Recent changes to cornea: Preferred Practice Patterns

(Image Credit: AdobeStock/Irene)

The recent updates to cornea Preferred Practice Pattern (PPP) guidelines bring notable changes for ophthalmologists, especially concerning pediatric patients with corneal diseases. Ophthalmology Times conducted a Q&A interview with Daniel S. Choi, MD, a member of the Cornea/External Disease Panel of the PPP Committee, to discuss key revisions, including the acknowledgment of dry eye syndrome in younger patients, risks of microbial keratitis linked to orthokeratology, and recommendations for monitoring rapid progression of keratoconus in patients younger than 18 years. In this discussion, Choi highlights the importance of these evidence-based guidelines, revised every 5 years, and their role in guiding clinical practice, although they do not establish strict standards of care.

The updated PPPs also incorporate new treatment modalities, such as cross-linking for keratoconus and recently approved medications for corneal conditions. Despite the lag in updates, the guidelines remain a critical resource for ophthalmologists navigating evolving treatment landscapes.

Ophthalmology Times (OT):

What are the PPP guidelines?

Choi:

The PPP guidelines^1-6 are developed by committees of disease state experts who volunteer to serve with the American Academy of Ophthalmology. The guidelines represent a broad overview of diagnostic criteria and evidence-based treatment modalities for each disease state, with recommendations for the history, physical [examination], and ancillary tests needed for diagnosis, along with recommendations for management, follow-up, and patient education. Newly revised guidelines are published in Ophthalmology and can be accessed at https://www.aao.org/education/guidelines-browse.

OT:

How often are the PPPs revised?

Choi:

The American Academy of Ophthalmology’s PPP committees meet annually and conduct an extensive revision of their respective PPP documents every 5 years on a fixed schedule. The revisions that were scheduled for 2023 included 6 topics in cornea/external disease. The updated PPPs were released earlier this year.1-6 The cornea topics will next undergo a major update in 2028. Some of the PPPs, such as the one for primary open-angle glaucoma, were first published in the late 1980s and since that time have been regularly updated ever since, while others, such as refractive surgery and retinal vein occlusions, were introduced more recently. The Retina Panel is revising 7 retina-related PPPs slated for release in early 2025. Annual updates for FDA-approved products and major clinical trial results for PPPs are placed on the
Academy website.

OT:

This year, there were several changes related to corneal disease in young patients. What can you tell us about these?

Choi:

Three separate cornea PPPs have updated recommendations for pediatric
patients. First, the Dry Eye Syndrome PPP1 acknowledges for the first time that dry eye can occur in pediatric patients. Although we think of dry eye as a condition common in middle-aged and [older] people, its prevalence in younger people is growing, especially with increased use of digital devices. Secondly, the Microbial Keratitis PPP2 specifically mentions orthokeratology for myopia control in young patients—and overnight contact lens wear, more generally—as a leading risk factor for microbial keratitis in the US. Finally, the updated Corneal Ectasia PPP3 now recommends close follow-up of [patients with] keratoconus younger than 18 years (as frequently as every 3 months) because these patients can progress faster than older [patients with] keratoconus. It also makes it [clearer] that there is no standardized way of diagnosing progression.

OT:

What are the recommendations for the management of keratoconus?

Choi:

When the last Corneal Ectasia PPP was published in 2018, corneal collagen cross-linking with the iLink system (Glaukos) had only recently been approved by the FDA, and there was limited US literature available to include in the committee’s review. The volume of evidence has expanded significantly since then, and the updated PPP3 now definitively says that cross-linking is the recommended treatment for progressive keratoconus because it stabilizes the cornea, reduces the risk of further progression, and is more cost-effective than a corneal transplant. The document also highlights that scleral lenses, which have greatly improved in the past 5 years, are an option for visual rehabilitation after cross-linking.

OT:

What new medications are mentioned in cornea-related PPPs this year?

Choi:

There has been an explosion of new treatment modalities. This year, we were able to include at least 5 new topical medications with sufficiently strong evidence to be recommended for corneal indications. These include lotilaner ophthalmic solution, 0.25% (Xdemvy; Tarsus Pharmaceuticals) for Demodex blepharitis, perfluorohexyloctane ophthalmic solution (Miebo; Bausch + Lomb) for evaporative dry eye, and varenicline nasal spray for dry eye (Tyrvaya; Oyster Point Pharma/Viatris).^1,4 Nerve growth factor agent cenegermin-bkbj (Oxervate; Dompé) is now a recommended treatment for neurotrophic keratopathy or nonhealing epithelial defects,⁵ and cyclosporine 0.1% (Verkazia; Harrow)
is a newer immunomodulating therapy for vernal conjunctivitis.⁶

OT:

What is it like to serve on the PPP Committee?

Choi:

It has been a remarkably positive experience. There is a well-established methodology for reviewing the literature from PubMed, Cochrane Review, and other sources. We update the recommendations based on strict evidentiary standards, with assistance from a methodologist and Academy staff. Draft guidelines are also reviewed by other stakeholders, such as professional societies and patient organizations.

OT:

Do the PPP guidelines establish standards of care?

Choi:

Not exactly. The American Academy of Ophthalmology specifically notes that the PPPs are not medical standards to be adhered to in all individual situations. They provide guidelines for the pattern of care, but the treatment of any patient should be customized to that patient based on the physician’s best medical judgment. It is also inevitable that the PPPs will lag behind what many are doing in clinical practice because major updates to the PPPs occur only every 5 years, and we have to have such high standards for evidence. However, I think it is a good idea for clinicians to be aware of what is in these documents. They are available to the public, so there is no doubt that they could play a role in perceptions of acceptable treatment in our fast-moving field of ophthalmology.

Daniel S. Choi, MD

E: danielmd@visionofhi.com

Choi is in private practice at the Cataract & Vision Center of Hawaii in Honolulu. He is a member of the American Academy of Ophthalmology’s PPP Committee Cornea/External Disease Panel. He has received an honorarium from Glaukos but has no other financial interests relevant to this article.

References:

1. Amescua G, Ahmad S, Cheung AY, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Dry eye syndrome preferred practice pattern.Ophthalmology. 2024;131(4):P1-p49. doi:10.1016/j.ophtha.2023.12.041

2. Rhee MK, Ahmad S, Amescua G, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Bacterial keratitis preferred practice pattern. Ophthalmology. 2024;131(4):P87-P133. doi:10.1016/j.ophtha.2023.12.035

3. Jhanji V, Ahmad S, Amescua G, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Corneal ectasia preferred practice pattern. Ophthalmology. 2024;131(4):P205-P246. doi:10.1016/j.ophtha.2023.12.038

4. Lin A, Ahmad S, Amescua G, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Blepharitis preferred practice pattern. Ophthalmology. 2024;131(4):P50-P86. doi:10.1016/j.ophtha.2023.12.036

5. Mian SI, Viriya ET, Ahmad S, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Corneal edema and opacification preferred practice pattern. Ophthalmology. 2024;131(4):P247-P305. doi:10.1016/j.ophtha.2023.12.039

6. Cheung AY, Choi DS, Ahmad S, et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Panel. Conjunctivitis preferred practice Pattern. Ophthalmology. 2024;131(4):P134-P204. poi:10.1016/j.ophtha.2023.12.037