sazor6 ‘The Best of Ophthalmology... FyelWorld News Magazine Cascrs 7 a Ns aol ‘The Newsmagazine of the American Society of Cataract & Refractive ar ‘Curent Issue Past issues REPLAY Meetings Search ee Shore this arte + Print Article aid ies ne) connea —_Epithel kness profiling: unmasking keratoconus by Maxine Lipner Senior EyeWorld Contributing Editor ‘An epithelial doughout-like pattern may provide an important clue ‘A unique epithelial thickness pattern may help to point the way tw detintive identification in cases of potential keratoconus, = according to Dan Z. Reinstin, M.D., medical director, London gag Vision Clinic, Londen, Inthe July 2009 issue of the Journal of Refractive Surgery, Dr. Reinstein reported on how enitnelial thickness maps could be used to help diagnose or exclude saan keratoconus in cases with uncertain keratoconus on standard Clisical, topography, and tomographical screening technology to derec sub-surface anterior svorel cones, which Mfth parmiaains Reingeln, fare Tikely keratoconic and which are most likely nt,” Dr Using the Artemis very high frequency digital ultrasound are scanner (ArcScan, Golden, Coo.) Investigators obtained the epithelial thickness praflles of 110 normal eyes. *What we found was that the average thickness of the epithelium in the population was fairly tightly controlled: central View Latest sue epithelial thickness was 53 microns with a standard deviation of about 3 microns,” Dr. Reinstein s2id. "The interesting thing was that while it was fairly similar all over the eye, the epithelium was slightly thinner superiorly than inferiorly and ever so slighty thinner temporally tran nasal. Br. Reinstein and colleagues theerized that blinking is at the root ofthis pattern. “Because the upper lid Ophthalmetoiss is much more active than the lower lid me theorize that there was mare force coming éown from the superior part of the cornea than coming up from the lower li” Or. Reinstein said. "The action Practice Managers of the upper lid causes chafing of the superior epithelial cells preferentially, relative to the inferior cornea." Investigators found that this pattern was very repeatable between patients, giving them @ benchmark to consider in eases of patental Keratoconus where the epithelial pattern deviated from eyecoNnect this norm, Distinct "epithelial doughnut pattern” Likewise, when they mapped the epithelium in clear-cut eases of keratoconus they found a unique pattern. "We found that in keratocanus the epithelium has @ very distinct pattern of thinner epithelium over the cone, surrounded by an annulus of thickened epithelium,” Dr. Reinstein explained, The difference between the thickest and thinnest epithelium was Gramaticaly different than in "normal patients. "The epithelium over the cone in corneas with kerateconus can be very thin—it ean get down to 25 of 26 mierons,” Dr. Reinstein sai. “Similarly, in the surrounding annulus of thicker epithelium, the epithelium can thicken to @ very high degree, sometimes hnipshwww-eyoworldergarticlo-opithell-byckness-prallingy-urmasking keraloconas 18sitazot6 ‘The Best of Ophthalmology... FyelWorld News Magazine reaching up to and beyond 200 microns.” These extremes are well outside the values possible within the normal corneal population, In early cases this pattern can help to mask 2 keratoconus cone. "In advanced kerateconus the epithellum sometimes breaks down because of excess thinning, but in very early Keratoconus the anterior surface cone will be so mild that epithelial thinning occurs in such a way as to completely mask the anterior surface cone,” Dr, Relnstein sald, "Frnt surface topography can look normal even though a mild sub-surface stromal cone exists.” ‘This cistinctive pattern can potentially help make a clagnosis In cases where anterior surface topography is equivocal "You can loak atthe topography ane think that It looks funny but not know whether Its Keratoconus oF not," Or. Reirstein said. “Tt might be thatthe corneal surface Is asymmetric with no underlying keratocorus, or it might be that there is indeed keratoconus that is being masked by epitelia remodeling.” Cases on the epithelial edge Inthe recent paper, investigators presented five cases including one of 2 normal eye, one of & definitive keratoconus case, and three cases where the keratoconus diagnosis was In question, 1n the first case topography showee a bit of inferior steepening, “This i one of the patterns that can be suggestive of kevataconus,” Or, Reinstein said, "The computerized éiagnosis trom the Atlas, placice topagrapner (Carl Zeiss Mecitec, Dublin Cali.) sald thatthe eye was normal, and the Orbscan (Bausch A Lomb, Rochester, N.Y.) anterior best fit sphere plot also looked relatively normal. However, the back surface best fit sphere on Oroscan showed an eccentric, elevated apex =a sign of a possible cone.” When investigators consicered the epithelial profile In conjunction with the Atlas and Orbscan information, they were able to make a defiitive diagnosis. "The epithelial thickness profile showed a clear pattern of thinner epithelium surrounded by an annulus of thicker epithelium, the pattern similar to that of corneas with keratoconus,” Dr. Reinstsin said “It had thin epithelium overlying the region where the equivacal back surrace eccentric elevation eccurred: ‘While there were ne changes on the front surface topography, the epithelium gave away the fact that there was indeed a sub-surface anterior stromal surface cone coincident with te back surface eccentric elevation. In acdtion, the epithelium was thickened inthe characteristic doughnut pattern, thus alerting us that this purportedly normal eye was infact mildly keratoconic." ‘The second case involved an eye that had topography that was virtually identical tothe first. *It had ever so slight inferior steepening and the automatic output from the topographer says that ‘there is suspect Kerataconus,” Or. Reinstein sald. "Again, the Orbscen anterior and posterior best ft sphere plots were relatively normal In this case, however, the epithelial profile tld a different Story from the first. "When we loaked atthe epithelial thickness profile we saw a pattern that was. identical to a normal patient—ever so slightly thinner on top and thicker on bettom,” Dr. Reinstein sd, “In this case, the epithelium overlying the zone of inferior steepening on placid topography was thicker, not thinner, implying that there could not have been a sus-surface anterior stromal Inthe thie case described here, the topography was completely normal. The enly thing that hinted at potential Keratoconus was an eccentric, elevated apex on the back surface best ft sphere pet. When investigators looked at the epithelium they found that it was actually thinning over the back surface "cone," with the typical thickening pattern around the erea of epithelial thinning, “In that case, the epithelium was able to compensate 100% for the cone an the back surface to make the front surface look completely symmetrical and normal," Dr. Reinstein said, Another stud, Published in the May 2008 issve of the Journal of Refractive Surgery, lends credence to the fact that eyes deemed normal by the epithelial profile are in fact non-kerateconic. "We were showing the stability of refraction in eyes where we had done LASIK in cases where the topography was slightly suspicious but the epithelium proved them to be normal,” Dr. Reinsten said. "When we compared these eyes to a contral group of patients wha were completely normal on topographic Screening—and di not require Artemis epithelial mapping to prove so—we found that there was no difference between the two groups inthe stability of the refraction and the topography at one Year." Going forward investigators are working to quantify the changes that occur in the epithelia maps in early keratoconus. "We're working to develop indices that can idetify keratoconus from normal rater than just loaking at the pattern,” Dr, Reinsten said, "The holy grail isto be able to Dut al the topography, refraction, epithelial, 2nd corneal thickness data into 2 big pot and work out ome multvariate derived function that will ell us whether the patient has Keratoconus or not.” Editors’ note: br. Reinstein has financial interests with Carl Zeiss Maditec (Dubin, Calif), nas @ proprietary interest in the Artemis technology (AreScan, Golden, Colo.), and is the author of patents related to VHF dattal ultrasound administered by the Cornell Research Foundation (New York). Contact information In: +44 207 224 1005, dzr@lonéonvisionclinic.com hnipshwww-eyoworldergarticlo-opithell-byckness-prallingy-urmasking keraloconas 28.nanos ‘The Best of Ophihalmology...EyeWorld News Magazine a Contribute | Editorial Board | Advertiser Index | Publishing Statement | Advertise with Us CASERS $2779" © 3997-2016 Eyewors News Serve hip dew: eyoworldcrgartile-epiholal-byckness-prafln-urmasking kraloconus