

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McCormick PlaceFriday, April 20, 2012

8:00AM – 4:30PM

For registration, housing, andprogram updates go to ... www.CorneaDay.org

2012 Cornea Day is geared toward practicing ophthalmologistswith an interest in comprehensiveophthalmology, anterior segment

surgery, and corneal disease.

Terry Kim, MD Co-chairASCRS Cornea Clinical Committee

Donald TH Tan, FRCS Co-chairCornea Society

Anthony J. Aldave, MDCornea Society

W. Barry Lee, MDCornea Society

Marian S. Macsai, MDCornea Society

Francis S. Mah, MDASCRS Cornea Clinical Committee

Neda Shamie, MDASCRS Cornea Clinical Committee

David T. Vroman, MDASCRS Cornea Clinical Committee

Program Outline (subject to change)

8:05 AM – 9:40 AMCorneal Challenges for theCataract Surgeon

Moderators David T. Vroman, MD, &Anthony J. Aldave, MD

FacultyIke K. Ahmed, MD, FRCSCGraham D. Barrett, FRACOSamar K. Basak, MD, FRCSRobert J. Cionni, MDDavid R. Hardten, MDWarren E. Hill, MDSamuel Masket, MDMike E. Snyder, MDAlejandro Navas, MD

9:40 AM – 9:55 AM Break

9:55 AM – 11:35 AMControversies in Cornealand Ocular Surface Transplantation

ModeratorsTerry Kim, MD, &Neda Shamie, MD

Faculty Anthony J. Aldave, MDWinston D. Chamberlain, MD, PhDLuigi Fontana, MD, PhDEdward J. Holland, MDJohn A. Hovanesian, MDFrancis W. Price Jr., MDChristopher J. Rapuano, MDAllan R. Slomovic, MD Mark A. Terry, MD

11:35 AM – 1:00 PM Lunch

1:00 PM – 2:35 PMAdvances in Diagnostics, Therapeutics, and Corneal Imaging

ModeratorsW. Barry Lee, MD, &Francis S. Mah, MD

FacultyRenato Ambrósio Jr., MDRichard E. Braunstein, MDReza Dana, MDRichard S. Davidson, MDSheraz Daya, MDDavid A. Goldman, MDJack T. Holladay, MDStephen C. Kaufman, MD, PhDJonathan H. Lass, MDVictor L. Perez, MDJ. Bradley Randleman, MDChristopher E. Starr, MDElmer Y. Tu, MD

2:35 PM – 2:50 PM Break

2:50 PM – 4:30 PMInnovations and Dilemmasin Refractive Surgery

ModeratorsMarian S. Macsai, MD, & Donald TH Tan, FRCS

Faculty Dimitri Azar, MDPerry S. Binder, MS, MDDeepinder K. Dhaliwal, MDWilliam J. Dupps Jr., MD, PhDJosé L. Güell, MD, PhD D. Rex Hamilton, MDRonald R. Krueger, MD, MSERichard L. Lindstrom, MDJohn Marshall, PhDJodhbir S. Mehta, MDShazad Mian, MDKerry D. Solomon, MDJohn Vukich, MDSonia H. Yoo, MD

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6 Cornea Society News – published quarterly by The Cornea Society

Cornea Society News is published by The Cornea Society.Opinions expressed are not necessarily those of The Cornea Society. Mention of products or services does not constitute endorsement. To submit comments,

suggestions, or news, contact Gail Reggio at GReggio@CorneaSociety.org. All rights reserved. Copyright 2012. The Cornea Society,

4000 Legato Road, Suite 700, Fairfax, VA 22033 703-591-0196 • Fax: 703-434-3000 • www.CorneaSociety.org

Pinpointing causes and treatmentof corneal stem cell deficiency

Corneal stem cell deficiencyrequires some unique diagnos-tic techniques and manage-ment, and presenters at the

AAO symposium “Unrecognized Stem Cell Deficiency: What EveryOphthalmologist Needs to Know” covered a range of related information.The symposium was sponsored by TheCornea Society.

Causes

Various causes of corneal stem cell defi-ciency range from infection to congen-ital causes to trauma, said Ivan R.Schwab, MD, professor and director,Cornea & External Disease Service,University of California Davis,Sacramento, Calif.

Regarding infection and cornealstem cell deficiency, “the trachomaagent is the most common worldwide,”Dr. Schwab said.

Other causes include herpes sim-plex virus, neurotrophic ulcers, viralagents, contact lens solutions and relat-ed preservatives, glaucoma medica-tions, radiation, mitomycin C, graft-vs.-host disease, and acquired/autoim-mune diseases, Dr. Schwab said.

Globally, the most common causeis infection. Dr. Schwab also noted thatcorneal stem cell deficiency fromautoimmune disease and congenitalcauses are the most difficult to treat.

Diagnosis

Corneal limbal stem cell deficiency ismore common than previouslythought, but it is also easy to confusewith other conditions, said MarkMannis, MD, professor and chair,Department of Ophthalmology &

Vision Science, University of CaliforniaDavis Eye Center, Sacramento, Calif.

Conditions that might appear simi-lar to corneal stem cell deficiencyinclude punctate epitheliopathy,macro-epithelial defects, herpes sim-plex and herpes zoster, Acanthamoebakeratitis, corneal vascularization, acnerosacea, and fibroses such as pterygiumand Salzmann’s degeneration, Dr.Mannis said.

Clinicians can pinpoint if a patientactually has corneal stem cell deficien-cy by considering the condition’s his-torical setting, whether it’s unilateral orbilateral, focal or diffuse, and whetherit’s accompanied by significant inflam-mation or associated lid or skin disease,he said.

Corneal stem cell disease is bestdiagnosed based on clinical featuresand the detection of cellular or molecular markers, said Stephen C.Pflugfelder, MD, professor of ophthal-mology, Baylor College of Medicine,Houston. “Cellular and molecular bio-markers may be good but require moreclinical trials,” Dr. Pflugfelder said.Cytologic biomarkers may also be usedin the future for diagnosis, he said.

Treating corneal stem cell deficiency

“Supportive therapy [for corneal stemcell deficiency] can improve vision andreduce symptoms,” said Deborah S.Jacobs, MD, medical director, BostonFoundation for Sight. Dr. Jacobs calledserum and plasma for the condition akind of “Miracle-Gro.” However, thelogistics of procuring the compoundand the risk of contamination makethem challenging treatment options.

Topical vitamin A is another treat-ment option not commonly availablein the United States and one that mustalso be compounded, she said.

Amniotic membrane should beused only if the patient experiencesacute setbacks. “It doesn’t change thecourse of disease,” she said.

The use of a contact lens or thera-peutic lens is an option as long as dailydisposables are avoided if the patientmight wear them overnight, Dr. Jacobssaid.

Friedrich E. Kruse, MD, professorof ophthalmology, University ofErlangen, Germany, spoke about autol-ogous and allogenic stem cell trans-plantation as a management option.However, he also noted that incom-plete stem cell disease should not besubject to transplant options.

Other presentations during the ses-sion included “Aniridic Keratopathy:Diagnosis and Management” from JoseGomes, MD, Sao Paolo, Brazil;“Corneal Stem Cell Transplantation:Immunosuppression” from Ali R.Djalilian, MD, assistant professor,Cornea Service, University of Illinois atChicago; “Other Stem Cell Sources;Mucosal, Ex Vivo Expansion, Etc.,”from Kohji Nishida, MD, professor ofophthalmology, Kyoto PrefecturalUniversity of Medicine, Kyoto, Japan;and “Permanent KeratoprosthesisSurgery for Corneal Stem CellDeficiency,” from James Chodosh,MD, professor of ophthalmology,Massachusetts Eye and Ear Infirmary,Harvard Medical School, Boston.

Castroviejo Lecture

Also at the stem cell deficiency session,this year’s Cornea Society Castroviejo

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Lecturer Joel Sugar, MD, professor,Cornea Service, University of Illinois atChicago, addressed the high frequencyof keratoconus, which occurs at a rateof 1 in 2,000 in the general population.Still, “its cause remains elusive,” Dr.Sugar said.

Various biochemical changes asso-ciated with keratoconus could begenetic or environmental in origin, hesaid. Eye rubbing also has a long histo-ry of association with keratoconus, Dr.Sugar said, noting that eye rubbingcould lead to K1 mediated apoptosis.Environmental factors associated with

keratoconus include floppy eyelid syn-drome, sleep apnea, contact lens wear,ultraviolet light exposure, altitude pres-sure, hormonal factors, and refractivesurgery. However, when patients haveboth diabetes mellitus and kerato-conus, the latter seems to be lesssevere. “This is a complex disease,” hesaid.

Editors’ note: Dr. Jacobs has financialinterests with the Boston Foundation forSight. Dr. Kruse has financial interestswith CellSeed (Tokyo) and Santen(Emeryville, Calif.). Dr. Pflugfelder has

financial interests with Allergan (Irvine,Calif.), Bausch + Lomb (Rochester, N.Y.),and Inspire Pharmaceuticals (Raleigh,N.C.). Drs. Mannis, Schwab, and Sugardid not report any financial interests.

Contact information

Jacobs: djacobs@bostonsight.orgKruse: Friedrich.Kruse@augen.imed.uni-erlangen.deMannis: mjmannis@ucdavis.eduPflugfelder: stevenp@bcm.tmc.eduSchwab: irschwab@ucdavis.eduSugar: joelsuga@uic.edu

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