Post on 18-Dec-2014
description
CXL AND TOPO-GUİDED PRK OR TORİC PHAKİC İNTRAOCULAR LENS İMPLANTATİON
AFTER KERARİNG İMPLANTATİON
WHEN AND HOW TO COMBİNE THE TREATMENTS
Efekan Coskunseven, MDDünya Göz / World Eye Hospital, Istanbul, Turkey
ESCRS 2013 AmsterdamKERARING USER MEETING
WHY A COMBİNED TREATMENT ?
Improve Vision
Stop Progression+
COMBINED TREATMENT OPTIONS
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COMBINED TREATMENT OPTIONS
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COMBINED TREATMENT OPTIONS
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COMBINED TREATMENT OPTIONS
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TRİPLE PROCEDURES
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TRIPLE PROCEDURE TOPO-GUIDED TRANSEPITHELIAL PRK AFTER INTRACORNEAL RING SEGMENT
IMPLANTATION AND COLLAGEN CROSSLINKING FOR THE TREATMENT OF
KERATOCONUS
METHODS
16 eyes of 10 patients with keratoconus Topo-guided Transepithelial PRK after Intracorneal Ring
Segment Implantation followed by CXL (ICR+CXL).
7 M 8,2 M
The Mean interval between ICR and CXL was 7 months and the mean interval between CXL and Topo-guided transepithelial PRK was 8,2 months.
The preoperative and postoperative visual acuity-refraction-pachymetry topography results were evaluated.
The mean follow-up period was 6,2 months.
METHODS
Channel creation (INTRALASE FS 60): 15 seconds.
Depth adjusted to 80% of the thinnest point at tunnel location.
Corneal incision : at steep axis.
Keraring:4.4-5.6 mm
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T-CAT PRK with WaveLight Allegretto 400 Hz
About 80% of the refraction, max 50 microns
Small OZ (5.5mm) with large TZ (9 mm)
0,1% B2 in 20% Dextran T-500 30 min
UV (Peschkemed) 370 nm 3 mW/cm² for 30 min
Pre-Op Post-ICR Post-ICR+CCL Post-TopoPRK-PTK0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.1
0.25
0.3
0.580000000000001
0.21
0.440000000000002
0.48
0.740000000000004
UCVABCVA
UCVA BCVAPre-Op 0,1 0,21Post-ICR 0,25 0,44Post-ICR+CCL 0,3 0,48Post-TopoPRK-PTK 0,58 0,74
Pr Pos
Post
...
Post
-...
-6
-5
-4
-3
-2
-1
0
-4,34
-2.63 -2.44
-0,98
-5.66
-3.05
-2
-0.98
CYLSEQ
CYL SEQPre-Op -4,34 -5,66Post-ICR -2,63 -3,05Post-ICR+CCL -2,44 -2Post-TopoPRK-PTK -0,98 -0,98
42
43
44
45
46
47
48
49
50
51
52Pre-Op; 51,23
48.05
46.99 Post-TopoPRK-
PTK; 45,34
Mean K
Mean KPre-Op 51,23Post-ICR 48,05Post-ICR+CCL 46,99
Post-TopoPRK-PTK 45,34
43
44
45
46
47
48
49
Pre-Op; 47,8
Post-ICR; 46,18
Post-ICR+CCL ;
44,84Post-TopoPRK-
PTK; 44,69
K1
47,8-46,1=1,7 D
K1Pre-Op 47,8Post-ICR 46,18Post-ICR+CCL 44,84
Post-TopoPRK-PTK 44,69
44,8-44,6=0,2D
40
42
44
46
48
50
52
54
56Pre-Op; 54,65
Post-ICR; 49,93
Post-ICR+CCL ;
49,14
Post-TopoPRK-PTK; 45,99
K2
K2Pre-Op 54,65Post-ICR 49,93Post-ICR+CCL 49,14
Post-TopoPRK-PTK 45,99
54,6-49,9=4,7 D
49,1-45,9=3,2 D
Post-ICRPre-op
Kmax-Kmin: 55,5-44,5= 11 D
Kmax-Kmin: 51,3-44,1= 7,2 D
11D-7,2D= 3,8 D
Pre-op Post-ICR Post-ICR+CCL
Kmax-Kmin: 55,5-44,5= 11 D Kmax-Kmin: 51,3-44,1=
7,2 D
Kmax-Kmin: 50,9-44,4= 6,5 D11D-6,5D= 4,5 D
3.8 D
0.7 D
PREOP POSTOP
Pre-op Post-ICR
Post-ICR+CCL
Post-ICR+CCL+TopoPRKPTK
Kmax-Kmin: 55,5-44,5= 11 D
Kmax-Kmin: 51,3-44,1= 7,2 D
Kmax-Kmin: 50,9-44,4= 6,5 D
Kmax-Kmin: 47,2-46,1= 1,1 D11D-1,1D= 9,9 D
3.8 D
0.7 D
5.4 D
Pre-Op
12.12.06
Post-ICR(ICR Date:10/01/07)
01.11.2007
Post-ICR+CCL (CCL Date:01/11/2007)
25.02.2010
Post-ICR+CCL+Topo PRK-PTK
(Op Date:25/02/2010) 18.03.2010
Manifest Ref.
-5(-6,75x155) -1(-1,25x60) -1.50 (-1.0x67) -1 (-0,5x50)
UCVA 0,05 0,16 0,16 0,7BCVA 0,2 0,3 0,3 0,9
K1 50 47,7 48,5 45,4K2 56,7 49,3 49,2 46,4
Pre-op Post-ICR
Post-ICR+CCL
Post-ICR+CCL+TopoPRKPTK
Kmax-Kmin: 47,2-46,1= 1,1 D
Kmax-Kmin: 46,9-45,1= 1,8 D
~K2: 47,2-46,9= 0,3
18/03/2010 06/10/2012
Pre-op Post-ICRPost-
ICR+CCL
Post-ICR+CCL+
TopoPRKPTK2010
~K2: 55,5-46,9= 8,6 D
~K2: 55,5-51,3=
4,2 D
~K2: 51,3-50,9=
0,4 D~K2: 50,9-47,2= 3,7 D
~K2: 47,2-46,9= 0,3 D
Post-ICR+CCL+
TopoPRKPTK2012
~K2: 47,2-46,9= -0,3
18/03/2010 06/10/2012 27/09/2013
~K2: 46,9-47,5= +0,6
Pre-op2006
Post-ICR2006
Post-ICR+CCL
2007
Post-ICR+CCL+
TopoPRKPTK2010
~K2: 55,5-47,5= -8,0 D
~K2: 55,5-51,3= -
4,2 D
~K2: 51,3-50,9= -0,4 D ~K2: 50,9-47,2= -3,7
D
~K2: 47,2-46,9= -0,3 D
Post-ICR+CCL+
TopoPRKPTK2012
Post-ICR+CCL+
TopoPRKPTK2013
~K2: 46,9-47,5= +0,6 D
P
PREGNANCY
7 Years results
KeraRing ICR implantation is an effective method for the improvement of UCVA and BCVA in keratoconic eyes .
Maximum Keraring effectiveness in diopter according to
corneal thickness is about 7 D.
<7 DIrregularity
The inhibiting effect of ICR to keratoconus progression is still unclear.
CXL to be a safe procedure that has shown to stop the progression of the keratoconus.
Stop Progression <1,5D Irregularity
<7 DIrregularity
50 µ 5.5 mm< 5 D
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Stop Progression <1,5D Irregularity
However combination of both treatments will be more effective than
ICR or Transepithelial Topo G.L.T alone
COMBINED TREATMENT OPTIONS
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TORIC ICL FOR CORRECTION OF AMETROPIA AFTER CXL FOR KERATOCONUS
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Pre corsslink-ing
Pre ICL After 7 days After 1month After 3months After 6months After 1year0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0.3
0.4
0.790.830000000000001
0.8500000000000010.88
0.630000000000005
0.820000000000001
0.870000000000005 0.88 0.89 0.89
BSCVA UCVA
BSCVA & UCVA
0.56
0.88
METHODS
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Stop Progression<1,5D Irregularity
Sph<-18 D
Cyl<5 D
COMBINED TREATMENT OPTIONS
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TORIC ICL IMPLANTATION AFTER INTRACORNEAL RING IMPLANTATION FOLLOWED BY CORNEAL COLLAGEN CROSSLINKING FOR THE TREATMENT OF KERATOCONUS
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J Cataract Refract Surg. 2013 Mar 13. doi:pii: S0886-3350(13)00003-5. 10.1016/j.jcrs.2012.11.027
METHODS 14 eyes of 9 patients with keratoconus
ICLToric implantation after Intracorneal Ring Segment Implantation followed by CXL (ICR+CXL).
7 M 8,4 M
• The Mean interval between ICR and CXL was 7 months and the mean interval between CXL and ICLToric implantation was 6,4 months.
• The preoperative and postoperative visual acuity, refraction, pachymetry and topography results were evaluated.
• The mean follow-up period was 7.2 months.
METHODS
Channel creation (INTRALASE FS 60): 15 seconds.
Depth adjusted to 80% of the thinnest point at tunnel location.
Corneal incision : at steep axis.
Keraring:4.4-5.6 mm
+ +
ICL operations were performed 8,4 months after CCL
ICL calculation was based on post op ICR+CXL refraction
ACD> 2,8 mm
0,1% B2 in 20% Dextran T-500 30 min
UV (Peschkemed) 370 nm 3 mW/cm² for 30 min
UCVA BCVAPre-Op 0,01 0,16Post-ICR 0,06 0,46Post-ICR+CCL 0,08 0,48Post-ICL 0,46 0,58
Pre-OP Post-ICR Post-ICR+CXL Post-ICL0
0.1
0.2
0.3
0.4
0.5
0.6
0.010.06
0.0800000000000001
0.46
0.16
0.46 0.48
0.58
UCVA & BCVA
UCVA BCVA
CYL SEQPre-Op -4,73 -16,4Post-ICR -2,36 -9,81Post-ICR+CCL -1,88 -9,56Post-ICL -0,96 -0,8
Pre-OP Post-ICR Post-ICR+CXL Post-ICL
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
-4.73
-2.36 -1.88
-0.9600000000
00001
-16.4
-9.81 -9.56
-0.8
CYLINDER & SEQ
CYL SEQ
Mean KPre-Op 58,36Post-ICR 55,77Post-ICR+CCL 54,07Post-ICL 54,03
Pre-OP Post-ICR Post-ICR+CXL Post-ICL51
52
53
54
55
56
57
58
5958,36
55,77
54.07 54.03
Mean K
K1
Pre-Op 56,16Post-ICR 54,78Post-ICR+CCL 53,54Post-ICL 53,57
Pre-OP Post-ICR Post-ICR+CXL Post-ICL52
53
54
55
56
57
56,16
54,78
53.54 53.57
K1
56,1-54,7=1,4 D
K2
Pre-Op 60,57Post-ICR 56,76Post-ICR+CCL 54,61Post-ICL 54,48
Pre-OP Post-ICR Post-ICR+CXL Post-ICL50
52
54
56
58
60
62
60,57
56,76
54.61 54.48
K2
60,5-56,7=3,8 D
METHODS
7 M 8,4 M
<7 DIrregularity
Sph<-18 DCyl<5 D
Stop Progression
<1,5D Irregularity
COMBİNED TREATMENT
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11/13/2008 PREOP FEMALE, 18 Y
OD: -18,75 / -6,75 / 88° Sim K’s Astig: 13,9 D
UCVA: 0,05 BCVA: 0,05
Contact Lens VA: 0,7Thinnest Pachy USG: 420
Axial Length: 27,71 ACD: 3,57
11/13/2008 PREOP FEMALE, 18 Y
11/13/2008 PREOP FEMALE, 18 Y
ICR SURGERY 14/11/2008POSTOP ICR 22/11/2008
ICR SURGERY 14/11/2008POSTOP ICR 22/11/2008
PREOP POSTOP ICR
CCL SURGERY 06/01/2009POSTOP CCL 30/03/2009
PREOP ICL 24/02/2012Man Ref:-4.00(-6.00x 80)UCVA: 0.1BCVA: 0.5
ICL SURGERY 03/07/2012PREOP ICL 24/02/2012
Man Ref:-4.00(-6.00x 80)UCVA: 0.1BCVA: 0.5
POSTOP ICL / PREOP TOPO 28/02/2013
Man Ref:-1.75(-2.00x 35)UCVA: 0.3BCVA: 0.5
TOPO SURGERY 05/03/2013 POSTOP TOPO 19/09/2013
Man Ref:-0.75(-1.00x 30)UCVA: 0.7BCVA: 0.8
PREOP2008
POSTOP ICR2008
POSTOP CCL2009
POSTOP TOPOSEPT/2013
POSTOP ICL2012
5 Years
-18,75 / -6,75 / 88° -4.50 / -6.00 / 85°
-4.00 / -6.00 / 80°
-1.75 / -3.00 / 35°
-0.75 / -1.50 / 30°
UCVA: 0,05 UCVA: 0,1 UCVA: 0,1 UCVA: 0,3 UCVA: 0,7
BCVA: 0,05 BCVA: 0,4 BCVA: 0,5 BCVA: 0,5 BCVA: 0,8
Sim K’s Astig: 13,9 D
Contact LVA: 0,7
Thin.PachyUSG: 420
Axial Length: 27,71
ACD: 3,57
PREOP 2008 POSTOP SEPT/2013
5 Years
-18,75 / -6,75 / 88° -0.75 / -1.50 / 30°
UCVA: 0,05 UCVA: 0,7
BCVA: 0,05 BCVA: 0,8
Sim K’s Astig: 13,9 D
Contact LVA: 0,7
Thin.PachyUSG: 420
Axial Length: 27,71
ACD: 3,57
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Stop Progression <1,5D Irregularity
Sph< -18 D
Cyl< 5 D
<7 DIrregularity
<5 DIrregularity
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CONCLUSION
Topo-Guided Transepithelial PRK ,Toric Phakic IOL Implantation , ICR implantation followed by CXL is an effective treatment sequence that can stop progression and improve vision and refraction in select keratoconus patients
However a long-term follow-up of a larger population study is required to validate these findings
THANK YOUefekan.coskunseven@dunyagoz.com