Elias F. Jarade, MD, FICS.Elias F. Jarade, MD, FICS.Corneal and Refractive Surgery Service, The Dubai Corneal and Refractive Surgery Service, The Dubai

Mall Medical Center, Dubai- U.A.E.Mall Medical Center, Dubai- U.A.E.

Tel: +971 4 4495111; Mob +971 50 8565919Tel: +971 4 4495111; Mob +971 50 8565919

ejarade@yahoo.com and/or and/or ejarade@emaarhealthcare.com

Poster Number: P287Poster Number: P287

New nomogram for combining New nomogram for combining treatment modalities for treatment modalities for

keratoconuskeratoconus

ASCRS, 2010Boston USA

KeratoconusManagement

Keratoconus (KC) and corneal ectasia treatment comprises different

modalities:Non interventional

(optical): Eye glasses Soft contact

lenses (SCL) Toric SCL Hard contact

lenses

Interventional(surgical):

Corneal collagen cross-linking by riboflavin and ultraviolet-A

Intra Corneal Ring Segment (ICRS) Surgery

Corneal graftPhakic Intraoculas Lens Phakic Intraoculas Lens (optical-surgical; stable KC (optical-surgical; stable KC

with good BCVA)with good BCVA)

New nomogram for combining New nomogram for combining different treatment modalities different treatment modalities

for keratoconusfor keratoconus

Purpose: To describe our nomogram for the Purpose: To describe our nomogram for the combination of different treatment combination of different treatment modalities for the treatment of keratoconus modalities for the treatment of keratoconus (KC) and corneal ectasia after refractive (KC) and corneal ectasia after refractive surgerysurgery

New nomogram for combining New nomogram for combining different treatment modalities different treatment modalities

for keratoconusfor keratoconusResults:Results: Early case of KC (form frust keratoconus) or Early case of KC (form frust keratoconus) or

corneal ectasia with mild drop of visual acuity corneal ectasia with mild drop of visual acuity are treated with corneal collagen crosslinking are treated with corneal collagen crosslinking (UV-X) as treatment of choice(UV-X) as treatment of choice

Goal of UV-X is to stabilise the cornea and holt Goal of UV-X is to stabilise the cornea and holt further progression of corneal ectasiafurther progression of corneal ectasia

Also, UV-X is indicated in: Also, UV-X is indicated in: young ageyoung age Progressive ectasiaProgressive ectasia Moderate to advanced ectasiaModerate to advanced ectasia Before phakic IOL (young age, progressive Before phakic IOL (young age, progressive

ecatsia and advanced cases) ecatsia and advanced cases) Visual acuity (VA) is reserved in most cases after Visual acuity (VA) is reserved in most cases after

UV-X with no remarkable changes in VA or k-UV-X with no remarkable changes in VA or k-readingreading

New nomogram for combining New nomogram for combining different treatment modalities different treatment modalities

for keratoconusfor keratoconusResults:Results:

Combination of simultaneous UV-X and eximer Combination of simultaneous UV-X and eximer laser surface ablation is performed in:laser surface ablation is performed in: Early case of ectasia with drop of vision (mild Early case of ectasia with drop of vision (mild

refractive errors) and corneal thickness of refractive errors) and corneal thickness of more than 500 μm.more than 500 μm.

Ectasia after LASIK: tissue ablation must be Ectasia after LASIK: tissue ablation must be limited to the corneal flap only (which does limited to the corneal flap only (which does not contribute to the corneal biostability) and not contribute to the corneal biostability) and stromal bed (biomechanically active) should stromal bed (biomechanically active) should remain intactremain intact

New nomogram for combining different New nomogram for combining different treatment modalities for keratoconustreatment modalities for keratoconus

Results:Results: Golden rule:Golden rule: ICRS is an additive-reversible ICRS is an additive-reversible

procedure, therefore, it is becoming as our procedure, therefore, it is becoming as our treatment of choice for visual rehabilitation for treatment of choice for visual rehabilitation for mild and moderate cases of KC and ectasia after mild and moderate cases of KC and ectasia after refractive surgery with a spherical equivalence refractive surgery with a spherical equivalence (SE) refraction of more than -8 to -10 D) (SE) refraction of more than -8 to -10 D) with or with or withoutwithout good best spectacle correct visual acuity good best spectacle correct visual acuity (BSCVA)(BSCVA)

If SE is beyond the capacity of ICRS: Phakic IOL, If SE is beyond the capacity of ICRS: Phakic IOL, bioptic, tri-optic, and bioptic, tri-optic, and ““quadropticsquadroptics””

Phakic IOL and corneal ecatsia: be careful Phakic IOL and corneal ecatsia: be careful about the anteriora chamber (AC) depth: about the anteriora chamber (AC) depth: usually it is over estimated in KC and ectasiausually it is over estimated in KC and ectasia

Follow Follow the manifest refraction axis of the manifest refraction axis of astigmatism regardless of the axis generated astigmatism regardless of the axis generated by automated machines (e.g. autorefraction by automated machines (e.g. autorefraction and topography)and topography)

New nomogram for combining New nomogram for combining different treatment modalities different treatment modalities

for keratoconusfor keratoconusResults:Results: In case of high SE and poor BSCVA, ICRS In case of high SE and poor BSCVA, ICRS

surgery (mainly one ring) is implanted to surgery (mainly one ring) is implanted to enhance the BSCVA before phakic IOL enhance the BSCVA before phakic IOL implantationimplantation

Corneal collagen cross linking is indicated before Corneal collagen cross linking is indicated before phakic IOL in most cases of:phakic IOL in most cases of:

moderate to advanced KCmoderate to advanced KC Young ageYoung age Progressive ectasiaProgressive ectasia

To To decrease decrease irregularirregularities& ities& enhance enhance BSCVABSCVA

New nomogram for combining different treatment modalities New nomogram for combining different treatment modalities for keratoconusfor keratoconus

Nomogram for the treatment of keratoconus Nomogram for the treatment of keratoconus and corneal ectasia after refractive surgery:and corneal ectasia after refractive surgery:

New nomogram for combining different New nomogram for combining different treatment modalities for keratoconustreatment modalities for keratoconus

Nomogram for ectasia with low to moderate Nomogram for ectasia with low to moderate SE:SE:

To decrease To decrease irregularitiesirregularities& enhance & enhance BSCVABSCVA

New nomogram for combining different treatment modalities New nomogram for combining different treatment modalities for keratoconusfor keratoconus

Nomogram for ectasia with high SE:Nomogram for ectasia with high SE:Advance ectasiaAdvance ectasia

Case presentation: Stable, mild KC: 27 y.o. patient

26 y.o. lady with stable keratoconus Ref:

-2.50 D -1.00 D axis 21 degrees: 20/22 -2.75 D -0.75 D axis 150 degrees: 20/25

Pachy: 530 µm OUTow months post Tow months post phakic IOL: phakic IOL: UCVA:

20/22 OU

Phakic IOLPhakic IOL

Case presentation: Stable, advanced Case presentation: Stable, advanced KC: 36 y.o. patientKC: 36 y.o. patient

Refraction:Refraction: -4 D -3.5 axis 70 -4 D -3.5 axis 70 BSCVA 20/25BSCVA 20/25 -8 D -5 axis 85 -8 D -5 axis 85 BSCVA 20/30BSCVA 20/30

UCVA: 20/20 OD UCVA: 20/20 OD and 20/25 OSand 20/25 OS

UV-XUV-X

Phakic IOL (Toric Phakic IOL (Toric ICL)ICL)

Case presentation: Progressive, Case presentation: Progressive, advanced KC: 26 y.o. patientadvanced KC: 26 y.o. patient

Refraction:Refraction: -6.75 D -4.5 axis 97 BSCVA 20/40-6.75 D -4.5 axis 97 BSCVA 20/40 -8 D -5 axis 133 BSCVA 20/40-8 D -5 axis 133 BSCVA 20/40

UV-XUV-X

Toric ICL: 20/25 Toric ICL: 20/25 OUOU

Case presentation: Stable, mild KC OD Case presentation: Stable, mild KC OD and stable advanced KC OS with drop of and stable advanced KC OS with drop of

BSCVA OU; 27 y.o.BSCVA OU; 27 y.o.Refraction:Refraction:

-1.5 D BSCVA 20/50-1.5 D BSCVA 20/50 -8 D -2.25 axis 120 BSCVA 20/50-8 D -2.25 axis 120 BSCVA 20/50

ManagementManagement ICRS OD: 20/20ICRS OD: 20/20 Only 1 ring OS: Ref: -8:00 D Only 1 ring OS: Ref: -8:00 D sphere with BSCVA 20/30sphere with BSCVA 20/30

ICL OS: ICL OS: 20/2220/22N.B. No UV-N.B. No UV-

XX

Case presentation: Keratoectasia after Case presentation: Keratoectasia after LASIK: Stable mild ectasia OD and LASIK: Stable mild ectasia OD and

progressive advanced ectasia OS with progressive advanced ectasia OS with severe drop of BSCVA OS; 35 y.o.severe drop of BSCVA OS; 35 y.o.Refraction:Refraction:

+1 -1.75 axis 53 BSCVA 20/40+1 -1.75 axis 53 BSCVA 20/40 -7 D -2 axis 135 BSCVA 20/200-7 D -2 axis 135 BSCVA 20/200

ManagementManagement ICRS OD: 20/25ICRS OD: 20/25 One ring OS: Ref -1.5 D -One ring OS: Ref -1.5 D -3.5 axis 128; BSCVA: 20/303.5 axis 128; BSCVA: 20/30

TICL OS: TICL OS: 20/2220/22

UV-XUV-X

Case presentation: Keratoectasia after Case presentation: Keratoectasia after LASIK: Stable mild ectasia OD and LASIK: Stable mild ectasia OD and

progressive advanced ectasia OS with progressive advanced ectasia OS with severe drop of BSCVA OS; 23 y.o.severe drop of BSCVA OS; 23 y.o.Refraction:Refraction:

-13 D -6 axis 45 BSCVA 20/80-13 D -6 axis 45 BSCVA 20/80 Plano: 20/20-Plano: 20/20-

ManagementManagement

Intacs SK (2 Intacs SK (2 different segment):different segment): Ref +0.5 D -3.5 Ref +0.5 D -3.5 axis 10; BSCVA: axis 10; BSCVA: 20/4020/40

TICL OD: TICL OD: 20/3020/30

OD: UV-OD: UV-XX

N.B. No touch OSN.B. No touch OS

New nomogram for combining New nomogram for combining different treatment modalities different treatment modalities

for keratoconusfor keratoconus Conclusion: Conclusion: This nomogram was This nomogram was

found very useful for the plan of found very useful for the plan of treatment strategy of different treatment strategy of different stages of keratoconus and corneal stages of keratoconus and corneal ectasia after LASIK. ectasia after LASIK.

Thank youThank you