Himanshu Matalia, MD
Ashwini Ranganath, MD
N Raghu, MD
Rohit Shetty, MD
Cornea & Refractive Services, Narayana NethralayaSuper Specialty Eye Hospital & Post Graduate Institute of OphthalmologyBangalore - INDIA
Authors have no financial interest Poster 605
Early results of mushroom shaped Intralase Enabled Keratoplasty (Mushroom-IEK) for
advanced keratoconus
Introduction • Traditional penetrating keratoplasty (PKP) for
keratoconus : Requires a small size graft to avoid disturbing normal endothelium but the smaller graft has higher risk of suture induced and unpredictable astigmatism leading to prolonged visual rehabilitation time.
1
• Mushroom graft− Ideal shape for PKP in keratoconic eyes.Post. diameter smaller (7 mm) taking less endotheliumAnt. diameter larger (9 mm) placing sutures away from the visual
axis.Technically difficult2
1. Lucio Baratto, Elisabetta Bohm. The use of femtosecond laser in penetrating keratoplasty. Am J Ophthalmol 2007;143:737-742
2. Busin M, Arffa RC. Microkeratome-assisted mushroom keratoplasty with minimal endothelial replacement. Am J Ophthalmol 2005;140:138 –140
Femtosecon laser enable keratoplasty
• The advent of femtosecond laser has provided more finite control and precision in corneal surgery with minimal collateral damage. 3,4
• IntralaseTM (Abbott Medical Optics, Santa Ana, California, USA) has enabled us to dissect cornea with great precision in various shapes like mushroom shape, top hat, zig-zag etc.1
• We present here the largest series of Mushroom-Intralase Enabled Keratoplasty (Mushroom-IEK)
1. Lucio Baratto, Elisabetta Bohm. The use of femtosecond laser in penetrating keratoplasty. Am J Ophthalmol 2007;143:737-
742
3. Yong M Por, Jacob Y Chuan Cheng, Anand Parthasarathy, Jodhbir S Mehta, Donald T H Tan. Outcomes of Femtosecond
Laser assisted penetrating keratoplasty. Am J Ophthalmol 2008;145:772-774
4. Louis Hoffart, Helene Proust, Frederic Matonti, Bernard Ridings, John Conrath. Short term results of penetrating keratoplasty performed
with the Femtec Femtosecond Laser. Am J Ophthalmol 2008;146:50-55
Purpose
To evaluate the efficacy of mushroom shaped Intralase Enabled Keratoplasty (Mushroom-IEK) for patients with advanced keratoconus
Methods Prospective, non-randomized interventional case series22 eyes of 22 consecutive patient (9:13, M:F) with advanced keratoconus
underwent Mushroom-IEK from October 2008-October 2009. Inclusion criteria: Mushroom-IEK with min. follow-up of 6 monthsPrimary outcome measures: Preop & postop 1, 3, 6 months
Uncorrected visual acuity (UCVA)Best corrected visual acuity (BCVA)Keratometry (K): using Pentacam
Secondary outcome measures: Time taken to achieve stable BCVAChange in the endothelial count: Preop & postop 6 months (clinical
confocal microscopy)
Methods - Operative Technique
IntraLase FS Laser60-kHz femtosecond laser
Mushroom graft for K’conusPreserves most host endotheliumSutures in periphery→less suture induced astigmatism
Graft size = Host size (no size disparity)Commonly use size:
Anterior diameter: 8.5 mmPosterior diameter: 7 mm
Modified suturing techniqueSutures superficial (up to anterior lamellae only)
8.5 mm
7.5 mm
Methods – statistical test
The statistical analysis was carried out using SPSS (SPSS Inc., Chicago, IL, version 15.0 for Windows).
All quantitative variables were estimated using measures of central location (mean, median) and measures of dispersion (standard deviation and standard error).
Normality of the data was checked For normally distributed data, means of preop and postop (1,3, 6
months) were compared using one-way ANOVA (analysis of variance).
For skewed data post hoc tests were performAll statistical tests were two-sided and performed at the significance
level of α=0.05.
Results - Visual Acuity
Pre op CF
1st month 20/60
3rd month 20/60 – 20/40
6th month 20/40
Pre op 20/200
1st month 20/40
3rd month 20/40 – 20/30
6th month 20/30
p= 0.001 p= 0.001
• No statistically significant change between postop groups• Preop v/s postop 6 months: p= 0.001
Results - Astigmatism
62.9
46.543.6 45.5
40
45
50
55
60
65
Preop 1 month 3 month 6 month
Keratometry
Avg. K
• Keratometric astigmatism
− Measured on Pentacam
– Statistically significant change between
preop and postop (p=0.001)
– No statistically significant change in
avg. K & keratometric astigmatism
from 1 to 6 months
– Suggestive of early topographic
stabilization of the cornea
8.56
4.783.85 3.22
0
2
4
6
8
10
preop 1 month 3 month 6 month
Keratometric Astigmatism
Astigmatism (± D)
Results - Refractive outcome
No statistically significant change in refraction from 1 month to 6 months
Suggestive of early visual rehabilitation
Correlates to early topographic stabilization by postop 1 month
UCVA: CF ½ m
BCVA: -6DS/-12DC X 10 20/60
UCVA: 6/9BCVA: ± /-2.5 DC X 70 20/25
ResultsEndothelial density: (on confocal microscope)
Preoperative: 2840 / mm2
Postop 3 months: 2330 / mm2
Postop 6 months: 2225 / mm2
Complications:One patient had acute endothelial rejection at 3
months postop, successfully treated but developed raised intraocular pressure (IOP controlled on medication) due to steroid response.
18% reduction by first 3 months
Conclusions
Early results showed that Mushroom-IEK for advanced keratoconus is, • Safe & effective technique• Provides early visual rehabilitation &• Faster topographic stabilization