INTACS vs Cross-Linking for Keratoconus
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1 INTACS vs Cross-Linking for Keratoconus Tomaso Caporossi MD Policlinico A. Gemelli -Roma Istituto di Oculistica Siena X-Linking: 1 Corso Nazionale Abilitante
2 Keratoconus Non inflammatory progressive corneal dystrophy. Collagen rigidity is reduced (3 aria structure modifications). Corneal shape is modified with progressive thinning. The infero-temporally dislocation and local curvature ray reduction produce asimmetric and hyper-refractive corneal surface. The last parameter is partially compensated by the thinning. Overmentioned shape modifications produces several optical effects.
3 Keratoconic induced optical effects APEX TILTING PRISMATIC EFFECT COMA SECONDARY-ASTIGMATISM CORNEAL RAY DECREASING INCREASED DIOPTRIC POWER OF THE ANTERIOR SURFACE MIOPIC SHIFT CORNEAL THINNING REDUCED CURVATURE EFFECT HYPEROPIC SHIFT DECREASED POSTERIOR CURVATURE RAY REDUCED CORNEAL POWER
4 The ideal conservative procedure for keratoconus Delay or stop corneal degeneration Improve KC related corneal asimmetry Reduce secondary refractive error (pseudoastigmatism) Low complications rate Metabolic error compensation (etiopathogenetic effect) Increase LAC tolerance Possibility of alternative techniques in the future (LK, PK)
5 Low-Invasive Techniques INTACS-ICRS, Ferrara Rings PRK, PTK, LASIK Termo-keratoplasty, Conductive KP (CK) Manual and automatized ARK Cross-Linking Riboflavin-UVA (CCL C3R)
6 INTACS FDA approval for myopia: 1997 First Keratoconus applications: FDA approval for the reduction of myopia and irregular astigmatism associated with keratoconus Additive technique Refractive technique Target: astigmatism reduction Improving corneal shape? Delaing keratoconus evolution? Intacs (Addition technology) Ferrara rings: 5 thicks( µm) implantable 5mm Intacs: 11 thicks ( mm) implantable 7mm
7 INTACS ICRS: procedure Topic anestesia One or two (PMMA) segments insertion towards intra-stromal corneal tunnels Manual or Fotodisruptive (IntraLASE) Tunnel Dissection Insertion depth: 70 % Implant side: Steepest axis, Elevative axis, Coma axis?
8 INTACS: indications Keratoconus: stage I II III Analisis Corneal of thickness results related 400 to µm good (implant and bad side) outcomes of Mean K 53 D (Orbscan, Intacs Pentacam) Implantation Relatively for low Keratoconus spherical equivalent correction J. L. Aliò JCRS Clear cornea May-2006 Pellucid Marginal Degeneration: Menagement of Keratoconus With Intacs S. Siganos AJO 2003 Intracorneal ring segment for Keratoconus correction: long-term follow-up J. L. Aliò JCRS 2006 European clinical evaluation: Use of Intacs for the treatment of keratoconus J. Colins JCRS 2006 Intacs for the correction of Keratoconus: Two-year follow-up J. Colins JCRS 2007
9 INTACS complications EARLY Chemosys and sub-conjunctival bleeding Epitelial plugs at the incision site (15,2% A. Ertan) Inclusions cysts Persistent epithelial defect on the implanted ring surface Corneal oedema LATE 7 eyes Ferrara ICRS for Keratoconus 1 eye INTACS for low Myopia Corneal Infection After Implantation of Intracorneal Ring Segment Hofling- Tunnel haze and deposits (30.7% J. Aliò)(8,5% A. Ertan steroid resolved) Lima Cornea August-2004 Infections Induced myopic and astigmatic shift with axis rotation (implatation site!-decentration) Reduced corneal sensitivity Neovascularization and corneal pannus (15.3% regressed J. Aliò) Corneal melting Migration Extrusion (Advanced Keratoconus grade IV?) 26,9% J. Aliò
10 Cross-linking corneale Riboflavina-UVA Indications: Keratoconus stage 1, 2 with clinical-instrumantal progression (f.u. 6 months) Corneal Thickness > 400 micron (orbscan, pentacam, visante) Thinnest point (Orbscan) > 380 micron Age > 14 anni Limits: Dangerous for endothelium if thickness < 400 micron Presence of central corneal scarring Few treated cases follow up Complications: Transient corneal oedema in over 10% patients Persistent Haze in stage III with Vogt striae or reticular pattern of the dark micro-striae in Confocal Microscopic Examination
11 Cross-linking advantages Easy procedure Uninvasive technique Pathogenetic targets Refractive outcomes comparable with INTACS Absence of long-term complications (Haze < 1%) INTACS-CCL combination possible Indication for corneal melting and post lasik ectasia Unexpensive procedure
12 Comparative refractive outcomes of Intacs vs CCL - UCVA / BSCVA Authors UCVA (pre-op.) UCVA (post-op.) BSCVA (pre-op.) BSCVA (post-op.) Colin (100 eyes) f-up: 24 m Siganos (33 eyes) f-up: 11 m Boxer W. (74 eyes) f-up 12 m Aliò (13 eyes) f-up: 36 m Wollensak (23 eyes) f-up: 36 m Caporossi (30 eyes) f-up: 18 m 1/10 2/50-6/10 1,3/10 1/50-5/10 0,9/10 1/10-10/10 1/10 N.A. 2,2/10 Mean 1.7 Mean 4/ ,8/10 Mean 4.05 Mean 5,6/ N.A. N.A. 1/50-8/10 3/50 10/10 Gain +2,2 Gain ,7/ % 4,1/10 6/10 +46% 1,3/10 1/20-3/10 3,8/10 2/10-8/10 3,9/10 1/50-10/10 2,5/10 2,5/10-10/10 2,5/10 N.A. 1/10-10/10 4/10 2/10-8/10 4,7/10 0,5/10-10/10 3,9/10 3,5-10/10 4,1/10 4/10-10/10 2/10-6/10 5,8/10 4/10-10/10 Mean Mean Mean Mean 6,4/10 1,1/10 3.,4/10 4,2/10 6,05/10 1/10-10/10 Gain Gain 5,6/10 6/10-10/10 +2,3/10 +1,65/10 6,2/ % 1/10 8/10 3/10 +38% 10/10
13 INTACS: Konus instability, decreased efficacy, or.? KC Instability (progression)? -INTACS efficacy decreased or biomechanical damage? -Incoerent implantation site Ring/Coma- Axis, Refractive Axis? Preop 6m 12m 18m 24m 36m Aliò J. Et al.: Intracorneal ring segments for Keratoconus correction: longterm follow-up. JCRS: 2006, June (13 casi)
14 INTACS: Konus instability, decreased efficacy, or.? KC Instability (progression)? -INTACS efficacy decreased or biomechanical damage? -Incoerent implantation site Ring/Coma- Axis, Refractive Axis? Preop 6m 12m 24m 36m 48m Aliò J. Et al.: Intracorneal ring segments for Keratoconus correction: longterm follow-up. JCRS: 2006, June (6 casi)
15 Uncoherence between Refractive and Elevative (Aberrometric) Axis In approximatively 20% of first-second stage KC we have this discrepancy between refractive and elevative axis orientation. This condition can produce impredictability in INTACS results
16 Single-Segment VS Double-Segment Segment Size / / / /0.35 total N treated eyes percentage comparison of Single-Segment and double-segment Intacs for Keratoconus and Post-Lasik Ectasia M. Sharma Am. J. O. May-2006
17 Single-Segment VS Double-Segment Variable Preoperative-postoperative Change Single- Segment Double- Segment UCVA 9 lines 2.5 lines BSCVA 2.5 lines < 1 lines
18 Single-Segment VS Double-Segment Preoperative to Postoperative Change D variable Single-segment (mean±sd) VS Double-segment (mean±sd) Cylinder 1.62 ± ± 1.70 Change I-S 9.51 ± ± 4.82
19 Cross-Linking: Konus stability or mid term efficacy? Preop 6m 12m 18m 24m 36m A.Caporossi e Coll.: JCRS 2006 aggiornato
20 Intacs insertion with femtosecond laser for the management of keratoconus one-year result Aylin Ertan JCRS Dec-2006 Comparative refractive outcomes of Intacs vs Cross-linking - Astigmatism Autors Colin 100 eyes F-up: 24 m Siganos 33 eyes f-up: 12 m Caporossi 30 eyes f-up: 18 m Aylin Ertan 118 eyes F-up: 12 m Astigmatism (pre-op) 4.62 D SD: 2.80 D 3,3 D SD: 2,10 D 4,5 D (- 1,5-6 D) 3,90 D SD: 2.11 D Astigmatism (post-op) 3.31 D SD: 1.83 D 3,06 D SD: 2,14 D 3,9 D (- 1-5,50 D) 2.20 D SD: 1.50 D
21 Comparative refractive outcomes of Intacs vs Cross-linking - Snellen lines Snellen lines (UCVA) Snellen lines (BSCVA) Authors Colin 100 eyes F-up: 24 m Siganos 33 eyes f-up: 12 m Caporossi 30 eyes f-up: 18 m Aylin Ertan 118 eyes F-up: 12 m lines + 2,5 lines + 2,4 lines + 2,0 lines lines + 1,7 lines + 1,9 lines + 1,8 lines
22 Conclusions CCL is a really low-invasive corneal procedure INTACS is a more invasive procedure for cornea CCL and INTACS outcomes at 12 months are very similar and comparable! CCL has lower complication rate! Biomechanically INTACS reversibility is still a open question CCL can be used to stabilize INTACS refractive effects CCL could be adiuvant therapy in several corneal deseases: melting, post-lasik ectasia, before or after refractive surgery
23 The ideal conservative procedure for keratoconus Delay or stop corneal degeneration Improve KC related corneal asimmetry Reduce secondary refractive error (Irregular astigmatism, Sphere) Low complications rate Metabolic error compensation (etiopathogenetic effect) Increase LAC tolerance Possibility of alternative techniques in the future (LK, PK) CCL Intacs +/
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