decision making in keratoconus -...

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ESOIRS 2013

• Moderator: Alaa Ghaith, MD

• Faculty: Ahmed El Masri, MD

Mohamed Shafik, MD

Mohamed El Kateb, MD

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• A systematic approach to the

management of Keratoconus through

the presentation of different cases of

keratoconus and discussing the

factors involved in the proper

management of each case.

Three main aims of

Keratoconus Management

1. Stopping disease progression

2. Treatment of the irregular corneal surface

3. Treatment of the associated refractive error

(myopia and astigmatism)

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Treatment Modalities

• Glasses

• Rigid Gas-permeable Contact Lenses

• CxL

• PRK + CxL

• Intracorneal Rings

• Phakic IOLs

• Keratoplasty (Lamellar or Penetrating)

Factors Involved in Keratoconus Management

1. Severity of keratoconus

1. Keratometry (K-max)

2. Thinnest pachymetric reading

3. Corneal scarring

2. Age

3. Associated Refractive Error

4. Uncorrected and Best-corrected visual acuity

5. Patient’s Expectations

6. Cost of Surgery

7. Availability of management tools

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Decision Making

All ophthalmologists are faced with keratoconus patients

who are seeking a solution for their eye problem.

The ophthalmologist has to look up a number of patient

factors and then come up with one or two options to discuss

with the patient.

There is still some controversy between ophthalmologists

about the limits of each treatment options

Keratoconus Management Parameters

Glasses

• Can be beneficial in early cases

• Quality of vision is much less than RGPs

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Rigid Contact lenses

• Indications:

• Mild and moderate cases of Keratoconus

• Absent or minimal apical scarring


Corneal Cross Linking (CXL)

Indications

1. Progressive Keratoconus :

* Increase in K-max of 1.00D or more in 1 year

* Deterioration of BSCVA

* Change of RGP parameters more than once in 2 years

2. Clear non-scarred cornea

3. Corneal thickness of at least 400 µ at its thinnest point

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Intracorneal Ring Segments (ICRS)

Indications:

– Central clear cornea

– Uncorrected VA ≥ 20/200

– Intolerance to RGP

– K’s between 45 and 60

– Pachymetry at least 350µ at thinnest part and at least 450µ at incision site


PRK + CXL These two procedures can be performed

• Sequentially, i.e., CxL followed by PRK (after 6 – 12 months) or

• Simultaneously, i.e., PRK followed by CxL In the same day.

– Indications

• Early Keratoconus, i.e., K around 50 D

• Clear central cornea

• Low refractive error

• Thinnest corneal location > 450 µ

• Patient’s desire to get rid of glasses and contact lenses

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Deep anterior lamellar keratoplasty (DALK)

– Indications

• 1) Clear cornea or minimal scarring

• 2) K-max > 65 D

• 3) Thinnest corneal location < 350 µ

• 4) Intolerance to or refusal of RGPs


• Penetrating Keratoplasty

• Indications: advanced, scarred keratoconus

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Systematic Approach

Factor Patient Parameter Treatment Option

Age

Corneal Transparency

K-max

Refractive Error

BSCVA

Thinnest corneal location

RGP Tolerance

Suggest Treatment

Case Presentation

• Case 1

A 26 years old female was recently

diagnosed with bilateral keratoconus.

Her manifest refraction was

Sphere Cylinder Axis UCVA BSCVA

OD +1.00 -5.00 40 0.2 0.6

OS 0.00 -5.00 125 0.2 0.6

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Case Presentation • Case 1

Patient Counseling:

The patient was concerned about the deterioration of the

condition and was content with her glasses.

She also welcomed the idea of having rigid gas permeable

contact lenses.

The findings of her left eye will be demonstrated as both eyes

are more or less similar.

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Case Presentation

Factor Patient Data Treatment options

Age 26 yrs CXL

Corneal Transparency Clear All options are possible

K-max 50.2 D All options are possible

Refractive error (SE) -2.5 D CXL + glasses or RGP, or

ICR + CXL or PRK & CXL

BSCVA 0.6 CXL + glasses or RGP, or


Corneal thickness at

thinnest location

460 CXL + glasses or RGP, or


CL tolerance Not tested

Treatment Decision CXL + glasses or RGP after patient counseling

• Case 1

The patient had CXL performed for both eyes.

The difference map of her left eye 3 months

postoperatively is shown here.

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Corneal Cross Linking (CXL)

1. Thickness: does it really matters?

2. Transepithelial CxL: does it really work as the original procedure?

3. Manipulating the parameters (e.g., the duration of UVA exposure, the

concentration of the riboflavin): does it make a difference?

4. Combinations: with RGP lenses, with ICRs (before and after), with ICLs or

PIOLs

5. Effects (on refraction, corneal thickness, keratometry, and BSCVA)

6. Complications (persistent haze, loss of BSCVA)

7. Duration of action

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Mohamed El Kateb, MD Lecturer at the Department of Ophthalmology Faculty of Medicine – Alexandria University Alexandria - Egypt

Case Presentation


OD 0.00 -1.00 15 0.9 1.0

OS -1.00 -4.50 160 0.3 0.7

• Case 2 A 19 years old female presented seeking vision

correction in the left eye. She had bilateral CXL one year ago. Her manifest refraction and BSCVA were as follows:

http://en.wikipedia.org/wiki/File:Alexandria_panorama.jpg

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Case Presentation

Factor Patient Data Treatment Options

Age 19 years CXL

Corneal Transparency Clear Glasses, RGP, ICR, PRK

K-max 54.1 D Glasses, RGP, ICR

Refractive Error (SE) -3.00 d Glasses, RGP, ICR

BSCVA 0.7 Glasses, RGP, ICR

Corneal thinnest location

397 µ Glasses, RGP, ICR, or DALK

RGP tolerance Not tested

Suggest Treatment Glasses, RGP, or ICR. PRK is not recommended because of the thickness of the cornea

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The patient opted to have ICR implantation. She had Kera rings implantation using femtosecond laser to form the intracorneal tunnels. Her postoperative Pentacam (difference map of the sagittal curvature) and refractive and visual outcome are presented below.

Sphere Cylinder Axis UCVA BCVA

Left eye 0.00 -1.50 30 0.7 0.8

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Intracorneal Ring Segments (ICRs)

Important tips

1. Mechanism of Action 2. Indications (good candidates with the best results) &

contraindications 3. Types 4. Surgical Planning:

Segment Selection: number, thickness, length, & position 5. Femtosecond Tunnels vs Mechanical tunnels 6. Results: Are they affected by the shape of the cone, the

location of the cone, the thinnest location, the concomitant refractive error, or the best corrected visual acuity?

7. Combination with CXL Timing: same day or later (when) Is it really necessary? Any study comparing ICR with and without CXL?

• Ahmed El Masri, MD Professor at the Department of Ophthalmology

Faculty of Medicine – Alexandria University Egypt

http://en.wikipedia.org/wiki/File:The_Roman_Theatre_in_Alexandria.JPG

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Case Presentation

• Case 3 A 36 years old female presented complaining of poor vision in her right eye. The right cornea demonstrated a faint central superficial opacity. The left eye had CXL 2 years ago. The pentacam and ocular data of her right eye are presented below.


Right Eye -7.00 -8.00 155 CF at 2 meters

0.1

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Factor Patient Data Suggested Treatment

Age 36 years No need for cross

linking

Corneal Transparency Faint central opacity RGP or DALK or PKP

K-max 72.7 D RGP or DALK or PKP

Refractive error (SE) -11.00 RGP or DALK or PKP

BSCVA 0.1 RGP or DALK or PKP


thinnest location

351 µ RGP or DALK or PKP

CL tolerance Intolerant DALK or PKP

Suggested treatment DALK is the best solution for such a patient


A female patient 23 years of age came asking for vision correction in her right eye. She had corneal cross linking for both eyes 10 months ago. Pentacam and ocular data of her right eye were as follows


OD - 9.50 - 4.00 45 CF 2

meters

0.6

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Factor Patient Data Suggested Treatment

Age 23 years CXL was done 10 ms ago

Corneal Transparency Clear All options are possible

K-max 54.3 D All options are possible

Refractive error (SE) -11.50 Glasses, RGP, PIOL

BSCVA 0.5 Glasses or RGP or PIOL


thinnest location

432 µ Glasses or RGP or PIOL

CL tolerance Patient refuses RGP Glasses or PIOL

Suggested treatment PIOL is the best solution for such a patient

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Phakic IOLs Important Tips

1. Indications: How to select a patient for PIOL? Range of error, degree of keratoconus, shape of the cone, stability of the condition, etc

2. Toric ICLs: How to calculate the astigmatic error and axis in a keratoconic eye? How to implant and align the lens axis with the astigmatic corneal axis?

3. Results?

Mohamed Shafik, MD Professor at Department of Ophthalmology Faculty of Medicine – Alexandria University Alexandria - Egypt

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A 30 years old male presented asking for refractive surgery for both eyes. His ocular findings and pentacam photos are presented below.


OD -1.00 -2.00 75 0.1 1.0

OS -2.50 -1.75 165 0.05 0.8

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Factor Patient Data Suggested Treatment Age 30 years CXL may be needed

Corneal Transparency Clear (OU) All surgical options are

possible

K-max OD: 45.5 D

OS: 51.1 D

All surgical options are

possible

Refractive error (SE) OD: -2.00 D

OS: -3.37 D

ICR or PRK + CXL

BSCVA 0.5 ICR or PRK + CXL


thinnest location

432 µ ICR or PRK + CXL

CL tolerance Patient refuses RGP ICR or PRK + CXL

Suggested treatment ICR + CXL or PRK + CXL

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• Case 5

The patient had bilateral PRK followed

by CXL simultaneously. Two months

postoperative results are listed below:

Sphere Cylinder Axis UCVA BCVA

OD 0.00 - 0.50 50 1.0 1.2

OS 0.00 - 0.75 170 0.8 0.9

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Thank You

decision making in keratoconus -...

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