apostila-refrativa-rio-ingles-final-pdf-revisado.pdf

CLINICAL CASE 1
Cone Type:
Witch Ring to Implant:
STEP 1: TYPE OF CONE
Refraction: -1,00 -3,00 40° (20/30p)
Type
:
oval
Arc
length
160

STEP 2: HOW MANY RINGS AND HOW THICK?
How Many ? .......................
How Thick? …………………….. 2
x
160º/200µ
CLINICAL CASE 1

STEP 3: RING POSITION AND DEPTH
Ø  Incision:
Ø  Depth:
Ø  Check The Thickness
In The Ring Path
45°
343 micra
CLINICAL CASE 1

CLINICAL CASE 1
POST OP.
2 seg 160º/200µ 45° axis
Observe centering
Note hypo or overcorrection
Post operative Pre operative Diﬀerential value

NIPPLE
LAGOA?
Pre op. Refraction: -1,50 -3,00 100° 20/40
210°
ou
320°
CLINICAL CASE 2
Witch Ring?
How Thick?

210°/20
CLINICAL CASE 2

CLINICAL CASE 2
STEP 3: RING POSITION AND DEPTH?
Ø  Incision:
Ø  Depth:
In The Ring Path
Ø  Check ectasia design,
where do you want the
flattening?
I:
41°
D:
465
micra

Preop OE: -1,50 -3,00 100
20/40
Postop OE: -1,00 -3,25 155
20/25
Observe whether there was
hypo or overcorrection
Post op: Pre op: Diﬀerential Value
CLINICAL CASE 2
POST OP.

KERATOCONUS
CORRECTING THE ASYMMETRY, CONSIDERABLE DECREASE IN COMA

Refraction: -4,25 -3,50 135 ° 20/30
160º
Oval
CLINICAL CASE 3
Witch Ring?
How Many & How Thick

1
seg
160°/200µ
CLINICAL CASE 3

I:
41°
P:
465
µ
CLINICAL CASE 3
STEP 3: RING POSITION AND DEPTH?
Ø  Incision:
Ø  Depth:
In The Ring Path
Ø  Check ectasia design,
where do you want the
flattening?

Pre op OE: -4,25 -3,50 135 20/30
Post op OE: -1,25 -2,00 90 20/20p
Observe whether was
hipo or overcorrection
Post op. Pre op. Diﬀerential Value
CLINICAL CASE 3
POST OP.

1.  Programming
2.  Centralization
3.  Axis
4.  Optical Zone
5.  To evaluate Hipo or Overcorrection
6.  To evaluate the possibility of
improving the results
How to optimize the results?

Cone Type:
How Many Rings?
How Thick?
Position and Depth:
.................
.................
...............................
Pré -op
24yo PATIENT, COMPLAINNING OF LOW
VISUAL ACUITY AFTER RING IMPLANT,
REPORTS THAT HIS VISION HAS
WORSENED
R:
Tipo
de
cone:
Nipple
1
seg
210/20
eixo:
110°
Case 01
.................

Ø  Inadequate
Scheduling
Pre Op. Post Op. 1st surgery Post Op. 1st surgery
Post Op. 2nd surgery Post Op. 2nd surgery
Ø  Improper
Positioning

Facing a Bad Result:
TIP 01
Ø Request preoperative examination and review schedule
Ø If there is a preoperative exam:
remove segments and reimplant in the same surgical time
Ø If there is no preoperative exam:
remove the ring, wait 1 month, retake the exam to reschedule

RIGHT EYE
+1,0 -2,25 60 20/20
LEFT EYE:
-2,00 -4,00 140 20/50
WHAT TO DO?
Case 02 44 yo. PATIENT, WITH COMPLAINT THAT HE
HAD NO VISUAL IMPROVEMENT AFTER
RING IMPLANTATION

STEP 1: REQUEST AS ROUTINE THOMOGRAFY SCAN MODULE
WHAT TO DO?
Explant Ring and reimplant centering on the purkinge
reflex and positioning at 15º (clock wise rotation)
Post Ring Refraction of Left Eye
RE: +1,00 -2,25 60 20/20
LE: -2,00 -4,00 140 20/50

Pre repositioning: Post repositioning
Refraction:
Pre op. LE -2,00 -4,00 140º
20/50
Post op. LE -1,00 -0,75 160º
20/25p

TIP 02
Ø Use Pentacam’s “Tomography” module as a
routine in the postoperative period
Ø Decentralization is not always visible in
biomicroscopy
Ø If the post Ring vision worsens review
centralization and positioning

Refração: +0,50 -4,75 45 20/30
Case 03:
1-Pelícida
like
2-
1
seg
140°/15
3-
Eixo:
142°
42 yo. PATIENT WITH POOR VISUAL QUALITY
OF RIGHT EYE
Cone Type:
How Many Rings?
How Thick?
Position and Depth:
.................
.................
...............................
.................

CAN WE IMPROVE THE RESULTS?
PRE RE: +0,50 -4,75 45 20/30 Q: -0,29 ASTIG: 3,1
POST RE: +1,00 -2,50 80 20/25 Q: 0,05 ASTIG: 3,7

OBSERVE POSITIONING OF THE RING ACCORDING TO THE SHAFT

OBSERVE THE DESIGN OF THE ECTASIA:
Pre op
Refraction:
RE: +0,50 -4,75 45 20/30
Before repositioning:
RE: +1,25 -2,50 80 20/25
After repositioning:
RE: Plano -0,75 65 20/20
Astigmatismo tomográfico:
-3,7 à -1,4

TIP 03
Ø Observe the design of the ectasia postoperative
Ø If there is a possibility of improvement, rotate the ring to
another axis
Ø Make the upper incision to enable the rotation

RE: +1,00 -6,50 85°
20/20
LE: +0,25 -7,50 85°
20/30
1-
Pellúcida
Like
2-
1
seg
140/20
3-
165°
442micra
Case 04 36 yo PATIENT, LOW VISUAL ACUITY WITH
SPECTACLES, DIDN’T ADAPT WITH CONTACT
LENSES
Cone Type:
How Many Rings?
How Thick?
Position and Depth:
.................
.................
...............................
.................

PRE OP POST OP
Pre op Refraction: +0,25 -7,50 85
20/30
Post op refraction: +0,50 -5,00 95
20/25

CONDUTCT: Ring Explantation
Reimplant in the same surgical time in the 5mm optical
zone
New axis: 180º make new incision to create new tunnel

Pre op. refraction
+0,25 -7,50 85 20/30
Post Op refraction
+0,50 -5,00 95 20/25
Post repositionuing
refraction:
Plano -3,00 90 20/20

Diante de
um resultado
ruim:
TIP 04
Ø The outerized ring flattens less,
so even if the result is fine if
positioned in the proper optical
zone the tendency is to improve
Ø If there is localizaed buckling and
you notice that rotating the ring
would improve it, dosn’t hesitate
to do it

-0,1….160/15
-0,2...160/15
-0,3--160/15
-0,4...160/20
-0,5...160/20
-0,6...160/25
-0,7...160/15 160/15
-0,8...160/15 160/20
-0,9...160/15 160/25
-1,0...160/20 160/20
-1,1... 160/20 160/20
-1,2...160/20 160/20
-1,3 120/20 160/25
Dynamic Refraction:
RE: +1,25 -5,25 40 ° 20/30P
LE: +0,25 -5,50 160 20/30
Case 05 32yo PATIENT, PAINTER, LOW VISUAL ACUITY WITH
SPECTACLES, DOES NOT FIT CONTACT LENSES
Observe if Q is at 30º

NOTE IF HIPO OR HIPERCORRECTIONS OCCURRED:
Before:
+1,25 -5,25 40° 20/30P
After:
+2,00 -3,00 50° 20/40P
After explantation:
+0,50 20/20
Solution: Replace 2 seg 160º/150 with 1 seg 140º/200

TIP 05
Ø SIGNS OF OVERCORRECTION
Ø Hipercorrection – Positive Value of Asphericity (Q)
Ø Flattening where it was already flat
Ø Hipermetric Patient

WHAT WILL YOU
START DOING THAT
YOU DIDN’T DO
BEFORE?

Refraction:
•  RE: -3,25 20/20
•  LE: -1,00 -1,75 95 20/20
WHAT TO DO?
Case 06 30 yo PATIENT, FRUSTRATED KERATOCONUS IN
RIGHT EYE, CONTACT LENSES INTOLERANT, WANTED
INDEPENDENCE OF SPECTACLES

RING FOR REFRACTIVE PURPOUSES?
RE: 1 HM Ring Implant
Pre op: -3,25
Post Op: -0,5O
20/20 S/C
LE: 1 seg 160º/150 5 mm
Pré Operatório: -0,50 -1,00 115 20/25
Pós operatório: +0,50 -1,50 115 20/20
S/C : 20/25

. Bio:
RE: endotelial rejection , kodadoust line, lost of corneal
transparency
OE: ndn
. Refraction:
RE: + 0,25 -1,00 20 20/25
LE: - 2,25 -5,75 170 20/20
Case 07 46 yo PATIENT, anesthesiologist, had corneal
transplant in 2003 in the right eye due to
keratoconus, reports visual worsening in this eye 1
month ago and poor visual quality in EO with
difficulty to practice profession.

Right Eye : +1,00 -1,00 20
20/25

LE: Who would implant Rings in
this eye?
•  RE: +0,25 -1,00 20° 20/25
•  LE: -2,25 -5,75 170° 20/20
If so, what would be the
schedule? ................................

2 seg 160/15-25 assymmétric:
Left Eye:
Pre: -2,25 -5,75 170 20/20
Posr: -1,50 -1,50 20 20/20
Final Refraction:
RE: +0,25 -1,00 20 20/20
LE: -1,50 -1,50 20 20/20
After Tzratmentt rejection
and post LE Ring
Without Correction
RE: 20/20 para longe
LE: J1 para perto

To Take Home ...
Ring for refractive purpose: When?
Ø  Patient wants mor independence from spectacles
Ø  Good Visual Acuity, but Poor Visual Quality
Ø  Improve Anisometropia
Ø MOST IMPORTANT: Patient awere of
unpredictability / reversible procedure

Is Keratometry a limiting
factor in the indication?
What would be the limit?
RINGS IN EXTREMELY ADVANCED
KERATOCONUS

Pore op: -6,00 -3,00 105 20/200
K máx: 65D
Would indicate Ring?
Whitch One?
.................
.................
Case 08 17 years old, keratoconus grade 4,
transplant had been indicated

Ring Indicated: .......................
Pré op: -6,00 -3,00 150 20/200
R:
320/25
Case 08

WHAT TO DO?
RE: PLAN -1,25 100 20/20 P
LE: -3,00 -1,50 85 20/50
Patient Intolerant to wearing contact
lenses with anisometropia and diﬃcut to
wear spectacles
Case 08

RINGS IN EXTREMELY ADVANCED
KERATOCONUS
Patient Intolerant to wearing contact lenses with
anisometropia and diﬃcut to wear spectacles
RE: PLAN -1,25 100 20/20 P
LE: -3,00 -1,50 85 20/50
Suggestions?
HM Ring Implant
Concentric to the 320° one
Post HM: -1,50 -2,50 105° 20/20P

Evolution:
FINAL RESULT
RE: PLANO -1,25 100 20/20
LE: -1,50 -2,50 105 20/20P
PRE OP:
-6,00 -3,00 150 20/200
POST OP 1 320° SEG
-3,00 -1,50 85 20/50
POST OP AFTER SECOND SEGMENT
-1,50 -2,50 105 20/20P

Visual Acuity
Without correction
20/200à 20/400
WHAT TO DO?
Case 09 Patient 18 years old, with advanced keratoconus
in frank evolution in 1 year:

Indicated 320º/250 Ring
R:
anel
320/25

Pre & Postoperative Right Eye - 320º/250 segment
PRE POST

Evolution:
Visual Acuity without correction
RE: 20/400 à 20/150
Visual Acuity with correction
30º post op
RE: -11,00 -2,75 170 20/100 à
-6,00 - 1,75 150 20/50
Performed CXL in
3rd month post op
Scleral Lenses fitting after CXL
VA 20/20

17 yo. patient, with advanced keratoconus in both
eyes VA W/C: RE: 20/40 LE: 20/150
LE VA with Scleral Lenses: 20/40p
WHAT TO DO?
Thinnest
point on the
path: 475 ∝
Case 10

EVOLUTION
Ø  Visual Acuity without correction pre op: 20/150
Ø  Visual Acuity with lens preoperative: 20/40p
Ø  Visual Acuity with lens post operative: 20/30

To take home... Ø  keratometry is not a limitation for
rings implant
Ø  Ring association may be an
alternative in cases of advanced cones
Ø Ring Implantation that was absolutely
contraindicated in cases of post
hydrops scarring, but may be an
alternative in an attempt to postpone
transplantatiion in very young patients
if the scar is out of the visual axis.

If the patient has extremely advanced
keratoconus, without opacities and
with pachymetry in the ring path >
300 micra, why not try intrastromal
rings implantation before
transplantation?

RINGS IN CASES OF
PELLUCIDA/LIKE &
INFERIOR OVAL CONES
How to Improve the results?

•  Unsatsfied Patient after 1 140º/250 Implant
POST OP:
LE: -4,75 -3,75 75 20/50
Q: -0,29 à -0,29
Post Op:
Pre Op:
Case 11

Resolution:
Ø  Paciente had 1 seg
140/200µ implant
with unsatisfied low
visual acuity,
intolerant to CL.
Ø  Post Op 1st Implant
LE: -4,75 -3,75 75
20/50
Ø  Post Op 2nd Implant:
LE: -2,00 -4,00 60
20/20P

Post op 2nd implant:
OE: -2,00 -4,00 60 20/20P
Post op 1st implant:
OE: -4,75 -3,75 75 20/50
PRE OP: POST OP
1 SEG 140/20
POST OP
SEG 140/20 + 210/20

Why was there a important visual
improvement?

Refraction after 1 seg 140° de LE Implant
•  RE: -1,00 -2,25 80 20/70
•  LE: -1,00 -1,25 170 20/40 P
WPS, 36 years old, with keratoconus in both eyes,
intolerant to the use of rigid contact lenses, had
already had an intra-stromal ring implant in the left
eye with not very satisfactory results and came with an
indication for an right eye implant
Case 12

.
RIGHT EYE LEFT EYE
What’s the program for the Right Eye?
Case 12

Pre op: RE: -1,00 -2,25 80
20/70
Post op: RE: +1,50 -4,25 30 35
20/20

Pre op:
RE: -1,00 -2,25 80 20/70
Post op:
RE: +2,75 -4,25 60 20/20

Result:
Post operative 12 months right eye &
18 months left eye
•  RE: +1,50 -4,25 30 20/20
•  LE: -1,00 -1,75 180 20/40
Visual Acuity Without correction:
•  RE: 20/30
•  LE: 20/40
OD

CLINICAL CASE 01 PATIENT 23 YEARS OLD, WITH CERATOCONE
IN BOTH EYES AND BAV OF EYE,
INTOLERANT TO THE USE OF RIGID
CONTACT LENSES WITH KERATOCONUS IN
CONSISTENT EVOLUTION ON 2
EXAMINATONS.
DEVELOPING REASONING

CLINICAL CASE 01
SUGGESTED PROGRAMMING
REFRACTION:
RE: PLAN -1,75 75 20/20
LE: -1,00 -4,00 105 20/60
Cone Type:
How Many Rings?
How Thick?
Position and Depth?

CLINICAL CASE 01
SUGGESTED PROGRAMMING
1- 2 SEG 160/20
2- 1 SEG 160/ 25
3- 1 SEG 210/25
4- 1 SEG 320/20

CLINICAL CASE 01
PROGRAMMING DISCUSSION
CONE TIPO OVAL:
Ø  2 SEG 160/20 à SHOULD WE NOT IMPLANT RING WHERE ITS ALREADY FLAT?
Ø  1 SEG 160/ 25 à HIPOCORRECTION
Ø  1 SEG 210/25 à THINKING OF CORRECTIONG COMA WILL NOT CORRECT ASTIGMATISM
Ø  1 SEG 320/20 à KEEP ASSYMETRY, HIPOCORRECT ASTIGMATISM

CASE RESOLUTION
1 SEG 210°/200 DE 6 MMà
TO CORRECT ASYMMETRY (COMA)
POSITIONED CURVED AXIS
1 SEG 140°/200 DE 5 MM à
POSITIONED IN THE REGION OF
GREATEST CURVATURE,
CORRECT ASTIGMATISM

CASE RESOLUTION
REFRACTION PRE OP:
RE: PLAN -1,75 75 20/20
LE: -1,00 -4,00 105 20/60
REFRACTION POST OP:
RE: PLAN -1,75 75 20/20
LE: +1,50 -1,00 135 20/25
PRE OP: POST OP:

Ø  REFRACTION
RE: PLAN -1,75 75 20/20
LE: +1,50 -1,00 135 20/25
CASE RESOLUTION
Ø PACIENT SATISFIED WITH
SPECTACLES
Ø HAS CL JELLY AS AN OPTION
Ø STABLE FOR 1 YEAR, MAINTAINS
FOLLOW UO EVERY 4 MONTHS

CLINICAL CASE 02 25 yo. PATIENT WITH KERATOCONUS IN BOTH
EYES, INCIPIENT IN RE, COULD NOT WEAR
GLASSES DUE TO ANISOMETROPIA OF OE.
DID NOT WANT TO USE CL, KERATOCONUS
EVOLVING FROM LE ANS STABLE IN RE
DEVELOPING REASONING

Refraction:
RE: -0,25 -0,25 10° 20/20
LE: -1,50 -3,25 160° 20/30
CLINICAL CASE 02

CLINICAL CASE 02
CHIOCE: RING FOLLOW UP. IF EVOLUTION POST RING DO CXL
Cone Type:
How Many Rings?
How Thick?
Position and Depth?

CLINICAL CASE 02
OVALCONE TYPE :
1 SEG 160°/20 & 1 SEG 160°/15
CHIOCE: RING FOLLOW UP. IF EVOLUTION POST RING DO CXL
TiCone Type: OVAL
How many rings? How thick?
1 SEG 160/200 & 1 seg 160/150
Positon & Depth: Ring Modules

CLINICAL CASE 02
PRE OP REFRACTION:
RE: -0,25 -0,25 10° 20/20
LE: -1,50 -3,25 160° 20/30
POST OP REFRACTION
RE: -0,25 -0,25 10° 20/20
LE: +0,25 -1,50 150° 20/15
PRÉ OPERATÓRIO PÓS OPERATÓRIO

TO TAKE HOME!
Rings combination promisses to be a solution
for very asymmetric keratoconus cases
Asymmetrical rings are not enough to correct
large asymmetries
If close monitoring is possible, do post ring CXL only if
necessary
It makes sense to add fabric to achieve greater
flattening in the case of assymetrical snow man
cone types
Evolving keratoconus with low visual acuity implant rings
Leave CL if necessary as an add-on

OBRIGADA…
jordana.oftalmo@gmail.com

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