optik vetenskap 9 14

VETENSKAP # 9/2014 www.optikbranschen.se

I höstmörkret behövs ljusglimtar

I detta nummer finns det två fallbeskrivningar som är gjorda under masterutbildningen vid Salus University. De finns också i sin helhet på Optik-branschens hemsida. Båda ger kunskap och in-

blick på nya situationer som tack vare att utvecklingen går framåt numera finns i vår kliniska vardag. Nya tek-niker och behandlingar kan resultera i att vi i vårt ar-bete med refraktioner och andra undersökningar kan få justera tillvägagångssättet lite.

Det första fallet handlar om Crosslinking-behand-ling vid keratokonus. Patienten följs från diagnos och behandling till undersökningar efteråt och resultaten av dessa.

Den andra är en patient med cataract och en ReSto-re multifocal IOL. Här beskrivs även refraktioneringen som efter operationen fick varieras något.

De båda fallen visar hur vanliga undersökningar som refraktion och topografimätningar inte alltid stämmer enligt förväntningarna när olika behandlingar har ut-förts. Att dessa möjligheter finns idag är en positiv ut-veckling och i dessa fall blev behandlingen omgående. Samtidigt måste vi vara medvetna om vår egen re-gions riktlinjer, det skiljer mycket mellan olika lands-ting när behandlingar utförs. För en bra vårdkedja ska vi vara uppdaterade på riktlinjerna som finns i våra närliggande områden, de ändras från år till år.

Min förhoppning är att denna del av tidningen ger en

bra uppdatering på utvecklingen och nya forsknings-resultat inom vårt yrkesområde. Tyvärr så är intresset svalt från de svenska utbildningarna och studenterna att delge branschen sina arbeten och resultat.

Arbetena från LNU ges tillgång till först när LNU själva har lagt ut dem på nätet. I år är detta flera må-nader försenat trots att arbetena är klara och de fö-reslagna tillvägagångssätt för att branschen ska få ta del av de möjliga arbetena har ännu inte besvarats.

KI låter studenterna själva skicka in sina arbeten hit. Kanske beror det låga antalet inskickade arbeten på att studenterna inte läser Optik så frekvent och att det inte ses som naturligt att de ska publiceras här. Tack till er från KI som har skickat era arbeten, men många saknas, mailadressen dit ni skickar dem finns här på sidan. Master och magisterarbeten är ett lyft då dessa ofta är från vår dagliga verksamhet på lite högre nivå.

Ett annat bra sätt att förgylla sitt arbete på är att hela tiden utvecklas, på Optikerförbundets hemsida finns de SOFEP kurser som nu erbjuds, där finns ock-så frågorna som är kopplade till dessa två fall. En ny kurs startar under hösten som ges på distans med ett fysiskt möte under våren. Passa på att utvecklas i ditt yrkesområde så ser du ljusglimtar i höstmörkret.

CATARINA ERICSON

Catarina Ericson är OPTIK:s vetenskapsredaktör. Hon är MSc i Klinisk Optometri och Leg Optiker.

e-post:[email protected]

n Artikel 1: Cross-Linking på patient med Keratoconus

n Artikel 2: Cataract surgery with Restor multifocal IOL

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n OPTIK VETENSKAP # 9-20142

Information about the patient

Initials MSAge 18Gender MaleRase CaucasianOccupation StudentDrivers licence BDate of exam December 20, 2011

HISTORYMS, an 18 year old male, came for an examination because he thought that his vision, especially at distance, had de-creased. He had worn spectacles since he was 13 years old.

His current glasses were 2 years old. Two years ago he also tried soft contact lenses for sport activities. He had difficulties with the insert and was not comfortable with them at all. So he continued only with glasses.

His latest eye examination was in March 31, 2010. He thought that the decreased vision had been for the la-

test six months. He had not experienced any headache or pain in his eyes. No itching or tearing as well.

Neither could he recall to have had any floaters, flashes or diplopia.

He had never had any infections, injuries, eye diseases or surgeries in his eyes. He had been to an ophthalmo-logist in February 16, 2009. He was referred to the opht-halmologist because at his first examination in our clinic, his fully corrected VA (Visual Acuity) in RE (Right Eye) was 20/25.

The ophthalmologists answer was that there was a slight amblyopia in his right eye. All medias and fundus were OK.

He was in good health with no diseases or allergies. He did not use any medications. There were no diseases like hypertension, cardiovascular disorders, diabetes or cancer in his family.

He was exercising three to four times a week, playing floorball.

His mother was myopic RE -7,0 and LE (Left Eye) -7,5, but went for a Lasek surgery for about 8 years ago.

In his family there was his mother´s grandmother who had had glaucoma.

He did not smoke and did not use any alcohol or drugs. He had his last physical exam in school, a couple of years

ago. MS had been wearing glasses since 2006.When he first was examined at our clinic, in February 3,

2009, his K-readings were:Right Eye: 7,03 / 7,73 x 15° K-cyl -4,347 Left Eye: 7,55 / 7,71 x 118° K-cyl -0,928

Then in March 31, 2010 his K-readings were: Right Eye: 6,84 / 7,68 x15° K-cyl -5,397Left Eye: 7,46 / 7,70 x 160° K-cyl -1,410 K-readings from TopCon autorefractor.

OBJECTIVE FINDINGSAt the examination MS wore his current glasses since Fe-bruary 3, 2009.

Table 1 shows the VAs and refraction in RE and LE.Table 1 VAs and refractionHis current spectacle Rx RE sf -1,25 cyl -3,75 ax 34° VA 20/60LE sf -1,50 cyl -0,75 ax 115° VA 20/40 Bino 20/40

UnCorrected VA (UCVA) RE 20/70 LE 20/100 Bino 20/70New Rx RE sf -0,75 cyl -4,75 ax 48° VA 20/30 -2LE sf +0,75 cyl -3,0 ax 95° VA 20/25-1 Bino 20/25There was no improvement with pinhole.

Cross-Linking på patient med Keratoconus

Redaktörens kommentar:

För att få ut det mesta bör allt läsas från början. De olika differential behand-lingarna och undersökningarna efter behandlingen mycket läsvärda.

Författare:

JEANETTE

BRANDT ,

SALUS

UNIVERSITY

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Table 2 shows the initial procedures. They were all per-formed with his current prescription, apart from confron-tation fields and motility, which was performed unaided.

Initial proceduresCover test Dist: Orthophoria Near: 3 exophoria

NPC TTN

Amplitude of RE: 10D Accommodation LE: 10D Bino: 10D

Stereopsis, Titmus Fly Stereotest 60”

Ocular motility Full and smooth in all directions, no pain or diplopia

Pupils 4/6 +4 Pupils were both round and had the same size PERRLA They equally reacted to light and ackommodation, RAPD- 4/6 +4

Hirschberg Symmetric

Confrontation fields RE: Full by PFC, CFC, HC and SFCLE: Full by PFC, CFC, HC and SFC

Colour visionRE: 15/15LE: 15/15

Anterior segment examinationSlit lamp examination showed a quiet bulbar and palpebral conjunctiva in both eyes. Lids and lashes appeared clean

and healthy and there were no signs of meibomian glands disorders or blepharitis.

The corneae had a diameter of 11,50 cm.Both corneae had a relative large cylinder with the rule.

The cornea in his right eye had a central thinning, a little bit temporally and there were striae in the center. The left eye showed a slight thinning near the center too and some striae could also be seen nasally, next to the center. Both eyes had a healthy-looking endothelium.

The keratometry readings were:RE 6,41 / 7,39 x 16° K-cylinder -6,982 x 16°LE 6,53 / 7,33 x 168° K-cylinder -5,641 x 168°

Anterior chambers were clear without any cells or fla-res. The anterior chamber angels were open and graded by van Herrick´s method to grade 4. The iridis were blue and had no nodules or transillumination.

The crystalline lenses and vitreous were clear.

Posterior segment examinationFundus examination was performed without dilation of the pupil with a slit-lamp ophthalmoscopy.

Fundus in both eyes appeared healthy with a pink, heal-thy and distinct optic disc. The cup-to-disc ratio was esti-mated to 0,3/0,3 in right and left eye.

The A/V-ratio was 2/3 in both eyes and no HR or AS.Macula reflex was present in both eyes and the maculae

looked normal, flat and dry.

Other relevant examinationsThe intraocular pressure was measured with a non-con-tact tonometer (Topcon CT-80) at 2 pm, and it was 9 mmHg in RE and 10 mmHg in LE.

Unfortunately no photos could be taken at the slitlamp.Pachometer would also have been relevant, but there is

no at our clinic.

AssessmentA1: Myopia in both eyes with astigmatism


A2: An astigmatism in both eyes that has increased since last visitA3: K-readings and topography pictures showing keratoconus in both eyes

Plan / ManagementP1: New glasses or contact lenses is necessary later onP2/P3: Referring to the Ophthalmologist with an inquiry of Cross-linking, to stabilize his probable keratoconus

Advice given to the patient - Avoid rubbing his eyes, due to the thinning of his cornea- The need of protecting his eyes in different situations, in-cluding floorball.

Report from the ophthalmologistMS came to an ophthalmologist in January 12, 2012, at the Eye-clinic Ryhov, County hospital in Jönköping.

He found that the right eye had a clinical picture of ke-ratoconus. There was a paracentral thinning of the cornea, temporally and there were also found striae around the op-tic axis.

The left eye had the same findings but less.So the diagnoses of both eyes were keratoconus.

An Orbscan was done and showed:RE: Astigmatism -6,6 x 26° - K max 51,7 D - thinnest

part of cornea 516umLE: Astigmatism -5,3 x 177° - K max 50,9 D – thinnest

part of cornea 531 um

A Cross-link was done that day in his right eye, and he was sent home with Oftaquix x 4 (antibacterial).

The report from the ophthalmologist also said that a cross-link will be planned in left eye too, in a near future and that the patient will take contact himself if earlier is necessary.Follow upFollow up was made at the hospital four days after the cross-linking, i.e. January 16, 2012.

The patient had no pain, just a feeling of scratching.The epithelium at the cornea in right eye was not fully

recovered but there were no infiltrates. Anterior chamber was normal and fundus showed a red, normal reflex.

The patient continued with Oftaquix x 4 and also Visco-tears (lubricants).

Next visit at the eye-clinic was in January 19, 2012.MS did not have any inconvenience now.The epithelium was now fully recovered and there were

no infiltrates. He was sent home with Oftaquix for a couple of more

days, but also Opnol x3 (corticosteroid)

Then he came back to the eye-clinic in February 6, 2012.Cornea was clear with no scars.An Orbscan was made:

RE Astigmatism -7,8 x 20° - K max 54,8 – thinnest part of cornea 332 um

LE Astigmatism -5,9 x 172° - K max 51,8 – thinnest part of cornea 539 um

They thought that right eye was stable and he was told to quit the Opnol.

LE showed no progress at the time, and therefore they decided to await the course of event.

MS was now booked to the optometrist at the hospital in three months.

In May 11, 2012 he had an appointment with the Hospital Optometrist at the eye-clinic. A contact lens on right eye was not relevant just now, since MS got a good VA with his left eye and was satisfied with that. So he got a prescription for left eye, so he could change that lens in his spectacles. As soon as the keratoconus starts to progress in his left eye, a Cross-link will be done. He was also told to come back to the optometrist at the eye-clinic in 3 months, and hopefully then, the right eye would be stabilized so a prescription could be done for contact lenses or new spectacles.

MS then came to our clinic in May 25, 2012. The keratometry readings were:RE 6,32 / 7,37 x 19° K-cylinder -7,608 x 19°LE 6,52 / 7,37 x 172° K-cylinder -5.970 x 172°

New topographics were taken with the TopCon autore-fractor, (Figure 2).

A new refraction was made:UCVA RE 20/60-1 LE 20/60

Bino 20/50

VA with his current Rx RE: sf -1,25 cyl -3,75 ax 34° VA 20/60 LE: sf -1,50 cyl -0,75 ax 115° VA 20/40 Bino 20/40

New RX RE: sf -0,50 cyl -1,0 ax 60° VA 20/40LE: sf -1,0 cyl -3,50 ax 123° VA 20/25 Bino 20/25

IOL was measured and was 9 mmHg in both eyes.The slitlamp examination in the right eye showed a clear

cornea with no scars from the cross-link. Still there was a paracentral thinning. Anterior chamber was clear without any cells or flare. The anterior chamber angels were open and the crystalline lens and the vitreous were clear.

Left eye looked the same as at the first examination, De-cember 20, 2011.

MS was now given new spectacles with the new Rx. Although he knew that the Rx will change he was in need of new spectacles. One reason was that he must have a visual acuity of 20/40 to be able to drive his car, and with new spectacles his VA goes from 20/40 with current glasses till 20/25 with new glasses.

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DISCUSSION KeratoconusKeratoconus is a non-inflammatory progressive disorder in which the cornea assumes a conical shape secondary to stromal thinning and protrusion1 (maximal thinning near the apex of the protrusion).

Keratoconus is usually bilateral but often asymmetric 2. The onset is around puberty with slow progression

thereafter until the third or fourth decades of life, when it usually will arrest, although the ectasia can become stationary at any time 4.

The mean age of onset is at 16 years old 7.It rarely develops after the age of 30 7. Family history of keratoconus is a risk factor, but off-

spring appear to be affected in only about 10 % of cases 4.

SymptomsPresentation is typically during puberty with unilateral im-pairment of vision due to progressive myopia and astigma-tism, which subsequently become irregular.

The patient may report frequent changes in spectacle prescription or decreased tolerance to contact lens wear.

As a result of the asymmetrical nature of the condition, the follow eye usually has normal vision with negligible as-tigmatism at presentation.

Approximately 50% of normal fellow eyes will progress to keratoconus within 16 years: the greatest risk is within the first six years of onset 4.

Acute corneal hydrops can cause a sudden decrease in vision. It will also give pain, red eye, photophobia and pro-fuse tearing. Acute hydrops is caused by a rupture in De-scemet membrane that allows an influx of aqueous into the cornea. This causes a sudden drop in visual acuity as-sociated with discomfort and watering 4.

Clinical picture The hallmark of keratoconus is a central or paracentral st-romal thinning, to as little as one-third of normal thickness and an apical protrusion and irregular astigmatism. This leads to a reduction in VA 4.

The astigmatism can be graded by keratometry accor-ding to severity as 7:

* Mild < 45 D in both meridians* Moderate 45 -52 D in both meridians* Advanced >52 D in both meridians* Severe > 62 D in both meridians These grading scales may alter in different litteratures.The classification of keratoconus can also be based on

the shape of the cone 7: The cone can be nipple (small diameter), oval (large dia-

meter, often displaced inferiorly) or globus (largest diame-ter, 75% of cornea affected)

Other signs to be seen are:• An “oil droplet” reflex, which shows with direct opht-

halmoscopy from a distance of one foot• Vogt striae, i.e. fine, vertical, deep lines in the posterior

cornea, in stroma (the striae disappear with external pres-sure on the globe). In corneal edema the striae is vertical,

but in keratoconus the striae can go in all directions 7

• Scissor reflex, an irregular corneal retinoscopic reflex• Egg-shaped mires on keratometry• Inferior steepening is seen on corneal topographic

evaluation• Fleischer ring, which is epithelial iron deposits at the

base of the cone (best seen with a cobolt blue filter)• Munson sign, i.e. bulging of the lower eyelid when loo-

king downward• Superficial corneal scarring• Might also be corneal hydrop, a sudden development of

corneal edema and that results from a rupture in • Descemets membrane These signs and symptoms happen in different stages

of keratoconus

Systemic associations There are several systemic disorders that are associated with keratonus. Below the most common are mentioned2.

• Down syndrome• Atopic disease, which includes atopic dermatitis, aller-

gic rhinitis, and asthma• Turner syndrome, a female condition with the genotype

XO, where O means the lack of one sex chromosome• Mitral valve prolapse, the most common heart valve

abnormality 10 • Marfan syndrome, a genetic disorder of the connec-

tive tissue. They tend to be tall with long limbs and long, thin fingers

• Ehlers-Danlos syndrome, is a group of inherited con-nective tissue disorders. They may have hyper-flexible joints and stretchy skin 4

• Osteogenesis imperfecta 4.These people break their bones easily, have low muscle mass and joint and ligament laxity

• Mental retardation 4

Ocular associations The most common ocular associations with keratoconus are 4:

• Vernal keratoconjunctivitis, i.e. a an allergic eye di-sease

• Blue sclera, i.e. a congenital thinning of the sclera, where the underlying epithelium shows through, giving a blue appearance.

• Aniridia which is absence of the iris.• Ectopia lentis, which is a displacement of the lens from

its normal position.• Leber congenital amaurosis. A group of inherited reti-

nal dystrophies representing the commonest genetic cau-se of visual impairment in infants and children.

• Retinitis pigmentosa, which defines a clinically and a genetically diverse group of diffuse retinal dystrophies, ini-tially predominantly affecting the rod photoreceptor cells with subsequent degeneration of cones.

• Persistent eye rubbing


Follow-upIn Keratoconus you follow up every 3 to 12 months, depen-ding on the progression of symptoms.

The corneal topography shows irregular astigmatism and is the most sensitive method of detecting early kerato-conus and in monitoring progression.

After an episode of hydrops, you examine the patient every 1 to 4 weeks until it is resolved.

Differential diagnoses When diagnosing keratoconus there are some differential diagnoses that has to be excluded, and they will be descri-bed here. PMD, Pellucid marginal degeneration is a rare, progressive, peripheral corneal thinning disorder typically involving the inferior portion, although rarely the superior cornea may be involved.

Occasionally it may coexist with keratoconus and kera-toglobus.

Like keratoconus, PMD is bilateral, although eyes may be asymmetrically affected.

PMD presents in the fourth to fifth decades.There is a crescent-shaped band of inferior corneal thin-

ning extending from 4 to 8 o´clock, 1 mm from the limbus. The cornea protrudes superior to the band of thinning.

There are flattening in the vertical meridian, which re-sults in severe irregular against-the-rule astigmatism.

Unlike keratoconus, Fleischer rings and Vogt striae do not occur in PMD. Corneal topography map shows a clas-sical “butterfly” pattern.

Like in keratoconus you try spectacles first and then RGP lenses. There are also here surgical options, but none are ideal, because the corneal thinning is peripheral 4.

Keratoglobus is another differential diagnosis to kerato-conus. Here we have a uniform circularly, thinned cornea with maximal thinning in the mid-periphery of the cornea. The cornea protrudes central to the area of maximal thin-ning.

Keratoglobus is rare, congenital (onset at birth) and not progressive. It is possibly related to keratoconus. It may be associated with Leber congentital amaurosis and blue sclera. Acute hydrops occurs less commonly than in either keratoconus or PMD but the cornea is more prone to rup-ture after relatively mild trauma.

Corneal topography shows generalized steepening.There is management with scleral contact lenses becau-

se the results of surgery are very poor 4.Other differential diagnoses are Post-refractive surgery

ectasia and Contact lens-induced corneal warpage 6.Post-refractive surgery ectasia may occur after lamel-

lar refractive surgery, such as LASIK4. LASIK permanently thins and weakens the cornea 3.

The contact lens-induced corneal warpage, is a topo-graphic irregularity due to contact lenses.

Differential treatments of keratoconusFirst of all, the patients are instructed not to rub their eyes, due to their thin cornea.

Then to correct refractive errors there are several ways.In mild cases, spectacles or soft contact lenses will do.

When the astigmatism increases, and the soft contact len-ses do not give a sufficient VA, you try RGP lenses.

There are the ordinary “small ones” in different designs, miniscleral and scleral RGP´s and also hybrid contact len-ses, which have a soft skirt for the comfort and a “breatha-ble” rigid center. Piggy-Back lenses are also an alternative, i.e. a high Dk RGP lens fitted on top of a high Dk soft lens.

If the keratoconus is long progressed with a bad visual acuity, even with glasses and contact lenses, or if contact lenses can not be tolerated, keratoplasty might be done. Also if there is a risk of perforation, keratoplasty is the way to go 7. There are two kinds of keratoplasty.

The Deep Anterior Lamellar Keratoplasty, DLK, (partial thickness corneal transplant/graft), is a full-thickness cor-neal stroma and epithelial button that may be placed into a host bed containing little or no stromal tissue on top of Descemet’s membrane.

Then there is Penetrating Keratoplasty, PK, which is a full thickness corneal transplant/graft.

DLK and PK have similar best-corrected visual acuity and refractive results.

DLK is more technically challenging than PK, but elimi-nates the possibility of endothelial rejection, has minimal effect on the endothelial cell count, and may reduce the risk of late endothelial failure5.

In 15-20% of the keratoconic population, a corneal transplant is required and then 70% of grafts require con-tact lens fitting 7.

Intracorneal ring segments have been successful in get-ting some patients back into contact lenses, especially in mild to moderate keratoconus 4.

An Intra Corneal Ring Segment (ICR) is semicircular PMMA devices, which when implanted into the corneal st-roma, cause an alteration in its curvature and thereby lead to a change in its refractive power. It works on the principle that when volume is added to the corneal periphery or re-moved from the center, it leads to flattening of the central cornea and reducing corneal power 12.

Then in acute corneal drops there are 4:- Hypertonic saline- Patching or a soft bandage contact lens- Glasses or a shield should be worn by patients at risk

for trauma or by those who rub their eyes.Acute corneal hydrops is caused by a rupture in Desce-

mets membrane that allows an influx of aqueous into the cornea. This causes a sudden drop in visual acuity associa-ted with discomfort and watering.

It heals usually within 6-10 weeks, the corneal edema clears, but stromal scarring may develop.

But healing may result in improved visual acuity as a re-sult of scarring and flattening of the cornea.

Acute corneal hydrops is not an indication for emergency corneal transplantation, except in the extremely rare case of corneal perforation, which is first treated medically and sometimes with tissue adhesives.

The edema should be resolved before a Keratoplasty.Then the treatment that is current in this case is Corneal

Collagen Crosslinking, CXLThis is a relative new treatment (was developed in 1998

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by Theo Seiler, MD 13) which can replace corneal trans-plantations.

The word Cross-link means “linking of polymer chains”, that is bonds that link one polymer chain to another.

This method has been developed to prevent the progres-sion of keratoconus.

Earlier corneal transplantation was the only treatment to keratoconus, but a corneal transplantation is often complicated and there is often a lack of donating corneas 1.

But a Cross-link will not be made in a cornea thinner than 400 um 7.

CXL is a relative easy treatment. A LASIK-ring is placed on the cornea, 35% alcohol is ad-

ded and the corneal epithelium can be scraped off. Then they drop riboflavin* under standardized forms on the cor-nea.

After that you put UV-light** to that area. That indu-ce chemical doubleboundings in cornea and this stabili-zes the structure and the shape of the cornea. The ribo-flavin causes new bonds to form across adjacent collagen strands in the stromal layer of the cornea, which recovers and preserves some of the mechanical strength in cornea.

The cornea should be at least 400 um before you start the CXL-treatment.

Very good results have been shown and CXL becomes more common 1.

At an eyeclinics website, they say that you can adjust the surface of the cornea after cross-linking with laser. In hig-her grades of myopia and astigmatism they can also put in an ICL, Intraocular Contact Lens 9.

In some clinics they also want to use CXL in treatment of keratitis.

The combination of riboflavin and UV-light is known to inactivate different kinds of microorganisms, i.e. many kinds of virus, bacterias and parasites, which can cause infections.

Now they have to proof the CXL treatments bacterial kil-ling effect 1.

In Cross-linking Riboflavin and UV-light is used.- *Riboflavin (Vitamin B2) is one of eight B vitamins.All B vitamins help the body to converte food (carbohy-

drates) into fuel, (glucose), which is burned to produce en-ergy. These B vitamins, often referred to as complex vita-mins, also help the body metabolize fat and protein.

B complex vitamins are necessary for healthy skin, hair, eyes and liver. They also help the nervous system function properly.

All the B vitamins are water-soluble, meaning that the body does not store them.

Riboflavin also works as an antioxidant in the body, figh-ting free radicals. Free radicals can damage cells and DNA and contribute to the aging process, as well as the develop-ment of heart disease and cancer.

Vitamin B2, along with other nutrients, is important for normal vision 1.

- **UV light UV-light, short for Ultraviolet light, is a light with a shorter wavelength than visible light, but longer than X-rays. There

is UVA, UVB and UVC.This means electromagnetic waves with a wavelength

between 400 nm and 10nm, with energies from 3 eV( elec-tron volt ) to 124 eV (1 electron volt = 1,60217646 x 10 (-19) joules). In Cross-link UVA is used which has a wavelength of 315-400 nm and has less energy than UVB and UVC.

UV-light is more energetic than visible light, letting it penetrate more readily through obstacles 1.

Discussion of findingsIt was found at the examination that MS best corrected VA had decreased from 20/25 till 20/35 in his right eye and from 20/20 till 20/25 in his left eye, during the latest 18 months. Along with that his astigmatism also had in-creased, especially at his left eye. Corneal topography sho-wed a keratoconus pattern and also the slitlamp evalution at the anterior segments was pointing at keratoconus.

Looking at the other differential diagnoses, none of them were appropriate, due to topographic pictures (PMD and Keratoglobus), age of onset (Keratoglobus and PMD), the progression of the astigmatism, (which not occur in Ke-ratoglobus) and the fact that he had never been wearing contact lenses or had any LASEK or LASIK (Post-refracti-ve surgery ectasia and Contact lens-induced corneal war-page)

A visit to the ophthalmologist was anyhow necessary for evaluation and there was also an inquiry along with the re-ferral letter about cross-linking.

According to the ophthalmologist, MS had keratoconus in both eyes but more marked in his right eye. There was a paracentral thinning temporally and also striae around the optic axis. These findings were also more marked at the right eye. Since MS was such a young patient and came with a progressive keratoconus, the ophthalmologist thought that cross-linking would be appropriate to make the cornea more stable.

At this time his keratoconus was classified as moderate, according to the classification of keratoconus 7.

At MS 4-month check-up after the cross-link, post-cxl, at the hospital, everything looked fine and he was schedu-led for a new check-up in 3 month. They also said that the left eye also will be cross-linked later on.

But at this time his keratoconus in his right eye was clas-sified as advanced and in his left eye still moderate, com-paring to the classification tables we looked at above 7. Also at the follow-up in our clinic in May, 2012, the K-readings showed a greater astigmatism then before, pre-cxl:

December 20, 2011: RE K-cylinder -6,982May 25, 2012: RE K-cylinder -7,608

According to the hospital optometrist 11 at the eye-clinic where MS had his Cross-link, it is not the whole truth, just looking at K-readings, when to judge if the cross-link has went well. That is because when you measure the cornea after cross-link, it might differ up to 8 D from one measu-re-point to another, and it might be in a distance of only 2 mm.


Then looking at the refraction in RE, done in our clinic, be-fore and after also gives strange figures:December 20, 2011: RE: sf -0,75 cyl -4.75 ax 48°May 25, 2012: RE: sf -0,50 cyl -1,0 ax 60°

The explanation for that is also, according to the Eye-clinic, the fact that the cornea has several different curvatures at the moment, and the refraction, as above, is made in one particular area of the cornea.

So in after-care of cross-link you do not pay so much attention to comparing topographics and K-readings, it is more the tendency of the curvature going towards stabili-zing you are interested in. The purpose with cross-link, and that is what you are looking for post-cxl, is that the cornea will not get steeper. If the corneal astigmatism increases afterwards, it is often a sign of edema, during the healing.

So we must be aware of that the cross-link is not a re-fractive method, it is just a way to stable the cornea.

The healing of the cornea after cross-link might take 12-18 months. But the time for visual acuity to stable and be OK might take 3-4 years. The visual acuity will decrease in the beginning after the treatment and then it recovers. They think that the reason for this is that it takes time for the bundles of stromal fibrils, the lamellae, to find its “pat-tern” 1.11. You do not know if that is the whole truth, and more studies are to be done 1. This decrease in VA over a long period does not happen to all, but approximately in < 20% of the cross-linked patients, it might take up to 10 years, to get the visual acuity the best there is to be. That is one of the reasons why they do not make a cross-link if visual acuity is 20/25 or better.

There have also been cases where the opposite has been, where the best VA has changed from 20/60, pre-cxl, till 20/20, post-cxl, in 6 months, according to the hospital optometrist 11.

Then there was a discussion at the eye-clinic of fitting a RGP-lens, later on at MS right eye.

The ones with keratoconus have in fact only one possible way to get their best visual acuity and that is with RGP contact lenses. That also applies for those who have had cross-link or keratoplasty. Since the cornea at a keratoconus patient does not look like a normal cornea, like a half sphere with a relative uniform surface, but instead that they have like steps on that sphere, the only way to make it a good refrective surface is to put a RGP-lens on. After cross-link you can, in principle, use the same contact-lens as before the treatment, because you have only stabled the cornea. Comparing the topographic pictures (bilderna är inte återgivna här/red) in Figure 1 and 2 above, they both almost look the same in RE, before and after the cross-link. It might though get a little flatter and a change in the prescription may be required. Almost always the cornea gets flatter post-cxl and then in most cases it will return to its baseline, pre-cxl, within 18 months. Contact lenses might be fitted 1-2 months after the cross-link 11. MS will go back to the optometrist at the eye-clinic after the summer 2012 and then probably get a contact-lens on his right eye.

After his follow-up at our clinic four month after he had the cross-link, he wanted new glasses. He was aware of the refractive changing that is to come, in both his eyes, but he still wanted the new glasses. The main reason for that was that his binocular visual acuity increased from 20/40 to 20/25 from his old glasses till the new ones. He thought that it made a big visual improvement especially driving his car. For his driving license his best corrected visual acuity must be at least 20/40.

His new spectacles was: RE: sf -0,50 cyl -1,0 ax 60° VA 20/40 LE: sf -1,0 cyl -3,50 ax 123° VA 20/25 Bino 20/25

He could also get contact lenses, but at this time he did not want that. He tried soft contact lenses once, but at that time he did not liked the handling of it. Later on he might consider this, if that would make his visual acuity even bet-ter. The fully-corrected VA then will tell us if only glasses would be an alternative.

MS had his keratoconus without any family history, like in most patients, neither did he have any other of the sys-temic and ocular associations.

CONCLUSIONSince MS had a decreased VA and an increased astigma-tism he was sent to an ophthalmologist.

He had a well marked keratoconus in both his eyes, which seems to have occurred without any systemic or ocular abnormalities. A cross-link was made in his right eye and that will probably cease the progression of kerato-conus. If the astigmatism stabilizes, there will be less risk of a corneal hydrop and hopefully no need for keratoplasty in the future. This will spare his VA and also the effort of going through a transplant surgery with at least one year of rehabilitation.

Left eye will probably be cross-linked later on. He will be followed up continuously at our clinic and the eye clinic.

Then visual acuity tells us if he can continue with only spectacles or if contact lenses will be the only choice. He tried soft contact lenses when he was 16 years old, but did not like it then. Hopefully it will work better now, if his best visual acuity will be improved.

He was educated about his condition and was told to be careful and protect his eyes in sports and other activities.

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REFERENCES

1 University hospital in Örebro, Sweden, http://www.remit-tent.se/sv/Behandlingar/Ogon/Ogonartiklar-Incitament/Crosslink/

2 Justis P. Ehlers and Chirag P. Shah The Wills Eye Manu-al, Fifth Edition

3 Post-LASIK Ectasia Reportetd to the FDA

4 Jack J Kanski, Clinical Ophthalmology, Butterworth, Hei-nemann, Elsevier,Sixth Edition, 2007

5 Medscape Medical News Ophthalmology. 2004;111:1676-1682, Reviewed by Gary D. Vogin, MD

6 Marian S. Macsai / Bruno Machado Fontes - Anterior Segment, Rapid Diagnosis in Ophthalmology, 2008

7 Vibeke Sundling, Handout-Keratoconus at MSc-course 2011-2012, Optometrist MSc, BUC Norway

8 James L. Fanelli OD, FAAO Handout-Corneal Injuries, Ir-ritants and Dystrophies, MSc-course 2011-2012, BUC Nor-way

9 Novius eyeclinic website, specialists at eye surgery in Stockholm, Sweden

10 Website: MedicineNet.com

11 Hospital Optometrist Lars Karlsson, Eye-clinic Ryhov, County Hospital, Jonköping Sweden

12 Dr.Netra Mandir, Borivli, MumbaiSushmita G. Shah Cornea, Anterior Segment & Refractive Surgery Services, Website: www.aios.org/cme/cmeseries15

13 All about vision, website: http://www.allaboutvision.com/conditions/corneal-crosslinking.htm,


A 53 years old, Caucasian female, came with distance and near problems. She was referred to an ophthalmologist for cataract surgery in both eyes. Cataract surgery was performed with Restor multifocal IOL.

AL, female, DOB 08-03-53, working at office 02-05-2007 The patient came to our clinic because she had problems mostly at far distance. She worked in an office and had some computer working and a lot of meetings. Her hobby was art painting. No medications. Cataract was found in both eyes one year ago and her mother had glaucoma. The patient had regular examinations at an ophthalmologist because of heredity for glaucoma. She denied any other diseases and her general health was good. She had com-puter glasses.

Best corrected visual acuity at distance had decreased from 20/20 OD/OS to 20/25 OD/OS in one year. Myopia had increased. Lens opacities, posterior subcapsular, were found in both eyes. No visible pseudoexfoliations. No metamorphopsia with Amsler grid and macula were found normal ou. Fundus exam was made undilated sin-ce optometrists in Sweden currently are not allowed to use ophthalmic drugs. No gonioscopy were made for the same reason. Rims were healthy and non contact tonometry was OD 18mmHg and OS 21mmHg. Distance glasses and cataract surgery were discussed. No glas-ses were made before she had discussed surgery with an ophthalmologist. A private ophthalmologist was con-tacted trough a health insurance at work. Due to her low age for cataract they decided to make a cataract surge-ry with a multifocal IOL lens. Six months later she came back, satisfied with her surgery and distance acuity but had some problems at computer distance. Refraction was not easy due to her IOL:s and final Rx had to be decided in a trial frame. No CME or metamorphopsias

were found and no posterior capsular opacification. Fol-low up in 2 years.

Cataract Cataract is opacifications of different types of the normally clear lens. Senile (age related) cataract is the most common. The different forms are nuclear, cortical and subcapsular which can be posterior or anterior, with posterior more common. The symptoms are visual impair-ment, blurred vision, distorted vision, glare and changes in color perception. It is often a slowly progression that can last for months to years. Before surgery with IOL, history of systemic or ocular diseases, medications and trauma has to be assessed to be sure the cataract is the cause of de-creased vision. CMO following IOL surgery is rare but has to be checked for at the follow ups. It can occur days or weeks after the surgery. Self resolution is most common and usually there is no need for treatment. Other posto-perative complications are endophtalmitis, bullous kerato-pathy, RD, posterior capsular opacification and non-infec-tious uveitis.

ReSTOR multifocal lens The ReSTOR IOL lens uses a pa-tented apodized diffractive technology similar to the tech-nology used in microscopes and telescopes to get better image quality. It makes it possible to focus on both near and distance vision by the means of diffractive optics

References: The wills eye manual, Kunimoto DY et al. fourth edition, pp 322-323 Ophthalmology, Lang GK, se-cond edition, pp 174-183, Clinical Ophtalmology, Kanski JJ, sixth edition, pp 337-339,354-361,650-652 http://www.allaboutvision.com/restor

Eye examination 02-05-2007 at our clinic, initial visitReason for visit Px came because of distance and some near problems. No itching, burning or tearing and no flas-hes/floaters.

Ocular history/family history Rx for computer (in door pro-

Cataract surgerywith Restor multifocal IOL

Redaktörens kommentar:

Som alla fallbeskrivningar är helheten viktig så även här. Den första undersök-ningen visar de olika undersökningsmomenten som bör göras. Även under-sökningen efter operationen för arbetsglasögon bör läsas .

FÖRFATTARE: GIT GRÖNVALL, SALUSUNIVERSITY

.

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gressives): OD: -0,25 -0,25 ax 15 add 2,25 OS: plano-1,00 ax 145 add 2,25 No injuries or surgery. Cataract confir-med 1 year ago ou. Mother has glaucoma. No heredity for ARMD. Last date of eye exam: 05-11-2006 Optometrist Git Grönvall BCVA 20/20 ou

General health history and status/family history No allergy. No other diseases and felt healthy. Drives and no smoker. No heredity for HTN, DM or CVA.

Medications No meds

Covertest/Motility/Pupils/Confrontation Fields/Color vi-sion/ Amsler Grid Cover T: without Rx ortho/ortho Ver-sions: FROM PERRLA No RAPD Confrontation Fields: FTFC ou Color vision Ishihara: OD 13/13 OS 13/13 Red Cap: No desaturation Amsler Grid: No metamorphopsia/scotoma

Visual field test FDT screening Not performed

Visual acuity distance, unaided OD 20/30 OS 20/30

Subjective refraction OD +0,25 -0,50 180 VA 20/25 Near add (40cm) +2,25 VA 20/25 OS -0.75 VA 20/25 Near add (40cm) +2,25 VA 20/25

Keratometry OD 7,28/7,41 ax 7 cyl -0,81 ax 7 OS 7,27/7,45 ax 2 cyl -1,12 ax 2

Phoria Rx aided 6 m 1 eso/ ortho 40 cm 5 exo

Amp. Accommodation Push up OD 2 D OS 2 D OU 2 D

Tonometry, Non contact Time 2:05 pm OD 18mmHg OS 21 mmHg

Ocular health examination: SLE/ SL Ophtalmoscopy 78 dptr lens undilated Lids and cornea were normal. No irist-ransillumination ou. No visible pseudoexfoliations. Lens opacities due to posterior subcapsular cataract ou, not graded. Anterior chamber deep and quite with V-H 4 ou. Vitreous clear ou. No arteriosclerosis . HR grade 0 ou. A/V ratio 2/3 ou. Neuro-retinal rim healthy ou. C/D ratios 0,4/0,4 OD 0,4/0,3 OS . Macula normal ou. No gonioscopy and no fundus photos were taken. Assessment and Plan A1 Posterior subcapsular cataract ou P1 Cataract surgery is discussed and Px should contact ophthalmologist after checking her health insurance at her company first. F/U by telephone as soon as she knows. If she needs referral she let me know.

A2 Hyperopia, astigmatism and presbyopia. P2 Distance glasses are recommended but wait until cataract surge-ry has been discussed with ophthalmologist. F/U by telep-hone.

A3 Heredity for glaucoma P3 Px educated. Continue with regular exams at her ophthalmologist.

Telephone contact 02-06-2007 She has insurance at her company and their ophthalmologist is going to be contac-ted.

Eye exam at ophthalmologist 02-07-2007 Dr. Nils Molander Capio Medocular,Malmö OD Keratometry : 45,86 46,49 ax

89 GAT 18mmHg Axial length 22,37 OS Keratometry : 45,3 45,73 ax 109 GAT 18 mmHg Axial length 22,32 Sub-capsular cataract oa Date of surgery is decided

Cataract surgery 03-13-2007 Dr. Nils Molander Restore multifocal lenses OD +21,5 dptr OS +22,0 dptr

F/U cataract surgery 03-22-2007 and 04-10-2007 Dr Inge-mar Håkansson Visual acuity uncorrected: OD 20/20 OS 15/20 OD and OS: Cornea clear, conjunctiva bulbar some hyperemia, IOL clear, fundus normal. Some photophobia

Eye examination 11-20-2007 at our clinic

Reason for visit IOL 03-13-2007 with Restor multifocal len-ses ou. She has some near and middle distance problems. Far distance is good.

Visual acuity distance, unaided OD 20/25 OS 20/25

Subjective refraction OD +0,25 -0,50 165 VA 20/20 Near add (40cm) +2,25 VA 20/20 OS +0.25-0,50 160 VA 20/20 Near add (40cm) +2,25 VA 20/20 Final Rx for best acuity at 45-65 cm distance made in a trial frame OD -0.50-0.50 ax 165 OS -0.50-0.50 ax 160

Tonometry Not performed

Amsler Chart No metamorphopsia/scotoma

Ocular health examination: SLE/ SL Ophtalmoscopy 78 dptr lens undilated Lids, cornea and iris were normal. No posterior capsular opacification. Vitreous clear ou. Neuro-retinal rim healthy ou. No CME. No fundusphotos were ta-ken.

A1 Myopia and astigmatism at computer distance P2 Rx for computer and near distance. Px educated. F/U in 2 years

optik vetenskap 9 14

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