dr. pietrini presentation at the mediphacos user meeting 2013

Topography-guided customized PRK combined with simultaneous CXL in patients previously implanted

ICRS for progressive keratoconus

Dominique PIETRINI, MDTony GUEDJ, OD, ORTH

CCK, Paris Vision Breteuil, Paris

Clinique de la Vision, Paris www.docteurpietrini.com

CORNEOPLASTIC PROCEDURES IN KERATOCONUS

• ICRS

• Topoguided PRK

• CXL

COMBINED TECHNIQUES

• ICRS+CXL

• Topoguided PRK + CXL

• ICRS+CXL+Topoguided PRK

PURPOSE

To evaluate safety and efficacy of topography-guided photorefractive keratectomy and

simultaneous CXL performed in patients with progressive keratoconus previously implanted

intracorneal ring segment (ICRS)

STUDY:

• 17 eyes , 15 patients• 4 females , 11 males• Consecutive case serie Mean age: 26.5 years+/-3,9 Mean Sphere pre op: -3.03+/-3.06 Mean Cyl pre op: -4.34+/-2.12 Mean pachymetry pre op : 475.2µm+/-22,84

SELECTED INDICATIONS:P

rogressive keratoconus

Poor results and /or unsufficient result after keraring

Residual ametropia or anisometropia

SURGERY:

• Kerarings Implantation Intralase• CXL (CBM Vega) Standard protocol (30 mn / 3 mw)• Topolink T-CAT (Allegretto WaveLight)

FOLLOW UP: - Mean follow up after Keraring : 6 months (+/- 5.48) - Mean follow up after Keraring+Topolink+Cxl : 12 months (+/- 7.44)

MATERIAL AND METHODS

SURGICAL PROCEDURE

• Epithelial removal: Amoils brush

• Topoguided PRK (T-CAT Allegretto WaveLight)

• Less than 50 microns (depending on pre op pachy)• Sphero cylindrical correction 70% of refraction

• Late hyperopic shift associated with CXL• Always myopic target (not a refractive surgery)• Refractive shift unpredictible because of various ablative

profiles.

• No mitomycine

• 20 mn riboflavin+ 30 mn UV-A

SPHERICAL EQUIVALENT AND KMAX

5D Reduction on Kmax

4.7D Reduction on SE

BEST AND UNCORRECTED DISTANCE VISUAL ACUITY

After Keraring:Gain of 2 lines of UCVA Gain of 0,8 lines of BCVA

After Topoguided CXL post Keraring:Gain of 2,5 lines of UCVA Gain of 1,8 lines of BCVA

Gain Total of 4.5 lines of UCVA after Triple Procedure Gain Total of 2.5 lines of BCVA after Triple Procedure

COMPLICATIONS

• One case of paracentral scar • Not haze but scar related to over CXL

• Default in evaluating thinnest point• No loss of BCVA compared to preop• Gain in refraction

KMAX 58.8D

KMAX 52.8D

KERARING 6 MONTHS

PRE OP

M.M Male, 26 years

UCVA 2/10

BCVA 5/10

REFRACTION - 4.50

UCVA 1/20

BCVA 3/10

REFRACTION -8.50 (-5.00) 0°

KERARING 6 MONTHS

PRE OP

-6D

M.MMALE

26 YEARS

7/10

9/10

+0.50 (-1.00) 30°

KERARING+TOPOLINK+CXL9 MONTHS

KERARING 6 MONTHS

KMAX 52.8D KMAX

45.6D

UCVA 7/10

BCVA 9/10

REFRACTION +0.50 (-1.00) 30°

UCVA 2/10

BCVA 5/10

REFRACTION - 4.50

KERARING+TOPOLINK+CXL 9 MONTHS

KERARING 6 MONTHS

-7D

KMAX 58.8D KMAX

45.6D

PRE OP KERARING+TOPOLINK+CXL9 MONTHS

UCVA 7/10

BCVA 9/10

REFRACTION +0.50 (-1.00) 30°

UCVA 1/20

BCVA 3/10

REFRACTION -8.50 (-5.00) 0°

-13D

KERARING+TOPOLINK+CXL 9 MONTHS

PRE OP

Conclusion

• TG PRK + CXL after ICRS is indicated when• KC is progressive• Visual result after ICRS is poor• If corneal pachymetry > 450 microns

• TG PRK +CXL after ICRS• Improves significantly the reduction of spherocylindrical refraction and K max

• improves UCVA by 2.5 lines• and BCVA 1.8 line.

• Triple procedure combining “topo-guided” PRK + CXL in patients previously implanted with Keraring is safe and effective in a short term