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Dr. Efekan Coskunseven presentation at Mediphacos User Meeting 2013
The document discusses combined treatment approaches for keratoconus, specifically involving intracorneal ring segments (ICR), corneal collagen crosslinking (CXL), and topo-guided PRK. It evaluates surgical outcomes on visual acuity and corneal topography in patients undergoing these procedures, highlighting effectiveness and reducing keratoconus progression. Results suggest that the combination of treatments provides superior outcomes compared to individual treatments alone.
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Dr. Efekan Coskunseven presentation at Mediphacos User Meeting 2013
- 1. ESCRS 2013 Amsterdam KERARINGUSER MEETING CXL AND TOPO-GUIDED PRK OR TORIC PHAKIC INTRAOCULAR LENS IMPLANTATION AFTER KERARING IMPLANTATION WHEN AND HOW TO COMBINE THE TREATMENTS Efekan Coskunseven, MD Dünya Göz / World Eye Hospital, Istanbul, Turkey
- 2. WHY A COMBINEDTREATMENT ? Improve Vision + Stop Progression
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- 8. TRIPLE PROCEDURE TOPO-GUIDED TRANSEPITHELIALPRK AFTER INTRACORNEAL RING SEGMENT IMPLANTATION AND COLLAGEN CROSSLINKING FOR THE TREATMENT OF KERATOCONUS
- 9. METHODS 16 eyes of10 patients with keratoconus Topo-guided Transepithelial PRK after Intracorneal Ring Segment Implantation followed by CXL (ICR+CXL). 7M 8,2 M The Mean interval between ICR and CXL was 7 months and the mean interval between CXL and Topo-guided transepithelial PRK was 8,2 months. The preoperative and postoperative visual acuity-refractionpachymetry topography results were evaluated. The mean follow-up period was 6,2 months.
- 10. METHODS + Channel creation (INTRALASE FS60): 15 seconds. 0,1% B2 in 20% Dextran T-500 30 min + T-CAT PRK with WaveLight Allegretto 400 Hz UV (Peschkemed) Depth adjusted to 80% of 370 nm 3 mW/cm² for 30 min the thinnest point at tunnel location. About 80% of the refraction, max 50 microns Corneal incision : at steep axis. Small OZ (5.5mm) with large TZ (9 mm) Keraring:4.4-5.6 mm
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- 13. Mean K 52 51 Pre-Op; 51,23 50 49 PostICR, 48.05 48 47 PostICR+CCL ,46.99 46 45 Pre-Op Post-ICR Post-ICR+CCL Post-TopoPRK-PTK Mean K 51,23 48,05 46,99 45,34 PostTopoPRKPTK; 45,34
- 14. K1 48 Pre-Op; 47,8 47 47,8-46,1=1,7 D Post-ICR; 46,18 46 44,8-44,6=0,2D PostICR+CCL; 44,84 45 44 Pre-Op Post-ICR Post-ICR+CCL K1 47,8 46,18 44,84 Post-TopoPRK-PTK 44,69 PostTopoPRKPTK; 44,69
- 15. K2 56 55 54 Pre-Op; 54,65 53 54,6-49,9=4,7 D 52 51 PostICR+CCL ; 49,14 50 Post-ICR; 49,93 49 49,1-45,9=3,2D 48 47 PostTopoPRKPTK; 45,99 46 45 Pre-Op Post-ICR Post-ICR+CCL K2 54,65 49,93 49,14 Post-TopoPRK-PTK 45,99
- 16. Pre-op Kmax-Kmin: 55,544,5= 11D Post-ICR Kmax-Kmin: 51,344,1= 7,2 D 11D-7,2D= 3,8 D
- 18. Pre-op Post-ICR Post-ICR+CCL Kmax-Kmin: 55,5-44,5= 11 D 3.8D Kmax-Kmin: 51,3-44,1= 7,2 D 0.7 D Kmax-Kmin: 50,9-44,4= 6,5 11D-6,5D= 4,5 D D
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- 20. Post-ICR Pre-op Kmax-Kmin: 55,5-44,5= 11D 3.8 D Post-ICR+CCL Kmax-Kmin: 50,9-44,4= 6,5 D Kmax-Kmin: 51,3-44,1= 7,2 D 0.7 D 11D-1,1D= 9,9 D Post-ICR+CCL+ TopoPRKPTK 5.4 D Kmax-Kmin: 47,2-46,1= 1,1 D
- 21. Pre-op Post-ICR Post-ICR+CCL Post-ICR+CCL+ TopoPRKPTK Pre-Op 12.12.06 Manifest Ref. UCVA BCVA K1 K2 Post-ICR (ICR Date:10/01/07) 01.11.2007 Post-ICR+CCL (CCL Date:01/11/2007) 25.02.2010 Post-ICR+CCL+TopoPRK-PTK (Op Date:25/02/2010) 18.03.2010 -5(-6,75x155) 0,05 0,2 50 56,7 -1(-1,25x60) 0,16 0,3 47,7 49,3 -1.50 (-1.0x67) 0,16 0,3 48,5 49,2 -1 (-0,5x50) 0,7 0,9 45,4 46,4
- 24. 18/03/2010 ~K2: 47,2-46,9= Kmax-Kmin: 47,2-46,1=1,1 D 06/10/2012 0,3 Kmax-Kmin: 46,9-45,1= 1,8 D
- 25. Pre-op Post-ICR PostICR+CCL ~K2: 51,3-50,9= 0,4 ~K2:55,5-51,3= 4,2 D PostICR+CCL+ TopoPRKPTK 2010 PostICR+CCL+ TopoPRKPTK 2012 ~K2: 47,2-46,9= D ~K2: 50,9-47,2= ~K2: 55,5-46,9= 8,6 D 3,7 D 0,3 D
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- 28. 7 Years results Pre-op Post-ICR 2006 2006 PostICR+CCL 2007 PostICR+CCL+ TopoPRKPTK 2010 PostICR+CCL+ TopoPRKPTK 2012 P PostICR+CCL+ TopoPRKPTK 2013 ~K2:46,9-47,5= ~K2: 51,3-50,9= -0,4 ~K2: 55,5-51,3= -4,2 D D ~K2: 47,2-46,9= ~K2: 50,9-47,2= ~K2: 55,5-47,5= -8,0 D +0,6 D -0,3 D -3,7 D PREGNANCY
- 29. KeraRing ICR implantationis an effective method for the improvement of UCVA and BCVA in keratoconic eyes . Maximum Keraring effectiveness in diopter according to corneal thickness is about 7 D. <7 D Irregularity
- 30. The inhibiting effectof ICR to keratoconus progression is still unclear. CXL to be a safe procedure that has shown to stop the progression of the keratoconus. Stop Progression <1,5D Irregularity
- 31. However combination ofboth treatments will be more effective than ICR or Transepithelial Topo G.L.T alone + <7 D Irregularity + Stop Progression <1,5D Irregularity 50 µ 5.5 mm <5D
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- 33. TORIC ICL FOR CORRECTIONOF AMETROPIA AFTER CXL FOR KERATOCONUS +
- 35. 1.0 BSCVA & UCVA 0.9 0.82 0.8 0.7 0.6 0.88 0.87 0.83 0.85 0.890.88 0.89 0.88 0.79 0.63 0.56 0.5 0.4 0.4 0.3 0.3 0.2 0.1 0.0 Pre corsslinking Pre ICL After 7 days After 1month BSCVA After 3months After 6months UCVA After 1year
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- 38. TORIC ICL IMPLANTATIONAFTER INTRACORNEAL RING IMPLANTATION FOLLOWED BY CORNEAL COLLAGEN CROSSLINKING FOR THE TREATMENT OF KERATOCONUS + + J Cataract Refract Surg. 2013 Mar 13. doi:pii: S08863350(13)00003-5. 10.1016/j.jcrs.2012.11.027
- 39. METHODS 14 eyes of9 patients with keratoconus ICLToric implantation after Intracorneal Ring Segment Implantation followed by CXL (ICR+CXL). 7M 8,4 M •The Mean interval between ICR and CXL was 7 months and the mean interval between CXL and ICLToric implantation was 6,4 months. •The preoperative and postoperative visual acuity, refraction, pachymetry and topography results were evaluated. •The mean follow-up period was 7.2 months.
- 40. METHODS + Channel creation (INTRALASE FS60): 15 seconds. Depth adjusted to 80% of the thinnest point at tunnel location. Corneal incision : at steep axis. Keraring:4.4-5.6 mm + 0,1% B2 in 20% Dextran T-500 30 min UV (Peschkemed) 370 nm 3 mW/cm² for 30 min ICL operations were performed 8,4 months after CCL ICL calculation was based on post op ICR+CXL refraction ACD> 2,8 mm
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- 47. METHODS 7M <7 D Irregularity 8,4 M Stop Progression <1,5D Irregularity Sph<-18 D Cyl<5 D
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- 49. 11/13/2008 PREOP FEMALE,18 Y OD: -18,75 / -6,75 / 88° Sim K’s Astig: 13,9 D UCVA: 0,05 BCVA: 0,05 Contact Lens VA: 0,7 Thinnest Pachy USG: 420 Axial Length: 27,71 ACD: 3,57
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- 52. ICR SURGERY 14/11/2008 POSTOPICR 22/11/2008
- 53. ICR SURGERY 14/11/2008 POSTOPICR 22/11/2008
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- 55. CCL SURGERY 06/01/2009 POSTOPCCL 30/03/2009
- 56. PREOP ICL 24/02/2012 ManRef:-4.00(-6.00x 80) UCVA: 0.1 BCVA: 0.5
- 57. ICL SURGERY 03/07/2012 PREOPICL 24/02/2012 Man Ref:-4.00(-6.00x 80) UCVA: 0.1 BCVA: 0.5
- 58. POSTOP ICL / PREOPTOPO 28/02/2013 Man Ref:-1.75(-2.00x 35) UCVA: 0.3 BCVA: 0.5
- 59. TOPO SURGERY 05/03/2013 POSTOPTOPO 19/09/2013 Man Ref:-0.75(-1.00x 30) UCVA: 0.7 BCVA: 0.8
- 60. 5 Years PREOP 2008 POSTOP ICR 2008 POSTOPCCL 2009 POSTOP ICL 2012 POSTOP TOPO SEPT/2013 -18,75 / -6,75 / 88° -4.50 / -6.00 / 85° -4.00 / -6.00 / 80° -1.75 / -3.00 / 35° -0.75 / -1.50 / 30° UCVA: 0,05 UCVA: 0,1 UCVA: 0,1 UCVA: 0,3 UCVA: 0,7 BCVA: 0,05 BCVA: 0,4 BCVA: 0,5 BCVA: 0,5 BCVA: 0,8 Sim K’s Astig: 13,9 D Contact LVA: 0,7 Thin.PachyUSG: 420 Axial Length: 27,71 ACD: 3,57
- 61. 5 Years PREOP 2008 POSTOPSEPT/2013 -18,75 / -6,75 / 88° -0.75 / -1.50 / 30° UCVA: 0,05 UCVA: 0,7 BCVA: 0,05 BCVA: 0,8 Sim K’s Astig: 13,9 D Contact LVA: 0,7 Thin.PachyUSG: 420 Axial Length: 27,71 ACD: 3,57
- 62. + <7 D Irregularity StopProgression <1,5D Irregularity + Sph< -18 D Cyl< 5 D <5 D Irregularity
- 63. CONCLUSION Topo-Guided Transepithelial PRK,Toric Phakic IOL Implantation , ICR implantation followed by CXL is an effective treatment sequence that can stop progression and improve vision and refraction in select keratoconus patients However a long-term follow-up of a larger population study is required to validate these findings
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