“Refractive PRK for Corneal Scars

to 20/20 vision”

Financial Disclaimer: Dr. Gulani has no financial interest in this presentation

Elegant Transplant Techniques

Gulani AC

Goal: VISION not Surgery

• Using Corneoplastique ™ principles and applying the “5S” system, practically any Corneal scar no matter how complex can be visually rehabilitated.

• Corneal scar affects vision by direct disturbance in optical pathway as well as indirect impact on refractive error.

• All principles of Corneoplastique™ surgery maintained:

Topical, Brief, Aesthetically pleasing & Visually promising.

Gulani AC

Why Laser PRK ?

• Shape of Cornea decides refractive status so why not use that principle with the law of Optics (Anterior lens surface shape is more significant than posterior irregularities in shape and or clarity).

• Myopic Laser PRK shapes the cornea (based on refraction) and while shaping the cornea (photoablation), it automatically moves the scar more posterior or removes it significantly.

** Many patients despite a residual corneal scar see 20/20

• Unlike Laser PTK which addresses the scar but may distort shape (which is the prime vision driver), PRK is aiming for vision despite the scar.

• No change in PRK protocol with 0.02% Mitomycin-C. Short Learning Curve.

• All interventional surgeries including lamellar and penetrating corneal transplants can still be a back up if the Laser PRK does not get the desired results.

Gulani AC

Gulani 5S Refractive Algorithm

Gulani “5S” Classification System

Sight Scar Shape Strength Site

Improv No Impro Clear Scar Irreg Reg Thin Thick Central Periph

superficial DeepMyopia

CL over RX Hyperopia

Astigmatism

Using this 5S system, we see that the Sight( vision), Scar, Shape (Irregular)& Site (central) are affected. This algorithm makes any complex case scenarioSimple to understand and effectively treat.

So in this case, since strength is normal, we need to peel off the scar with simultaneous Laser refractive ablation (not PTK) so we can measure the actual refractive error. The present ref error is a play of the corneal scar.Once we have the true ref error then we can accurately correct it.

Gulani Co Scar Laser Algorithm

Gulani “Corneal Scar” Laser PRK Algorithm

Depth Refraction Pach Topography Pattern

InCornea

OnCornea

>20/30 <20/40 >400 <250 Reg Irreg Diffuse Focal

>20/30

NI

LK

Laser PRK

DLK

PKP

Hard CL RxLaser PRK

2 Staged Laser PRK

LK +AMT

Laser PRK

Laser +Scar Peel (On-Cornea)

On-Cornea Scar

Laser +Scar Peel (On-Cornea)

In-Cornea Scar

Laser Thru In-Cornea Scars

Reversing Multifocal Nightmare

Patient referred with corneal scar following Excimer Laser x 2 to correct Multifocal lens surprise. Best corrected Vision: 20/200.

Using Corneoplastique ™ principles, I peeled off her corneal scar under the Laser and simultaneously ablated her cornea in a PRK mode.Upon healing, this resulted in a Clear Cornea with a measurable, true refractive error of +6.00 D -0.50 x 170 and best corrected vision

of 20/25.

Corneal Scar Pre-Laser Clear Cornea Post-Laser

Algorithm in Action : 20/200 to 20/20

Corneal Scar Pre-Laser: Vsc 20/200

Post Laser + Piggy-back IOL: Vsc 20/20

Laser Scar Peel + PRK

Piggy-back lens on ReStor

Previous Ref Surgery

Ant Corneal Dystrophies

Gulani AC

Conclusion

Refractive Laser PRK Surgery when

Practiced as an ART can not only address virgin eyes with all levels ofammetropia but also reverse and correctcomplex as well as complicated cases with corneal scars back to 20/20 vision

Refractive surgery truly then can come to its own Rescue !

References:

Gulani AC. Corneoplastique™. Techniques in Ophthalmology 5(1):11-20, 2007Gulani AC. Irregular Astigmatism: Management in Unstable Cornea. Textbook of Irregular Astigmatism. Slack Inc. 2007; Slack Inc Gulani AC, John T. Combined corneal scar excision, Laser PRK surgery seeks unaided emmetropia. Ocular Surgery News. Cornea & External

disease section, June. 2008. Gulani AC. " Corneoplastique system repairs cornea before or after Laser refractive surgery” Ocular Surgery News, Nov 2007; 25 (21). 124-125

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