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