Curso de Atualização em Implante de Anel de Ferrara
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Transcript of Curso de Atualização em Implante de Anel de Ferrara
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Curso de Implante de
Anel de Ferrara
Curso de Implante de
Anel de Ferrara
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1950 1950 -- Barraquer, J., Intracorneal implantsBarraquer, J., Intracorneal implants
1966 1966 -- Blavatskaya Blavatskaya -- Corneal rings from corneal tissueCorneal rings from corneal tissue
1986 1986 -- Simon, G. Simon, G. -- Silicon RingsSilicon Rings
1987 1987 -- Fleming Fleming -- Adjustable ringsAdjustable rings
1991 1991 -- NosNoséé, W , W -- Single piece rings for low myopiaSingle piece rings for low myopia
19911991-- Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia19911991-- Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia
1996 1996 -- Ferrara, P. Ferrara, P. -- Ring segments for KeratoconusRing segments for Keratoconus
1997 1997 -- Colin, J.Colin, J.-- Ring segments for KeratoconusRing segments for Keratoconus
Barraquer, J., Intracorneal implantsBarraquer, J., Intracorneal implants
Corneal rings from corneal tissueCorneal rings from corneal tissue
Silicon RingsSilicon Rings
Adjustable ringsAdjustable rings
Single piece rings for low myopiaSingle piece rings for low myopia
Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia
Ring segments for KeratoconusRing segments for Keratoconus
Ring segments for KeratoconusRing segments for Keratoconus
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BARRAQUERBARRAQUER’’ ss
MYOPIA CORRECTION MYOPIA CORRECTION
Remove tissue of the center of the cornea;Remove tissue of the center of the cornea;
Add tissue to the periphery of the cornea.Add tissue to the periphery of the cornea.
HYPEROPIA CORRECTIONHYPEROPIA CORRECTION
Add tissue to the center of the corneaAdd tissue to the center of the cornea
Remove tissue from the periphery of the corneaRemove tissue from the periphery of the cornea
THICKNESS LAWTHICKNESS LAW
MYOPIA CORRECTION MYOPIA CORRECTION
Remove tissue of the center of the cornea;Remove tissue of the center of the cornea;
Add tissue to the periphery of the cornea.Add tissue to the periphery of the cornea.
HYPEROPIA CORRECTIONHYPEROPIA CORRECTION
Add tissue to the center of the corneaAdd tissue to the center of the cornea
Remove tissue from the periphery of the corneaRemove tissue from the periphery of the cornea
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BLAVATSKAYABLAVATSKAYA
The larger (diameter) the ring the lesser the The larger (diameter) the ring the lesser the
correctioncorrection
The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction
BLAVATSKAYABLAVATSKAYA’’ S LAWS LAW
The larger (diameter) the ring the lesser the The larger (diameter) the ring the lesser the
correctioncorrection
The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction
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Material PMMAMaterial PMMA
YELLOW FILTERYELLOW FILTER
Apical Diameter 5mmApical Diameter 5mm
Triangular cross section= prismatic Triangular cross section= prismatic
effecteffect
Flat Basis width 0,6 mmFlat Basis width 0,6 mm
Variable arch lengh and thicknessVariable arch lengh and thickness
Triangular cross section= prismatic Triangular cross section= prismatic
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Variable thicknessesVariable thicknessesVariable thicknessesVariable thicknesses
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Asphericity (Q)Asphericity (Q)Asphericity (Q)Asphericity (Q)
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CORNEAL ASPHERICITYCORNEAL ASPHERICITY
OblateOblate
0,50,5
CORNEAL ASPHERICITYCORNEAL ASPHERICITY
HyperprolateHyperprolateProlateProlate
00 --11 --22--0,230,23
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INDICATIONSINDICATIONS
�� CORNEAL IRREGULARITIESCORNEAL IRREGULARITIES
�� PRIMARYPRIMARY
��KERATOCONUSKERATOCONUS
PELUCID MARGINAL DEGENERATIONPELUCID MARGINAL DEGENERATION
�� IATROGENYIATROGENY
��PKPPKP��PKPPKP
PRK; LASIK; RKPRK; LASIK; RK
TRAUMATRAUMA
�� REFRACTIVEREFRACTIVE
INDICATIONSINDICATIONS
CORNEAL IRREGULARITIESCORNEAL IRREGULARITIES
PELUCID MARGINAL DEGENERATIONPELUCID MARGINAL DEGENERATION
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INDICATIONSINDICATIONSINDICATIONSINDICATIONS
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CONTRAINDICATIONSCONTRAINDICATIONS
11.. VeryVery advancedadvanced keratoconuskeratoconus11.. VeryVery advancedadvanced keratoconuskeratoconus
andand significantsignificant apicalapical opacityopacity
22.. HydropsisHydropsis;;
33.. ThinThin corneas,corneas, withwith thicknessthickness
tracktrack;;
44.. PatientsPatients withwith intenseintense
beforebefore thethe
implant)implant)
CONTRAINDICATIONSCONTRAINDICATIONS
keratoconuskeratoconus withwith curvaturescurvatures overover 6060 dioptersdiopterskeratoconuskeratoconus withwith curvaturescurvatures overover 6060 dioptersdiopters
opacityopacity andand scarringscarring;;
thicknessthickness belowbelow 300300 micramicra inin thethe
atopiaatopia (these(these shouldshould bebe treatedtreated
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FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Evolution of the NomogramEvolution of the Nomogram
First generation (1997 First generation (1997
Second generation (2002 Second generation (2002
equivalentequivalent
Third generation (2006 Third generation (2006
Evolution of the NomogramEvolution of the Nomogram
(criteria for ring selection)(criteria for ring selection)
Third generation (2006 Third generation (2006
astigmatismastigmatism
Fourth generation (May 2009 to now): Fourth generation (May 2009 to now):
(Q)(Q)
FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Evolution of the NomogramEvolution of the Nomogram
-- 2002): keratoconus grade2002): keratoconus grade
Second generation (2002 Second generation (2002 -- 2006): spherical 2006): spherical
-- 2009): topographic 2009): topographic
Evolution of the NomogramEvolution of the Nomogram
-- 2009): topographic 2009): topographic
Fourth generation (May 2009 to now): Fourth generation (May 2009 to now): asphericity asphericity
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FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Second generation (2002 Second generation (2002
equivalentequivalentequivalentequivalent
Eye 1Eye 1
Refraction: Refraction: --10.00 D10.00 D
Are these the same?Are these the same?
NO !NO !
cornea hypercorrection in axial myopia cornea hypercorrection in axial myopia
FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Second generation (2002 Second generation (2002 -- 2006): spherical 2006): spherical
Eye 2Eye 2
Refraction: Refraction: --10.00 D10.00 D
Are these the same?Are these the same?
NO !NO !
cornea hypercorrection in axial myopia cornea hypercorrection in axial myopia
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FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Third generation (2006 Third generation (2006 --
astigmatismastigmatismastigmatismastigmatism
Eye 1Eye 1
Keratometry: 42.00 x 47.00 DKeratometry: 42.00 x 47.00 DKeratometry: 42.00 x 47.00 DKeratometry: 42.00 x 47.00 D
Are these the same ?Are these the same ?
NO !NO !
FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
2009): topographic 2009): topographic
Eye 2Eye 2
Keratometry: 52.00 x 57.00 DKeratometry: 52.00 x 57.00 D
Are these the same ?Are these the same ?
NO !NO !
Keratometry: 52.00 x 57.00 DKeratometry: 52.00 x 57.00 D
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Asphericity (Q)Asphericity (Q)
NOMOGRAMNOMOGRAM
Concept related to the shape of the cornea;Concept related to the shape of the cornea;
““ NormalNormal”” cornea: mild prolate;cornea: mild prolate;
Range: oblate (hiperopes Range: oblate (hiperopes
Asphericity (Q)Asphericity (Q)
Range: oblate (hiperopes Range: oblate (hiperopes
to prolate (myopes to prolate (myopes -- keratoconus)keratoconus)
Q values: Q values: tt --0.23 0.23 ±± 0.08 0.08
GonzGonzáálezlez--MMééijome JM, Cerviijome JM, Cerviñño A, ET AL. Asfericidad corneal en una poblo A, ET AL. Asfericidad corneal en una pobláá
2004;79:3852004;79:385--392.392.
Asphericity (Q)Asphericity (Q)
NOMOGRAMNOMOGRAM
Concept related to the shape of the cornea;Concept related to the shape of the cornea;
cornea: mild prolate;cornea: mild prolate;
Range: oblate (hiperopes Range: oblate (hiperopes -- post myopic ablation) post myopic ablation)
Asphericity (Q)Asphericity (Q)
Range: oblate (hiperopes Range: oblate (hiperopes -- post myopic ablation) post myopic ablation)
keratoconus)keratoconus)
0.08 0.08 (young adults, at 4,5 mm)(young adults, at 4,5 mm) YebraYebra--Pimentel E, Pimentel E,
áácion de adultos jcion de adultos jóóvenes. Implicaciones clvenes. Implicaciones clíí nicas. Arch Soc Esp Oftalmol nicas. Arch Soc Esp Oftalmol
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HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
Asphericity law
Addition in the cornea
change – frequently without
concomitant significant corneal
Ring diameter = how
flattened, the astigmatism
asphericity will be changed
HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
cornea periphery = asphericity
without
corneal flattening;
much the cornea will
astigmatism and
changed
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HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
Asphericity lawAsphericity law
Ring arc length = how
keratometry and astigmatism
changed. The shorter thechanged. The shorter the
astigmatic correction, the
asphericity change.
HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
how much the asphericity,
astigmatism will be
segment, the greater thesegment, the greater the
the lesser the
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NOMOGRAMNOMOGRAM
The asphericity is the best parameter, at the The asphericity is the best parameter, at the
present moment, for ring selection;present moment, for ring selection;
There is a tendency to implant There is a tendency to implant
achieve the same (or better) correction than was achieve the same (or better) correction than was
achieved in the past;achieved in the past;
QQ value = value = QQuality of visionuality of vision
NOMOGRAMNOMOGRAM
The asphericity is the best parameter, at the The asphericity is the best parameter, at the
present moment, for ring selection;present moment, for ring selection;
There is a tendency to implant There is a tendency to implant ““ lessless”” tissue to tissue to
achieve the same (or better) correction than was achieve the same (or better) correction than was
uality of visionuality of vision
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140 arc = PMD140 arc = PMD
-- Q 0 or positiveQ 0 or positive
-- Low K valuesLow K values
210 arc = Nipple210 arc = Nipple
-- Q negative (hyperprolate Q negative (hyperprolate
cornea)cornea)
160 arc = 90% of keratoconus (160 arc = 90% of keratoconus (““ standardstandard”” ring)ring)
--
hyperprolate cornea)hyperprolate cornea)
Q negative (hyperprolate Q negative (hyperprolate
ring)ring)
Q negative (prolate to Q negative (prolate to
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General GuidelinesGeneral Guidelines
NOMOGRAMNOMOGRAM
IT MUST BE DETERMINED:
1. The type of keratoconus:
Central
Nipple
Oval (paracentral)Oval (paracentral)
PMD
2. The corneal asphericity (Q)
3. The pachymetry at the corneal steepest axis and
probable ring track
General GuidelinesGeneral Guidelines
NOMOGRAMNOMOGRAM
Central
Oval (paracentral)Oval (paracentral)
2. The corneal asphericity (Q)
3. The pachymetry at the corneal steepest axis and
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1. Type of keratoconus1. Type of keratoconus
NOMOGRAMNOMOGRAMNOMOGRAMNOMOGRAM
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1. Type of keratoconus1. Type of keratoconus
NOMOGRAMNOMOGRAM
CentralCentral
(Nipple(Nipple))
NOMOGRAMNOMOGRAM
OvalOvalOvalOval
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NOMOGRAMNOMOGRAMNOMOGRAMNOMOGRAM
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-0,07
-0,569999993
-0,340000004-0,310000002
150 200 250 150-150
-0,800000012
-0,730000019
-0,99000001-1,019999981
-0,860000014
150-200 150-250 200-200 200-250 250-250
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variation according to ring thicknessvariation according to ring thickness
Single Segments (Single Segments (µµm)m) ∆∆Q Q
150150 -- 0.07 0.07
200200 -- 0.310.31
250250 -- 0.340.34
Paired Segments (Paired Segments (µµm)m)
150 150 –– 150 150 -- 0.570.57
150 150 –– 200 200 -- 0.730.73
150 150 –– 250 250 -- 0.800.80
200 200 –– 200 200 -- 0.860.86
200 200 –– 250 250 -- 1.021.02
variation according to ring thicknessvariation according to ring thickness
Q Q ∆∆KK pp valuevalue
0.07 0.07 0.78 D 0.78 D 0.0420.042
0.310.31 1.82 D1.82 D < 0.001< 0.001
0.340.34 2.74 D 2.74 D < 0.001< 0.001
0.570.57 3.40 D3.40 D < 0.001< 0.001
0.730.73 4.35 D4.35 D < 0.001< 0.001
0.800.80 3.86 D 3.86 D 0.0010.001
0.860.86 5.65 D5.65 D < 0.001< 0.001
1.021.02 6.27 D 6.27 D < 0.001< 0.001
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NOTENOTE:: (THIS(THIS ISIS VALIDVALID FORFOR
segmentsegment oror pairpair ofof segmentssegments
postoperativepostoperative corneacornea asphericityasphericitypostoperativepostoperative corneacornea asphericityasphericity
thisthis happenshappens soso itit isis advisableadvisable
choosechoose aa pairpair ofof segmentssegments
fitsfits thisthis conditioncondition eveneven ifif
achievedachieved KERATOMETRICKERATOMETRIC
correctioncorrection isis smallersmallercorrectioncorrection isis smallersmaller
thanthan thethe desireddesired oneone..
FORFOR ALLALL MAPS)MAPS)
segmentssegments SHOULDSHOULD notnot turnturn thethe expectedexpected
asphericityasphericity (Q)(Q) significantlysignificantly belowbelow --00..2323asphericityasphericity (Q)(Q) significantlysignificantly belowbelow --00..2323
advisableadvisable
segmentssegments thatthat
ifif thethe
AVOID POSTOPERATIVE OBLATE CORNEAS !AVOID POSTOPERATIVE OBLATE CORNEAS !
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NippleNipple
NOMOGRAMNOMOGRAM
NippleNipple
NOMOGRAMNOMOGRAM
Q change induced by the 210 Q change induced by the 210
ringring
210210//150150 -- 00..3636
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Nipple ConesNipple Cones
NOMOGRAMNOMOGRAM
Nipple ConesNipple Cones
NOMOGRAMNOMOGRAM
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Nipple ConesNipple Cones
The 210 ringThe 210 ring
Nipple ConesNipple Cones
The 210 ringThe 210 ring
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Pellucid Marginal DegenerationPellucid Marginal Degeneration
NOMOGRAMNOMOGRAM
Pellucid Marginal DegenerationPellucid Marginal Degeneration
NOMOGRAMNOMOGRAM
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ITIT MUSTMUST BEBE DETERMINEDDETERMINED::
NOMOGRAMNOMOGRAM
ITIT MUSTMUST BEBE DETERMINEDDETERMINED::
TheThe pachymetrypachymetry atat thethe cornealcorneal
probableprobable ringring tracktrack
((55 mmmm opticaloptical zone)zone)
IncisionIncision ((8080%% depth)depth)::
11 segmentsegment:: atat 9090
ringring atat thethe steepeststeepest axisaxis
22 segmentssegments:: atat thethe
NOMOGRAMNOMOGRAM
cornealcorneal steepeststeepest axisaxis andand
909000
axisaxis –– thethe tiptip ofof thethe
axisaxis
thethe steepeststeepest axisaxis
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WHYWHY THETHE INCISIONINCISION SHOULDSHOULD BEBE ATAT
NOMOGRAMNOMOGRAM
SuperficialSuperficial stromastroma
8080%% DEPTH?DEPTH?
NOMOGRAMNOMOGRAM
DeepDeep stromastroma
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NOTENOTE::(THIS(THIS ISIS VALIDVALID FORFOR ALLALL
PACHYMETRYPACHYMETRY’’ SS LAWLAW
TheThe thickestthickest segmentsegment ofof aa
segmentssegments cannotcannot exceedexceed
thicknessthickness ofof thethe corneacornea
bedbed..
thisthis happenshappens soso oneonethisthis happenshappens soso oneone
choosechoose aa pairpair ofof segmentssegments
fitsfits thisthis conditioncondition eveneven
achievedachieved correctioncorrection isis smallersmaller
thanthan thethe desireddesired oneone..
ALLALL MAPS)MAPS)
aa pairpair ofof
exceedexceed halfhalf
corneacornea inin itsits
oneone hashas totooneone hashas toto
segmentssegments thatthat
eveneven ifif thethe
smallersmaller
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IncisionIncision
544 micra544 micra
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superiorsuperiorinferiorinferior
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SUMMARYSUMMARY
GENERAL RULESGENERAL RULES
NOMOGRAMNOMOGRAM
Q preoperative Q preoperative -- Q change induced by the ringQ change induced by the ring
-- 0.23 (TARGE FINAL Q VALUE)0.23 (TARGE FINAL Q VALUE)
SUMMARYSUMMARY
GENERAL RULESGENERAL RULES
NOMOGRAMNOMOGRAM
Q change induced by the ringQ change induced by the ring = =
0.23 (TARGE FINAL Q VALUE)0.23 (TARGE FINAL Q VALUE)
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ASPHERICITY _ RING SELECTIONASPHERICITY _ RING SELECTION
VI. NOMOGRAMVI. NOMOGRAM
Oblate corneas (Q < -0.23):
single 140 or 160 (arc) segments
Moderately prolate corneas
single or paired 160 (arc)
Hyperprolate corneas
paired 160 (arc) segments or
ASPHERICITY _ RING SELECTIONASPHERICITY _ RING SELECTION
VI. NOMOGRAMVI. NOMOGRAM
:
segments
corneas (- 0.23 < Q < -1
segments
(Q > - 1
or 210 segment if nipple
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VII. SURGICAL TECHNIQUEVII. SURGICAL TECHNIQUE
ManualManual
FemtosecomdFemtosecomd
VII. SURGICAL TECHNIQUEVII. SURGICAL TECHNIQUE
ManualManual
FemtosecomdFemtosecomd
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um descompressor
são necessários para ver esta imagem.
ero DP, Alio JL, El Kady B, Coskunseven E, Morbelli H
Refractive and aberrometric outcomes of intracorneal ri
femtosecond-assisted procedures. Ophthalmology. 2009 Sep;116(9):1675
MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e umCodec YUV420 descompressor
são necessários para ver esta imagem.
Morbelli H, Uceda-Montanes A, Maldonado MJ, Cuevas D, Pascua
ntracorneal ring segments for keratoconus: mechanical versus
assisted procedures. Ophthalmology. 2009 Sep;116(9):1675-87.
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um descompressor
são necessários para ver esta imagem.
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um descompressor
são necessários para ver esta imagem.
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um descompressor
são necessários para ver esta imagem.
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MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
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FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL
O QuickTime™ e umDV/DVCPRO - NTSC descompressor
são necessários para ver esta imagem.
FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL
O QuickTime™ e umDV/DVCPRO - NTSC descompressor
são necessários para ver esta imagem.
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FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL
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FERRARA RING +TORIC ICLFERRARA RING +TORIC ICL
O QuickTime™ e umCodec YUV420 descompressor
são necessários para ver esta imagem.
FERRARA RING +TORIC ICLFERRARA RING +TORIC ICL
O QuickTime™ e umCodec YUV420 descompressor
são necessários para ver esta imagem.
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FERRARA RING +TORIC IOLFERRARA RING +TORIC IOLFERRARA RING +TORIC IOLFERRARA RING +TORIC IOL
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VIII . CLINICAL CASESVIII . CLINICAL CASES
20/200 20/200 --6.006.00--2.50x102.50x10
PREOPPREOP
POSTOPPOSTOP
20/40 pl20/40 pl--5.000x505.000x50
SURGICAL PLANNING ?SURGICAL PLANNING ?
20/40 pl20/40 pl--5.000x505.000x50
VIII . CLINICAL CASESVIII . CLINICAL CASES
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VIII . CLINICAL CASESVIII . CLINICAL CASES
20/400 +3.0020/400 +3.00--6.00x85 6.00x85
Cataract + PMDCataract + PMD
PREOPPREOP
POSTOPPOSTOP
20/30 +0.5020/30 +0.50--3.00x853.00x85
SURGICAL PLANNING ?SURGICAL PLANNING ?
20/30 +0.5020/30 +0.50--3.00x853.00x85
VIII . CLINICAL CASESVIII . CLINICAL CASES
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VIII . CLINICAL CASESVIII . CLINICAL CASES
Nipple Nipple
20/60 20/60 --8.508.50--1.50x140 1.50x140
PREOPPREOP
POSTOPPOSTOP
20/40 20/40 ----0.500.50--1.50x401.50x40
SURGICAL PLANNING ?SURGICAL PLANNING ?
20/40 20/40 ----0.500.50--1.50x401.50x40
VIII . CLINICAL CASESVIII . CLINICAL CASES
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•• -- RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
COMPLICATIONSCOMPLICATIONS
•• -- RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
•• -- RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM
-- RELATED TO THE RINGRELATED TO THE RING•• -- RELATED TO THE RINGRELATED TO THE RING
RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
COMPLICATIONSCOMPLICATIONS
RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
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•• RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
-- Extrusion 0.1% Extrusion 0.1% •• -- Extrusion 0.1% Extrusion 0.1%
•• -- Infection 0.08%Infection 0.08%
•• -- Bad centration of the segmentBad centration of the segment
•• -- MigrationMigration
•• -- RotationRotation•• -- RotationRotation
•• -- Misplacement or asimmetry of the Misplacement or asimmetry of the
segmentssegments
RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
Bad centration of the segmentBad centration of the segment
Misplacement or asimmetry of the Misplacement or asimmetry of the
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EXTRUSIONEXTRUSION
ExtrusionExtrusion
EXTRUSIONEXTRUSION
Shallow tunnelShallow tunnel
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EXTRUSIONEXTRUSIONEXTRUSIONEXTRUSION
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INFECTIONINFECTIONINFECTIONINFECTION
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MIGRATIONMIGRATIONMIGRATIONMIGRATION
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ASYMMETRY of SEGMENTSASYMMETRY of SEGMENTSASYMMETRY of SEGMENTSASYMMETRY of SEGMENTS
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WRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RING
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RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM
(corneal bio(corneal bio
11--OvercorrectionOvercorrection
22--UndercorrectionUndercorrection
RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM
(corneal bio(corneal bio--mechanics)mechanics)
OvercorrectionOvercorrection
UndercorrectionUndercorrection
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RELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RING
Halos and GlareHalos and Glare
Periannelar depositsPeriannelar deposits
NeovascularizationNeovascularizationNeovascularizationNeovascularization
RELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RING
Halos and GlareHalos and Glare
Periannelar depositsPeriannelar deposits
NeovascularizationNeovascularizationNeovascularizationNeovascularization
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YELLOW RINGYELLOW RING
Preop CPreop C
YELLOW RINGYELLOW RING
Preop CPreop C--QuantQuant
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YELLOW RINGYELLOW RING
Postop CPostop C
YELLOW RINGYELLOW RING
Postop CPostop C--QuantQuant
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METHODSMETHODS
SampleSample:: 10731073 eyeseyes ofof 810810 patientspatients consecutivelyconsecutively
toto JulyJuly 20082008
TwoTwo groupsgroups (type(type ofof ringring implanted)implanted)
GroupGroup II –– patientspatients implantedimplanted withwith
GroupGroup IIII –– patientspatients implantedimplanted
StudiedStudied parametersparameters::
UncorrectedUncorrected visualvisual acuityacuity (UCVA)(UCVA)
BestBest--correctedcorrected visualvisual acuityacuity (BCVA)(BCVA)
KeratometryKeratometry (K)(K)
AsphericityAsphericity (Q)(Q)AsphericityAsphericity (Q)(Q)
PachymetryPachymetry atat thethe thinnestthinnest pointpoint
METHODSMETHODS
consecutivelyconsecutively operatedoperated fromfrom JanuaryJanuary
implanted)implanted)::
withwith thethe 160160--degreedegree ofof arcarc ringring (n=(n=972972
withwith thethe 210210--degreedegree ofof arcarc ringring (n=(n=101101
(UCVA)(UCVA)
(BCVA)(BCVA)
pointpoint (PTP)(PTP) ofof thethe corneacornea.. (Pentacam)(Pentacam)
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METHODSMETHODS
MeanMean patientpatient ageage:: 2929..22 ±± 99..44 (Group(GroupMeanMean patientpatient ageage:: 2929..22 ±± 99..44 (Group(Group
FollowFollow--upup:: 2323..88 ±± 1212..22 (Group(Group I)I) andand
AllAll patientspatients completedcompleted atat leastleast sixsix monthsmonths
StatisticalStatistical analysisanalysis::StudentStudent´́ ss tt testtest
(SPSS,(SPSS, Chicago,Chicago, IL)IL)..
METHODSMETHODS
(Group(Group I)I) andand 3030..22 ±± 88..77 (Group(Group II)II);;(Group(Group I)I) andand 3030..22 ±± 88..77 (Group(Group II)II);;
andand 2222..99 ±± 1515..11 monthsmonths (Group(Group II)II)..
monthsmonths ofof followfollow--upup;;
testtest forfor pairedpaired datadata -- SPSSSPSS softwaresoftware
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RESULTSRESULTS
GROUP IGROUP IGROUP IGROUP I
PreopPreop PostopPostop
UCVAUCVA 20/22020/220 20/8020/80 0.0000.000
BCVABCVA 20/10020/100 20/4020/40 0.0000.000
Sph. Eq. (D)Sph. Eq. (D) --3.993.99 --2.262.26 0.0000.000
Asphericity Asphericity --0.880.88 --0.350.35 0.0000.000
Keratometry (D)Keratometry (D) 49.1849.18 45.7245.72 0.0000.000Keratometry (D)Keratometry (D) 49.1849.18 45.7245.72 0.0000.000
Pachymetry (Pachymetry (m)m) 448448 465465 0.0000.000
RESULTSRESULTS
GROUP IIGROUP IIGROUP IIGROUP II
pp PreopPreop PostopPostop pp
0.0000.000 20/35020/350 20/13020/130 0.0010.001
0.0000.000 20/11020/110 20/6020/60 0.0000.000
0.0000.000 --8.528.52 --4.144.14 0.0000.000
0.0000.000 --1.171.17 --0.560.56 0.0000.000
0.0000.000 51.9251.92 48.1048.10 0.0000.0000.0000.000 51.9251.92 48.1048.10 0.0000.000
0.0000.000 418418 435435 0.0000.000
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RESULTSRESULTS
Preoperative and postoperative UCVAPreoperative and postoperative UCVA
350
400
210220
150
200
250
300
6080
0
50
100
I II
RESULTSRESULTS
Preoperative and postoperative UCVAPreoperative and postoperative UCVA
400
250
200 PreopPostop
100
III IV
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800
RESULTSRESULTS
Preoperative and postoperative BCVAPreoperative and postoperative BCVA
300
400
500
600
700
6035
94
400
100
200
I II
800
RESULTSRESULTS
Preoperative and postoperative BCVAPreoperative and postoperative BCVA
400PreopPostop
5590
III IV
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RESULTSRESULTS
Complications (treatment)Complications (treatment)
Undercorrection (implantation of additional segment)Undercorrection (implantation of additional segment)
Overcorrection (segment removal followed for reimplantation)Overcorrection (segment removal followed for reimplantation)
Extrusion (segment removal)Extrusion (segment removal)
Malposition (segment repositioning)Malposition (segment repositioning)
Progressive corneal steepening (keratoplasty)Progressive corneal steepening (keratoplasty)
Ring neovascularization (bevacizumab)Ring neovascularization (bevacizumab)
TOTALTOTAL
RESULTSRESULTS
Complications (treatment)Complications (treatment) Eyes (%)Eyes (%)
Undercorrection (implantation of additional segment)Undercorrection (implantation of additional segment) 16 (1.49)16 (1.49)
Overcorrection (segment removal followed for reimplantation)Overcorrection (segment removal followed for reimplantation) 11 (1.02)11 (1.02)
Extrusion (segment removal)Extrusion (segment removal) 6 (0.56)6 (0.56)
Malposition (segment repositioning)Malposition (segment repositioning) 4 (0.37)4 (0.37)
Progressive corneal steepening (keratoplasty)Progressive corneal steepening (keratoplasty) 2 (0.18)2 (0.18)
Ring neovascularization (bevacizumab)Ring neovascularization (bevacizumab) 2 (0.18)2 (0.18)
41 (3.82%)41 (3.82%)
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Preoperative Preoperative 1 month1 month 1 year1 year
KKMAXMAX52.95 52.95 ±± 6.78 6.78 49.36 49.36 ±± 6.666.66 47.69 47.69 ±± 5.435.43
KKMINMIN47.86 47.86 ±± 5.195.19 45.27 45.27 ±± 5.395.39 44.03 44.03 ±± 4.524.52
KKMEANMEAN50.36 50.36 ±± 5.685.68 47.29 47.29 ±± 5.915.91 45.79 45.79 ±± 4.854.85
UCVAUCVA 0.12 0.12 ±± 0.140.14 0.25 0.25 ±± 0.190.19 0.33 0.33 ±± 0.230.23
2 years2 years 3 years3 years 4 years4 years 5 years5 years
5.435.43 47.77 47.77 ±± 5.265.26 47.81 47.81 ±± 5.875.87 48.07 48.07 ±± 6.266.26 48.09 48.09 ±± 5.925.92
4.524.52 44.29 44.29 ±± 4.464.46 44.04 44.04 ±± 4.854.85 44.82 44.82 ±± 5.575.57 44.45 44.45 ±± 5.975.97
4.854.85 45.96 45.96 ±± 4.654.65 45.83 45.83 ±± 5.085.08 46.44 46.44 ±± 5.905.90 46.24 46.24 ±± 5.895.89
0.29 0.29 ±± 0.180.18 0.34 0.34 ±± 0.230.23 0.42 0.42 ±± 0.310.31 0.31 0.31 ±± 0.230.23
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Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10
Leonardo Torquetti, Guilherme Ferrara, Paulo Ferrara
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10-year follow-up.
Leonardo Torquetti, Guilherme Ferrara, Paulo Ferrara
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KERATOMETRY
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10
KERATOMETRY
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10-year follow-up.
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VISUAL ACUITY (UCVA
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10
VISUAL ACUITY (UCVA – BCVA)
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10-year follow-up.
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Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10-year follow-up.
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Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10
Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10-year follow-up.
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Calculated exponential cell loss rate over the Calculated exponential cell loss rate over the
mean interval of followmean interval of follow
1.4% per year1.4% per year
Calculated exponential cell loss rate over the Calculated exponential cell loss rate over the
mean interval of followmean interval of follow--up (4 years):up (4 years):
1.4% per year1.4% per year
Endothelial Cell Loss (per year) in:Endothelial Cell Loss (per year) in:
Young normal eyes:Young normal eyes:
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PreoperativePreoperative
UCVAUCVA 20/18520/185
BCVABCVA 20/12520/125BCVABCVA 20/12520/125
Apex PachymetryApex Pachymetry 457.7457.7
Asphericity (Q)Asphericity (Q) --0.950.95
Keratometry (K)Keratometry (K) 45.4145.41
PreoperativePreoperative PostoperativePostoperative
20/6620/66 p = 0.005p = 0.005
20/4020/40 p = 0.008p = 0.00820/4020/40 p = 0.008p = 0.008
466.2466.2 p =0.025p =0.025
--0.230.23 p = 0.006p = 0.006
42.8842.88 p = 0.000p = 0.000
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WAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RING
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Easy procedureEasy procedure
Topical anesthesiaTopical anesthesia
Quick recoveryQuick recovery
X. CONCLUSIONX. CONCLUSION
Reversible and reajustableReversible and reajustable
Do not interfere with PKPDo not interfere with PKP
Improves contact lens toleranceImproves contact lens tolerance
Independent of tissue donationsIndependent of tissue donations
Low rate of complicationsLow rate of complicationsLow rate of complicationsLow rate of complications
Improves UCVA and BSCVAImproves UCVA and BSCVA
Reduces ocular aberrationsReduces ocular aberrations
DELAYS OR STOPS konus evolutionDELAYS OR STOPS konus evolution
X. CONCLUSIONX. CONCLUSION
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•• -- The surgical technique is safe and The surgical technique is safe and
X. CONCLUSIONX. CONCLUSION
•• -- The surgical technique is safe and The surgical technique is safe and
reproducible;reproducible;
•• -- The technique has a longThe technique has a long
•• -- There is stabilization of the disease after There is stabilization of the disease after
Ferrara ring implantation.Ferrara ring implantation.
The surgical technique is safe and The surgical technique is safe and
X. CONCLUSIONX. CONCLUSION
The surgical technique is safe and The surgical technique is safe and
The technique has a longThe technique has a long--lasting effect;lasting effect;
There is stabilization of the disease after There is stabilization of the disease after
Ferrara ring implantation.Ferrara ring implantation.
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