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

+ +

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