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    Binkhorst Lecture: Predicting, treating keratoconus in 2016

    New Orleans—The Binkhorst Lecture and Medal have been conferred since 1975 on “an individual whose career has made significant contributions to the science and practice of ophthalmology and established that person among the world’s most prominent ophthalmologists.”

    Doyle Stulting, MD—this year’s recipient—is considered “a primary force in the surgical management of complex cataracts, corneal disease, and intraocular lens complications.”

    With more than 200 authored papers and 10 years at the helm of Cornea, Dr. Stulting has also served on the board of directors for the American Society of Cataract and Refractive Surgery (ASCRS), has been awarded the American Academy of Ophthalmology’s Senior Honor award, and has received the Paton Award from the Eye Bank of America.

    More recently, however, Dr. Stulting was the principal investigator for a physician-sponsored clinical trial of riboflavin-ultraviolet A corneal collagen crosslinking, the first of its kind in the United States.

    A history of ectasia

    In 1998, Theo Seiler, MD, brought ophthalmology’s attention to post-LASIK-induced ectasia, Dr. Stulting said. He and colleagues began retrospectively evaluating the risk factors that might contribute to the complication, and developed an ectasia risk score system in 2008.

    “Preoperative refraction, pachymetry, forme fruste keratoconus (FFKC), and residual stromal bed (RSB) were all predictors of post-LASIK keratectasia,” he said. “Of those, FFKC was by far the largest risk factor.”

    The group also determined age played a factor, with younger patients more affected than older patients, he said.

    An analysis of an additional 171 cases found a “significant association with younger age, preoperative manifest refraction, pachymetry and abnormal topography, but we wanted to address the criticisms we’d heard about our strict criteria,” he said.

    William Trattler, MD, provided another population of patients, “and we found the same consistent risk factors,” Dr. Stulting said. “Patients often have multiple risk factors.”

    Dr. Stulting’s scoring system “has a 9% false positive and a 9% false negative rate, though. Wouldn’t it be great if it worked perfectly?”

    A consistent dilemma for surgeons is classifying the corneal topography maps, especially when the patient is on the cusp.

    “Even the best of us have a hard time judging these images,” he said.

    Over the years, however, Dr. Stulting said the sensitivity has fallen, “but why is our risk system failing today? RSB is increasing, but FFKC is decreasing. Corneal thickness is also increasing. The mean patient age is decreasing—We’re still operating on young patients and the elimination of other risk factors are making age a much more relevant factor.”

    Moving forward and the role of CXL

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