Complications of Combined Topography-Guided Photorefractive Keratectomy and Corneal Collagen Crosslinking in Keratoconus
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1 Complications of Combined Topography-Guided Photorefractive Keratectomy and Corneal Collagen Crosslinking in Keratoconus Michelle Cho, M.D. 1 Anastasios John Kanellopoulos, M.D 1,2 New York University School of Medicine, Department of Ophthalmology, New York, NY 1 Laservision.gr Institute, Athens, Greece 2
2 Financial Disclosure I have no financial interests or relationships to disclose.
3 Keratoconus Rabinowitz Y. Keratoconus. Surv Ophthalmol. 1998;42:
4 Collagen Crosslinking Wollensak G, Spoerl E, Seiler T. Stress-strain measurements of human and Porcine corneas after riboflavin-ultraviolet A-induced cross-linking. J Cat Refract Surg 2003;29:
5 Combined topography-guided PRK and CXL: The Athens Protocol
6 Combined tgprk CXL superior to sequential procedure for visual rehabilitation of KCN and ectasia One procedure Less PRK-associated scarring Increased riboflavin and UVA light penetration No need to remove cross-linked cornea Underscore refraction
7 Combined topography-guided PRK and CXL: The Athens Protocol PTK tgprk MMC CXL
8
9 Kanellopoulos AJ. Comparison of sequential vs same-day simultaneous collagen cross- Linking and topography-guided PRK for treatment of keratoconus. J Refract Surg 2009;25:S812-8.
10 JRS Sept 2009
11 Prospective cohort study Private clinical facility in Athens, Greece 412 keratoconic eyes Inclusion criteria: Diagnosis of progressive keratoconus Progressive corneal steepening of at least 1.00 D in keratometry Exclusion criteria: CCT 350 µm; Other ocular disease Mean follow up: 35 months ± 18 months (range 14 to 72 months)
12 Early Complications Postoperative pain Delayed epithelial healing Salzmann-like epithelial scarring
13 Pain POD# 1 % patients % patients with pain Pain Pain Scale 1- None 2- Mild 3- Moderate 4- Severe
14 Delayed epithelial healing
15 Delayed epithelial healing % cases Day % cases with delayed epithelial healing
16 Salzmann-like scarring
17 Management Lubrication Bandage contact lens Autologous serum administration Surgical removal
18 Late Complications Subepithelial corneal scar (2.9%, n = 12) Stromal haze (3.8%, n = 16) Ectatic progression (1.7%, n = 7)
19 Subepithelial corneal scar
20 Subepithelial corneal scar and haze
21 Stromal haze
22 Management of Ectatic progression Repeat combined topography-guided PRK and CXL Penetrating keratoplasty
23 Other Complications Infectious keratitis Corneal melt
24 Corneal melt
25 Unknown potential risks Ocular surface disease Conjunctival squamous cell carcinoma Endothelial toxicity Cataracts Poor glaucoma management
26 Summary Combined topography-guided PRK and CXL is a promising technique to halt the progression of keratoconus and provide improved functional vision. Early complications are postoperative pain, delayed epithelial healing, and Salzmann-like scarring. Late complications are subepithelial corneal scarring, stromal haze, and ectatic progression.
27 References Rabinowitz Y. Keratoconus. Surv Ophthalmol. 1998;42: Wollensak G, Spoerl E, Seiler T. Stress-strain measurements of human and porcine corneas after riboflavin-ultraviolet A-induced cross-linking. J Cat Refract Surg 2003;29: Kanellopoulos AJ. Comparison of sequential vs same-day simultaneous collagen cross-linking and topography-guided PRK for treatment of keratoconus. J Refract Surg 2009;25:S Krueger RR, Kanellopoulos AJ. Stability of simultaneous topography-guided photorefractive keratectomy and riboflavin/uva cross-linking for progressive keratoconus: case reports. J Refract Surg 2010;26:S Kanellopoulos AJ, Binder PS. Management of corneal ectasia after LASIK with combined, sameday, topography-guided partial transepithelial PRK and collagen cross-linking: the Athens Protocol. J Refract Surg 2011;27: Kanellopoulos AJ. Simultaneous collagen cross-linking (CXL) and topography-guided PRK (tprk) for keratoconus (KCN). Surgical techniques in ophthalmology: corneal surgery. Garg A, Alio JL. New Delhi: Jaypee Brothers Medical Publishers Ltd,
Short and long term complications of combined. Protocol) in 412 keratoconus eyes (2 7 years follow up)
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