5/24/2013 ESOIRS Moderator: Alaa Ghaith, MD. Faculty: Ahmed El Masri, MD Mohamed Shafik, MD Mohamed El Kateb, MD

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1 ESOIRS 2013 Moderator: Alaa Ghaith, MD Faculty: Ahmed El Masri, MD Mohamed Shafik, MD Mohamed El Kateb, MD 1

2 A systematic approach to the management of Keratoconus through the presentation of different cases of keratoconus and discussing the factors involved in the proper management of each case. Three main aims of Keratoconus Management 1. Stopping disease progression 2. Treatment of the irregular corneal surface 3. Treatment of the associated refractive error (myopia and astigmatism) 2

3 Treatment Modalities Glasses Rigid Gas-permeable Contact Lenses CxL PRK + CxL Intracorneal Rings Phakic IOLs Keratoplasty (Lamellar or Penetrating) Factors Involved in Keratoconus Management 1. Severity of keratoconus 1. Keratometry (K-max) 2. Thinnest pachymetric reading 3. Corneal scarring 2. Age 3. Associated Refractive Error 4. Uncorrected and Best-corrected visual acuity 5. Patient s Expectations 6. Cost of Surgery 7. Availability of management tools 3

4 Decision Making All ophthalmologists are faced with keratoconus patients who are seeking a solution for their eye problem. The ophthalmologist has to look up a number of patient factors and then come up with one or two options to discuss with the patient. There is still some controversy between ophthalmologists about the limits of each treatment options Keratoconus Management Parameters Glasses Can be beneficial in early cases Quality of vision is much less than RGPs 4

5 Keratoconus Management Parameters Rigid Contact lenses Indications: Mild and moderate cases of Keratoconus Absent or minimal apical scarring Keratoconus Management Parameters Corneal Cross Linking (CXL) Indications 1. Progressive Keratoconus : * Increase in K-max of 1.00D or more in 1 year * Deterioration of BSCVA * Change of RGP parameters more than once in 2 years 2. Clear non-scarred cornea 3. Corneal thickness of at least 400 µ at its thinnest point 5

6 Keratoconus Management Parameters Intracorneal Ring Segments (ICRS) Indications: Central clear cornea Uncorrected VA 20/200 Intolerance to RGP K s between 45 and 60 Pachymetry at least 350µ at thinnest part and at least 450µ at incision site Keratoconus Management Parameters PRK + CXL These two procedures can be performed Sequentially, i.e., CxL followed by PRK (after 6 12 months) or Simultaneously, i.e., PRK followed by CxL In the same day. Indications Early Keratoconus, i.e., K around 50 D Clear central cornea Low refractive error Thinnest corneal location > 450 µ Patient s desire to get rid of glasses and contact lenses 6

7 Keratoconus Management Parameters Deep anterior lamellar keratoplasty (DALK) Indications 1) Clear cornea or minimal scarring 2) K-max > 65 D 3) Thinnest corneal location < 350 µ 4) Intolerance to or refusal of RGPs Keratoconus Management Parameters Penetrating Keratoplasty Indications: advanced, scarred keratoconus 7

8 Systematic Approach Factor Patient Parameter Treatment Option Age Corneal Transparency K-max Refractive Error BSCVA Thinnest corneal location RGP Tolerance Suggest Treatment Case Presentation Case 1 A 26 years old female was recently Sphere Cylinder Axis UCVA BSCVA diagnosed with bilateral keratoconus. OD Her manifest refraction was OS

9 Case Presentation Case 1 Patient Counseling: The patient was concerned about the deterioration of the condition and was content with her glasses. She also welcomed the idea of having rigid gas permeable contact lenses. The findings of her left eye will be demonstrated as both eyes are more or less similar. 9

10 Case Presentation Factor Patient Data Treatment options Age 26 yrs CXL Corneal Transparency Clear All options are possible K-max 50.2 D All options are possible Refractive error (SE) -2.5 D CXL + glasses or RGP, or ICR + CXL or PRK & CXL BSCVA 0.6 CXL + glasses or RGP, or ICR + CXL or PRK & CXL Corneal thickness at thinnest location 460 CXL + glasses or RGP, or ICR + CXL or PRK & CXL CL tolerance Not tested Treatment Decision CXL + glasses or RGP after patient counseling Case 1 The patient had CXL performed for both eyes. The difference map of her left eye 3 months postoperatively is shown here. 10

11 Keratoconus Management Parameters Corneal Cross Linking (CXL) 1. Thickness: does it really matters? 2. Transepithelial CxL: does it really work as the original procedure? 3. Manipulating the parameters (e.g., the duration of UVA exposure, the concentration of the riboflavin): does it make a difference? 4. Combinations: with RGP lenses, with ICRs (before and after), with ICLs or PIOLs 5. Effects (on refraction, corneal thickness, keratometry, and BSCVA) 6. Complications (persistent haze, loss of BSCVA) 7. Duration of action 11

12 Mohamed El Kateb, MD Lecturer at the Department of Ophthalmology Faculty of Medicine Alexandria University Alexandria - Egypt Case 2 Case Presentation A 19 years old female presented seeking vision correction in the left eye. She had bilateral CXL one year ago. Her manifest refraction and BSCVA were as follows: Sphere Cylinder Axis UCVA BSCVA OD OS

13 Case Presentation Factor Patient Data Treatment Options Age 19 years CXL Corneal Transparency Clear Glasses, RGP, ICR, PRK K-max 54.1 D Glasses, RGP, ICR Refractive Error (SE) d Glasses, RGP, ICR BSCVA 0.7 Glasses, RGP, ICR Corneal thinnest location RGP tolerance Suggest Treatment 397 µ Glasses, RGP, ICR, or DALK Not tested Glasses, RGP, or ICR. PRK is not recommended because of the thickness of the cornea 13

14 Case Presentation Case 2 The patient opted to have ICR implantation. She had Kera rings implantation using femtosecond laser to form the intracorneal tunnels. Her postoperative Pentacam (difference map of the sagittal curvature) and refractive and visual outcome are presented below. Sphere Cylinder Axis UCVA BCVA Left eye

15 Intracorneal Ring Segments (ICRs) Important tips 1. Mechanism of Action 2. Indications (good candidates with the best results) & contraindications 3. Types 4. Surgical Planning: Segment Selection: number, thickness, length, & position 5. Femtosecond Tunnels vs Mechanical tunnels 6. Results: Are they affected by the shape of the cone, the location of the cone, the thinnest location, the concomitant refractive error, or the best corrected visual acuity? 7. Combination with CXL Timing: same day or later (when) Is it really necessary? Any study comparing ICR with and without CXL? Ahmed El Masri, MD Professor at the Department of Ophthalmology Faculty of Medicine Alexandria University Egypt 15

16 Case Presentation Case 3 A 36 years old female presented complaining of poor vision in her right eye. The right cornea demonstrated a faint central superficial opacity. The left eye had CXL 2 years ago. The pentacam and ocular data of her right eye are presented below. Sphere Cylinder Axis UCVA BSCVA Right Eye CF at 2 meters

17 Factor Patient Data Suggested Treatment Age 36 years No need for cross linking Corneal Transparency Faint central opacity RGP or DALK or PKP K-max 72.7 D RGP or DALK or PKP Refractive error (SE) RGP or DALK or PKP BSCVA 0.1 RGP or DALK or PKP Corneal thickness at thinnest location 351 µ RGP or DALK or PKP CL tolerance Intolerant DALK or PKP Suggested treatment DALK is the best solution for such a patient Case Presentation Case 4 A female patient 23 years of age came asking for vision correction in her right eye. She had corneal cross linking for both eyes 10 months ago. Pentacam and ocular data of her right eye were as follows Sphere Cylinder Axis UCVA BSCVA OD CF 2 meters

18 Factor Patient Data Suggested Treatment Age 23 years CXL was done 10 ms ago Corneal Transparency Clear All options are possible K-max 54.3 D All options are possible Refractive error (SE) Glasses, RGP, PIOL BSCVA 0.5 Glasses or RGP or PIOL Corneal thickness at thinnest location 432 µ Glasses or RGP or PIOL CL tolerance Patient refuses RGP Glasses or PIOL Suggested treatment PIOL is the best solution for such a patient 18

19 Important Tips Phakic IOLs 1. Indications: How to select a patient for PIOL? Range of error, degree of keratoconus, shape of the cone, stability of the condition, etc 2. Toric ICLs: How to calculate the astigmatic error and axis in a keratoconic eye? How to implant and align the lens axis with the astigmatic corneal axis? 3. Results? Mohamed Shafik, MD Professor at Department of Ophthalmology Faculty of Medicine Alexandria University Alexandria - Egypt 19

20 Case Presentation Case 5 A 30 years old male presented asking for refractive surgery for both eyes. His ocular findings and pentacam photos are presented below. Sphere Cylinder Axis UCVA BSCVA OD OS

21 21

22 Factor Patient Data Suggested Treatment Age 30 years CXL may be needed Corneal Transparency Clear (OU) K-max Refractive error (SE) OD: 45.5 D OS: 51.1 D OD: D All surgical options are possible All surgical options are possible ICR or PRK + CXL OS: D BSCVA 0.5 ICR or PRK + CXL Corneal thickness at thinnest location 432 µ ICR or PRK + CXL CL tolerance Patient refuses RGP ICR or PRK + CXL Suggested treatment ICR + CXL or PRK + CXL 22

23 Case 5 The patient had bilateral PRK followed by CXL simultaneously. Two months postoperative results are listed below: Sphere Cylinder Axis UCVA BCVA OD OS

24 Thank You 24

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