Advanced Use of Intacs and Holcomb C3-R Brian S. Boxer Wachler, MD

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Megan Armstrong
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1 Advanced Use of Intacs and Holcomb C3-R Brian S. Boxer Wachler, MD Beverly Hills, CA

2 New Intacs Discovery! Two segments produce global flattening Single segment produces inferior flattening and superior steepening Single segment better for peripheral KC Sharma S, Chan CCK, Boxer Wachler BS. American Journal of Ophthalmology, Two segments better for central KC

3 Postop Day 1 elevation of shelf flattening of cone Preop Intacs

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8 Postop Day X 90 20/20 Preop X 85 20/20

9 Photophobia Responds to 2 week tapering dose of NSAID Rule out iritis Rule out epi ingrowth in channel May require surgical epi removal

10 There Can be Trouble in Paradise

13 Setting Patient Expectations Expect to gain on average of 2 lines of BSCVA (range 1 to 6 lines) If preop BSCVA on MRx: 20/20 to 20/50 SCTLs, Synergeyes,glasses 20/50 to 20/80 SCTLs, Synergeyes, RGPs 20/80 or worse Synergeyes,RGPs Expect reduction in astigmatism Some residual astigmatism typical though

14 Contact Lens Fitting Expectations Soft Lenses - after 2 weeks Proclear Compatible Toric (XR) HydraKone Hydrasoft XW Piggy-Back or Scleral - after 1 month RGP designs: Dyna Z, Rose K, Rose K2 Scleral desgin: 18.2 Jupiter from Medlens Innovations RGP or Synerges - after 6 months Too early fit can cause FBS and photophobia Will require multiple visits 5-6 visits expected Charge global fee - i.e. $1600 includes visits over 6 mos Lens cost: $300 - $800/per eye a year

15 Holcomb C3-R (corneal collagen crosslinking with riboflavin) 30 minute treatment time I have been performing nearly 7 years now

16 Indications Unstable/Progressing Corneas Keratoconus Forme Fruste Ectasia RK (radial keratotomy) Combined with other surgical procedures Intacs for keratoconus CK and LTK

17 Safety Profile

18 Holcomb C3-R Mechanism UVA Riboflavin Corneal Collagen Cross-linking Biomechanical Stiffness Stability

19 Technique

20 Technique

21 Technique Crosslinked

22 Safety Profile Holcomb C3-R Transepithelial Epi On Crosslinking No complications reported (Boxer Wachler, Pinelli, Ertan) No infection, No Scar/haze, No cornea denervation No cataracts No endothelial loss No retinal pathology Crosslinking with Removal of Epithelium Complications can occur 1-3% corneal infection rate (FDA study) 5.5% corneal infection rate (Seiler s study) 1% corneal scarring (same) 100% Uniform corneal nerve denervation (Pallikaris) 1-2% delayed epithelization (FDA study, Selier s IROC group)

23 Net flattening

24 Preop Postop

25 Another Case Postop 2 months Preop C3-R

26 Prevent Progression 19 year old woman Wearing soft contact lenses Newly diagnosed with keratoconus Sept 2003

27 September x 55 20/ x /25

28 Progression Right Eye 1.5 yrs April x 69 20/25 Sept x 55 20/20

29 Progression Left Eye 1.5 yrs April x /30 Sept x /25

30 Holcomb C3-R alone could have easily prevented this We treat referred patients

31 Holcomb C3-R Aids Intacs Effect

32 + C3-R (Same Day)

33 Postop Day X /20 Preop X /30

34 Postop Day 1 UCVA 20/20 Preop x 73 20/25

35 Postop Day 1 UCVA 20/ x /25

36 Postop 1 Month BCVA 20/40 Preop BCVA 20/160

37 Postop 1 Month Preop Intacs + C3-R

38 Intacs and C3-R 27 eyes of 23 patients with keratoconus and LASIK-induced ectasia (keratectasia) were evaluated Single segment used to flatten peripheral cone Axis of incision was on steepest axis on manifest refraction (Boxer Wachler et al. Ophthalmology 2003) Outcomes: UCVA, BCVA, manifest refraction, keratometry (steep, flat and average), L-U ratio Mean follow up was 99.0 ± 37.5 days

39 Preoperative Matching Preoperative Intacs+C3-R Intacs measurements 12 eyes of 9 patients 15 eyes of 14 patients UCVA (Log Mar) 1.12 (20/250) ± (20/400) ± 0.81 BCVA (Log Mar) 0.23 (20/32) ± (20/40) ± 0.18 Sphere ± ± 3.39 Cylinder ± ± 1.43 K steep (D) ± ± 5.02 K flat (D) ± ± 3.12 K average (D) ± ± 3.89 MRx L-U (D) ± ± Matched with p>0.05

40 Lower-Upper (L-U) Ratio I-S ratio L-U ratio (more accurate)

41 Change in Cylinder ± ± Intacs +C3-R Intacs only p =.04

42 Change in K Steep (D) ± ± Intacs +C3-R Intacs only p =.03

43 Change in K Average (D) ± ± Intacs +C3-R Intacs only p =.03

44 Change in LU ratio ± ± Intacs +C3-R Intacs only p =.04

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46 More Details at

47 Thank You

Surgical Advances in Keratoconus. Keratoconus. Innovations in Ophthalmology. New Surgical Advances. Diagnosis of Keratoconus. Scheimpflug imaging

Surgical Advances in Keratoconus Keratoconus Ectatic disorder 1 in 1,000 individuals Starts in adolescence & early adulthood Uncertain cause 20% require corneal transplant Innovations in Ophthalmology