dr. lovisolo "the triple procedure: icr + tomo-linked ptk + cxl"
DESCRIPTION
Dr. Carlo Lovisolo presentation at the 2014 Total Keratoconus Solution user meeting organized by Mediphacos London, 2014 ESCRSTRANSCRIPT
The Triple Procedure:ICR + tomo-linked PTK + CXL
Carlo F. Lovisolo, [email protected]
Quattroelle Custom Eye Centers Milan Italy
Dr. Lovisolo has no proprietary or financial interest in
any device or product mentioned in this presentation
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Since 1999: ICRS’s
reproducible flattening & recentering effect
The shorter the segment, the bigger
the astigmatic correction
SI6 mm
SI5 mm
, The thickest the segment, the
largest the flattening effect
Significant reduction of Coma after ICRSCorneal apex recentered
Coma: 1.97 Coma: 0.52
PreOp PostOp
The Athen’s Protocol: Excimer laser (Allegretto) topo-linked ablation
Kanellopoulos AJ Clin Ophthalmol 2012;6:87-90
LIGI CIPTA topo-guided transepithelial ablation
Stojanovic J Refract Surg 2010;26:145-52
Simultaneous topo-guided PRK + CXL for KC
Kymionis GD et al: Am J Ophthalmol 2011;152:748-55
Since 2006: Trans-epithelial Topo-guided Ablation (CIPTA) combined with CXL to improve coma& irregular astigmatism
Old Issues Fixed
Overall lack of predictability
• Excessive Flattening (Hyperopic shift)
• Comprehension of Epithelium compensation
• Ablation rate of KC stroma
•Lack of information on posterior corneal surface
Inaccurate astigmatism correction
Overoblate asphericity
• tilt compensation (aberropia)
• Residual thickness safety limit (400 µm?)
•Soaking time after Bowmann removal?
Epithelium compensation revealedwith VHF Echography (Artemis 2)
• Thins over cone apex• Thickens at cone base• Thins on segments’ top• Thickens at segments’ edge
Normal cornea Keratoconus
Cornea with ring segments
Total Cornea AnalysisModern AS-OCT and Scheimpflug camera devices includePosterior surface astigmatism & asphericity
Help to identify Ha and Hp location values& to understand mismatch between topo, cyl & coma axis
Ha Hp
Isoclinal Contour Map
New HOA indices
Corneal aberration indexes above 2nd ordershowed between 2.0 & 8.0 mm andexpressed, through ray tracing analysis,either for the whole cornea or dividedbetween anterior and posterior surface
-0.24 um
0.23 um
Now the ablation planning may be accurate to correct bothlower & higher order aberrations
Unsolved issue: excessive tissue sacrifice
Minimised Ablation (Max depth <50 μm, volume 0.5 mm3)Moderate ectasia, nipple cones excellent indications
Safety limits:topo-guided ablations not safley feasible in the vast majority of cases
Downward displacement of corneal apex
To correct tilt: Max Ablation Depth: 274 μm
Minimal residual pachymetry: 179 μm
PreOpRequired max ablation:118 μm
Post-KeraRing
Post-CXL + Topo-linkMax ablation: 39 μm
Triple procedure:1) ICR2) after 3-6 months CXL + topoguided ablation
Post-ICR
Max depth for simulated topo-link: 31 μm
Residual min pachymetry: 432 μm
Max depth for simulated topo-link: 97 μmResidual min pachymetry: 366 μm
PreOp
Post-CXL + Topo-link
PreOp
Post-ICR
Post-CXL + Topo-LinkMax ablation: 36 μm
Methods
• 150 KC eyes, 3 homogeneous (age, stage) groups– Group A: ICRs + aCXL
– Group B: Custom topo-linked PTK + aCX
– Group C: ICRs; after 6 months custom topo-linkedPTK + aCXL
• Prospective comparison of tomographic & functional outcomes (safety & efficacy indexes)
• Min-average-max follow up: 14-21-26 months
Results
• All tomographic indices, mean UCVA, meanBSCVA & coma improved in all groups, with slight(not s.s.) difference between Group A and B
• Group C showed a s.s. (p<0.05) improvement of allfunctional parameters when compared to Group A & B
• No s.s. difference in safety index
Best case must become average outcome!
24 yo PreOp UCVA 20/200
BSCVA: 20/30 with -5.0 sph -3.0 cyl
PostOp UCVA 20/25++; BSCVA: 20/20 with -0.50 cyl
Quadruple Procedure:Adding Toric (Custom?) Phakic IOL’s
Preop BSCVA 20/80 -13.0 -12.0 x 115°
Kera Ring + CXL + Topo-link + T-ICL. Postop UCVA: 20/20
Conclusions
• The triple procedure (ICR’s implantationfollowed after 3-6 months by topo-linkedcustom PTK and CXL) presents the greatestfunctional improvement in treating progressive keratoconus
• Toric phakic IOL’s (t-ICL’s) provide safe and very effective outcomes in stabilised KC withsignificant residual ammetropia
Thank you for Attention
Carlo F. Lovisolo, [email protected]
Quattroelle Custom Eye Centers Milan Italy
Dr. Lovisolo has no proprietary or financial interest in
any device or product mentioned in this presentation
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