Short and long term complications of combined. Protocol) in 412 keratoconus eyes (2 7 years follow up)
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1 Short and long term complications of combined topography guided PRK and CXL (the Athens Protocol) in 412 keratoconus eyes (2 7 years follow up) Anastasios John Kanellopoulos, MD Director, Laservision.gr Institute, Athens, Greece Clinical Professor NYU Medical School, NY
2 The Athens Protocol 7-years Kanellopoulos MD
3 Over the last 7 years we have treated over 1000 cases of KCN and ectasia with CXL J Cornea August 2007 CXL followed 6 months later by a partial tprk Kanellopoulos MD 3
4 Topo-guided partial PRK Topolyzer:Placido disc topography Pentacam (Oculyzer) Pentacam HD (oculyzer II)-Refractive suite WaveLight FS200 Femtosecond Laser WaveLight EX500 Excimer Laser WaveLight Refractive Suite Kanellopoulos MD
5 The Athens Protocol PTK 50um Topo PRK MMC CXL
6 Kolozsvári et al IOVS 2002;43: JRS Sept 2009
7 Which is the better biomechanical model to CXL? A B Kanellopoulos MD
8 Results JRS Sept 09: Sequential (left) Vs same-day Combined (right) UCVA LogMar BSCVA LogMar Mean Decrease MRSE Mean K Decrease Mean Haze Score PreOp PostOp 0.9 ± ± ± ± ± ± ±0.5 Mean CCT 465±45 395±25 UCVA LogMar BSCVA LogMar Mean Decrease MRSE Mean K Decrease Mean Haze Score Pre op Post op 0.96 ± ± ± ±0.16 (p<0.001) 3.2±1.4 (p<0.005) 3.50±1.3 (p<0.005) 0.5±0.3 (p< Mean CCT 475±55 405±35
9 Post-LASIK ectasia in a pilot @135: 20/40 Athens Protocol: PTK + topoprk( @ 140) + CXL At 3 years UCVA to 20/15! Kanellopoulos MD 9
10 Both groups: 40% Significant pain with PRK in both Groups Reepithelializatio n 90% by day 4 Mean endothelial cell counts unchanged in both groups
11 Combined same-day topo guided PRK and CXL appear to be superior to the rehabilitation of KCN and ectasia. d 1-one procedure 2-less PRK-associated scarring 3-Better riboflavin penetration 4-Less shielding of UV by Bowman s-wider CXL area 5-redistribution of cornea strain (biomechanics) 6-No need to remove cross-linked cornea Underscore refraction Kanellopoulos MD
12 Conclusions Our experience additionally suggests synergistic effect when the two modalities (tgprk and CXL) were combined. Minor complications included post-op haze and delayed epithelial healing. There were minimal cases registered that failed to stabilize. In our experience the Alcon/Wavelight topography guided platform has been very effective in predictably offering cornea normalization and enhanced visual function Kanellopoulos MD
13 J Ophthalmol June 07: CXL and then topoguided PRK in post LASIK ectasia
14 Higher fluence CXL AAO 2008: CXL for 15 minutes utilizing 7mW/cm 2 fluence Kanellopoulos MD 14
15 Variable UV fluence(1-120mw/cm2) Kanellopoulos MD
16 Ectasia after LASIK
17 Possible tprk/cxl complications SHORT TERM Infectious Keratitis LONG TERM Delayed healing Delayed Epithelial Healing Cornea Scarring Endothelial Damage Regression White spots overcxl? Continuing flattening Pain Poor collagen regeneration
18 Typical Ground Glass appearance to fine CXL lines
19 Complications encountered: Delayed epithelial healing: Epithelial healing occurred in 75% of the cases on day 4, 15 of the cases by day 5 and 10% by day 10. Postoperative pain: 45% of the cases reported no signifivant postoperative pain, 25% descrinbed moderate postoperative pain and 30% severe post-operative pain over the first postop day. Epithelial scarring: 25% of the cases showed Saltzman s-like epithelial scarring that persisted for an average 1 month, and resolved with lubrication (30%), bandage contact lens use and lubrication (25%), autologous serum administration besides, only 5% retained long term scarring Regression: 1.5% required second CXL treatment for regression Other reports: Infection, Herpetic keratitis, melts
20 Unknown Possible Long Term CXL Cataracts Risks Conjunctival squamous cell carcinoma Long Term Dry Eyes due to UV A Damage to ocular surface Progressive thinning Poor glaucoma management
21 From UDVA 20/20 to 20/40 over 4 years with a 2.5D hyperopic shift
22 Delayed epithelial healing with white spots
23 Haze
24 edema
25 Deep scar
26 Peripheral melt
27 Salzman s-like nodule(s) can persist to 3 months postop
28 Scar and white spot
29 PRK-like haze 1 year after, in heavy sunbathing improved with steroids
30 Prof. Kanellopoulos, MD
31 CWCXL
32 Thank You!
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