Mini-Scleral Design - MSD <ul><li>Large RGP </li></ul><ul><li>Vaults the cornea, rests on the sclera. </li></ul><ul><li>Cr...
MSD - Advantages <ul><li>Very Stable lens. </li></ul><ul><li>Fluid filled environment. </li></ul><ul><li>Improved comfort....
Mini-Scleral Design
MSD – Fitting Pearls <ul><li>Central Feather-touch. </li></ul><ul><li>Intra-limbal adjustment. </li></ul><ul><li>With or w...
Practice Management Issues <ul><li>Setting Fees. </li></ul><ul><li>Bill for services performed. </li></ul><ul><li>Insuranc...
Refractive Surgery Specific <ul><li>Moderate – Large Diameter </li></ul><ul><ul><li>(10.5 mm Standard Diameter, 9.5 mm to ...
A New Option for Keratoconus Keratoconus Intacs -1 Day PKP -1 Week
<ul><li>Contact Lens Intolerant Keratoconus </li></ul><ul><ul><li>Steep K  ‘ s, 45 to 60 </li></ul></ul><ul><ul><li>Changi...
Reshape the Cornea for CL Success
History Adjustable Ring 1984
INTACS Design Features <ul><li>Precision manufactured to ± 0.01mm:   </li></ul><ul><ul><li>150° arcs PMMA </li></ul></ul><...
How INTACS Work… <ul><li>Inserts placed at 75% corneal depth </li></ul><ul><li>Inserts separate corneal lamellae </li></ul...
Watch the Pre-op and Post-op mire   INTACS Normalize Corneal Shape The INTACS Procedure Courtesy David Schanzlin, MD Shile...
INTACS – PKP Comparison +8.00 (.)-2.00 X 180° -0.75 Transplant Intacs
INTACS - PKP Comparison <ul><li>PKP </li></ul><ul><li>Irreversible Procedure </li></ul><ul><li>Time: 1 Hour </li></ul><ul>...
INTACS - PKP Comparison <ul><li>PKP </li></ul><ul><li>Significant loss of endothelial cells </li></ul><ul><li>Permanently ...
3 lenses for most of the situations The most common cones : nipple and ovale
<ul><li>Keratoconus show high flattening between the very steep apex of the cone (forward) and the flat periphery (behind)...
The more advanced is the cone , higher the slope (flattening)  is.
<ul><li>Lenses have to follow as close as possible this very prolate cornea in order to : </li></ul><ul><ul><li>respect th...
Good center and periphery
A lens is expressed by <ul><li>Material </li></ul><ul><li>Geometry </li></ul><ul><li>Diameter </li></ul><ul><li>Base Curve...
<ul><li>Different expressions of the lens flattening </li></ul><ul><li>Axial Edge Lift </li></ul><ul><li>Sagittal depth </...
Axial Edge Lift AEL AEL is the height that seperates the edge of the lens and the edge of the lens if this one wouldn’t ha...
<ul><li>For a good fitting, AEL of the lens have </li></ul><ul><li>to be close to the cornea one </li></ul>
How can we increase the AEL ? <ul><li>By decreasing Optic Zone size </li></ul>OZ OZ AEL small OZ  >  AEL large OZ
<ul><li>By increasing peripheral curves </li></ul>How can we increase the AEL ? Rayon périphérique Rayon périphérique
AEL Periph.curves ++  >  AEL Periph.curves +
Rose K Principle Lens changes with the cone evolution  <ul><li>When a keratoconus is getting more and more advanced, the a...
Rose K lenses principle <ul><li>For  each BC  that respects the apex of the cone, an  unique AEL  will be associated to it...
For a 8.70mm diam.
Axial Ege Lift (AEL)    Edge Lift (EL) <ul><li>Rather than talking about AEL in mm which is difficult to evaluate for the...
available EL +3.00 à -1.3 / 0.1 <ul><li>EL Standard “0”  65% </li></ul><ul><li>EL “quick” +1.0  20% </li></ul><ul><li>EL “...
Trial Box <ul><li>Std EL for all lenses  (but AEL unique for each BC) </li></ul><ul><li>Powers increase in steep curves : ...
 
Fitting steps <ul><li>Keratometry from a keratometer or a topograph </li></ul>7,00  mm  12 ⁰ 6,60  mm  102⁰ Km.  6.80 Cyl....
<ul><li>In the trial box, choose the lens according to the rule : </li></ul><ul><li>BC = av.K -0.10 </li></ul><ul><li>Asse...
Remarques <ul><li>Wait 1 minute before evaluation </li></ul><ul><li>Analyze fluo pattern, lens centered </li></ul>
<ul><li>After  finding the best BC </li></ul><ul><ul><li>If too  thin periphery (< 0.6 mm)    EL « quick » +1.0 </li></ul...
<ul><li>Centration and mobility </li></ul>Up riding .steep the lens .and/or reduce diameter  .and/or reduce EL Low riding ...
<ul><li>This is not the central fitting that involves discomfort but the periphery </li></ul><ul><li>Too steep periphery i...
<ul><li>Find the best sphere giving the best </li></ul>
Spherical Aberrations <ul><li>Peripheral rays are more refracted than central rays. </li></ul><ul><li>Ex : -7.00 in the ce...
<ul><li>Those aberrations induced by the lens are higher when :  </li></ul><ul><ul><li>Pupil is large </li></ul></ul><ul><...
Rose K2 Advantages  <ul><li>Easy to fit </li></ul><ul><ul><li>Only 1 trial box : one lens name </li></ul></ul><ul><ul><li>...
 
Indications  <ul><li>Pellucid  Marginal Degeneration - PMD </li></ul><ul><li>Keratoglobus </li></ul><ul><li>P ost lasik ec...
<ul><li>reversed design for BC > 7.20 </li></ul><ul><li>flatter the BC is, more reversed the design is </li></ul><ul><li>L...
 
5 Edge Lift +0.6 /+1.2 / -0.5 / -1.0
  1st lens: BC  = K’ +0.30 mm Fitting: 1. Keratometry 2. BC    3. central Fitting 4. peripheral fitting 5. Centration/Mobi...
BC  plat  OK / serré serré
EL périphérie très serrée EL Lent (-) périphérie serrée EL standard Périphérie ok EL rapide (+)
Mobility Look for enough mobility to insure enough tear flow Mobility ++  Mobility -- increase diameter  Decrease diameter...
  1st lens  = Km - 0.30 mm Fitting : 1. Keratometry 2. BC  3. central fitting 4. peropheral fitting 5. Centration / mobili...
ROSE K2 Post Graft: Rose K2 PG <ul><li>the hardest fitting </li></ul><ul><li>irregular cornea shape </li></ul><ul><li>High...
<ul><li>Optimal </li></ul>
www.mencon.fr [email_address] [email_address] [email_address] Thank you for your attention
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RoseK2 part2

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  • Slide 11 The INTACS design that is approved for the correction of low myopia in Europe and in the United States consists of two 150 degree arcs of PMMA that are lathe cut to specified thicknesses. The inner diameter of the INTACS is 6.8 mm and the outer diameter is 8.1 mm. The INTACS are normally positioned at 2/3 depth, centered on the geometric corneal center, and they are normally oriented in a vertical pattern as demonstrated in this slide.
  • A head to head comparison of keratoplasty and Intacs shows that the major advantages of Intacs are the rehabilitation time (several weeks as opposed to several months).
  • A head to head comparison of keratoplasty and Intacs shows that the major advantages of Intacs are the rehabilitation time (several weeks as opposed to several months).
  • Les indications de ces 3 lentilles sont… Pour chaque lentille, le protocole d’adaptation est le même : centre, périph,diam…
  • Pour un rayon central cambré et un diam.donné
  • For 8.7 diamètre Trial set. Different OZ for different diamètres.Set OZ for any base but does vary with diamètre.
  • RoseK2 part2

    1. 1. Mini-Scleral Design - MSD <ul><li>Large RGP </li></ul><ul><li>Vaults the cornea, rests on the sclera. </li></ul><ul><li>Creates a fluid filled environment. </li></ul><ul><li>Can be used to treat any corneal condition. </li></ul><ul><li>Can be used to treat other anterior segment conditions. </li></ul>
    2. 2. MSD - Advantages <ul><li>Very Stable lens. </li></ul><ul><li>Fluid filled environment. </li></ul><ul><li>Improved comfort. </li></ul><ul><li>Good visual acuity. </li></ul>
    3. 3. Mini-Scleral Design
    4. 4. MSD – Fitting Pearls <ul><li>Central Feather-touch. </li></ul><ul><li>Intra-limbal adjustment. </li></ul><ul><li>With or without fenestration or fenestrations. </li></ul><ul><li>Watch edge for tightening. </li></ul>
    5. 5. Practice Management Issues <ul><li>Setting Fees. </li></ul><ul><li>Bill for services performed. </li></ul><ul><li>Insurances and fee collection. </li></ul><ul><li>Appropriate diagnostic and treatment equipment. </li></ul><ul><ul><li>Topography/corneal mapping. </li></ul></ul><ul><ul><li>Pachymetry. </li></ul></ul><ul><ul><li>Fitting sets. </li></ul></ul>
    6. 6. Refractive Surgery Specific <ul><li>Moderate – Large Diameter </li></ul><ul><ul><li>(10.5 mm Standard Diameter, 9.5 mm to 12.0 mm). </li></ul></ul><ul><li>Reverse Geometry Transition. </li></ul><ul><ul><li>Post Surgical Central BC. </li></ul></ul><ul><li>Curves </li></ul><ul><ul><li>Paracentral Fitting Curves. </li></ul></ul><ul><ul><li>Asymmetric Corneal Technology (ACT). </li></ul></ul>
    7. 7. A New Option for Keratoconus Keratoconus Intacs -1 Day PKP -1 Week
    8. 8. <ul><li>Contact Lens Intolerant Keratoconus </li></ul><ul><ul><li>Steep K ‘ s, 45 to 60 </li></ul></ul><ul><ul><li>Changing refractions, eyes irritated, frequent visits/re-fits </li></ul></ul><ul><ul><li>Lenses not providing functional vision </li></ul></ul><ul><ul><ul><li>Outright failure </li></ul></ul></ul><ul><ul><ul><li>Shortened wearing time </li></ul></ul></ul><ul><ul><ul><li>Inability to achieve 20/40 </li></ul></ul></ul><ul><ul><li>“ keratoconus personality ” exacerbated </li></ul></ul><ul><ul><li>Apprehensive about transplant </li></ul></ul><ul><ul><ul><li>Active, younger or risk averse </li></ul></ul></ul>Objective - Bridge the gap between frustration and (PKP) “ the point of no return ”
    9. 9. Reshape the Cornea for CL Success
    10. 10. History Adjustable Ring 1984
    11. 11. INTACS Design Features <ul><li>Precision manufactured to ± 0.01mm: </li></ul><ul><ul><li>150° arcs PMMA </li></ul></ul><ul><ul><li>Unique hexagonal cross-section design with 7mm wide optical zone </li></ul></ul><ul><ul><li>Positioning holes for manipulation </li></ul></ul><ul><li>Inserts placement: </li></ul><ul><ul><li>In peripheral cornea </li></ul></ul><ul><ul><li>Between stromal layers </li></ul></ul>6.9 mm 8.1 mm Stromal Lamellae
    12. 12. How INTACS Work… <ul><li>Inserts placed at 75% corneal depth </li></ul><ul><li>Inserts separate corneal lamellae </li></ul><ul><li>Separation shortens corneal arc length </li></ul><ul><li>Central cornea flattens </li></ul><ul><li>Increased flattening achieved with thicker segments </li></ul>Stromal Lamellae
    13. 13. Watch the Pre-op and Post-op mire INTACS Normalize Corneal Shape The INTACS Procedure Courtesy David Schanzlin, MD Shiley Eye Inst. UCSD
    14. 14. INTACS – PKP Comparison +8.00 (.)-2.00 X 180° -0.75 Transplant Intacs
    15. 15. INTACS - PKP Comparison <ul><li>PKP </li></ul><ul><li>Irreversible Procedure </li></ul><ul><li>Time: 1 Hour </li></ul><ul><li>Rehab Time: 12-18 Months </li></ul><ul><li>Intraocular Procedure </li></ul><ul><li>Lifetime Follow-up required </li></ul><ul><li>Complications </li></ul><ul><ul><li>Cataract </li></ul></ul><ul><ul><li>Glaucoma </li></ul></ul><ul><ul><li>Endophthalmitis </li></ul></ul><ul><ul><li>Rejection </li></ul></ul><ul><ul><li>Expulsive hemorrhage </li></ul></ul><ul><ul><li>Corneal ulcer </li></ul></ul><ul><ul><li>Neovascularization </li></ul></ul><ul><ul><li>Induced astigmatism </li></ul></ul><ul><ul><li>Disease recurrence </li></ul></ul><ul><ul><li>Risk of viral transference </li></ul></ul><ul><li>INTACS </li></ul><ul><li>Reversible Out-Patient Procedure </li></ul><ul><li>Time: 20-30 Minutes </li></ul><ul><li>Rehab Time: 1-2 Weeks </li></ul><ul><li>(Visual Function Immediate) </li></ul><ul><li>Corneal Lamellar Procedure </li></ul><ul><li>Periodic Follow-up </li></ul><ul><li>Complications </li></ul><ul><ul><li>Unsatisfactory ring placement </li></ul></ul><ul><ul><li>Segment extrusion </li></ul></ul><ul><ul><li>(All easily managed with segment removal) </li></ul></ul>
    16. 16. INTACS - PKP Comparison <ul><li>PKP </li></ul><ul><li>Significant loss of endothelial cells </li></ul><ul><li>Permanently weakened cornea with risk of additional trauma </li></ul><ul><li>Outcomes: unpredictable, often unstable </li></ul>INTACS <ul><li>Endothelial cell loss, not clinically significant 1 </li></ul><ul><li>Provides structural integrity, PKP still an option without complication </li></ul><ul><li>Outcomes: predictable, case dependent </li></ul><ul><li>1 Two-Year Endothelial Cell Assessment following INTACS implantation, Azar et al, J Refract Surg . 2001 Sept-Oct </li></ul>
    17. 17. 3 lenses for most of the situations The most common cones : nipple and ovale
    18. 18. <ul><li>Keratoconus show high flattening between the very steep apex of the cone (forward) and the flat periphery (behind). </li></ul>2 mm 6.70 8.70
    19. 19. The more advanced is the cone , higher the slope (flattening) is.
    20. 20. <ul><li>Lenses have to follow as close as possible this very prolate cornea in order to : </li></ul><ul><ul><li>respect the cornea </li></ul></ul><ul><ul><li>Stabilize properly </li></ul></ul><ul><ul><li>Be comfortable </li></ul></ul><ul><li> Need to have « very » steep lenses in the center that get flatter « quickly ». </li></ul>
    21. 21. Good center and periphery
    22. 22. A lens is expressed by <ul><li>Material </li></ul><ul><li>Geometry </li></ul><ul><li>Diameter </li></ul><ul><li>Base Curve </li></ul><ul><li>Power </li></ul>
    23. 23. <ul><li>Different expressions of the lens flattening </li></ul><ul><li>Axial Edge Lift </li></ul><ul><li>Sagittal depth </li></ul><ul><li>Excentricity </li></ul>
    24. 24. Axial Edge Lift AEL AEL is the height that seperates the edge of the lens and the edge of the lens if this one wouldn’t have peripheral curves.  For known BC and total diameter the higher AEL is, the higher the flattening is
    25. 25. <ul><li>For a good fitting, AEL of the lens have </li></ul><ul><li>to be close to the cornea one </li></ul>
    26. 26. How can we increase the AEL ? <ul><li>By decreasing Optic Zone size </li></ul>OZ OZ AEL small OZ > AEL large OZ
    27. 27. <ul><li>By increasing peripheral curves </li></ul>How can we increase the AEL ? Rayon périphérique Rayon périphérique
    28. 28. AEL Periph.curves ++ > AEL Periph.curves +
    29. 29. Rose K Principle Lens changes with the cone evolution <ul><li>When a keratoconus is getting more and more advanced, the apex of the cone is getting steeper but the periphery remains the same. </li></ul><ul><li>For a known apex of the cone, the periphery is often the « same » fom one patient to another : Paul Rose’s Statistic and mathematic models : correlation between BC and slope </li></ul>
    30. 30. Rose K lenses principle <ul><li>For each BC that respects the apex of the cone, an unique AEL will be associated to it </li></ul><ul><ul><li>Unique Optic Zone </li></ul></ul><ul><ul><li>Unique Peripheral curves </li></ul></ul><ul><ul><li>World sales indicate that the original AEL </li></ul></ul><ul><ul><li>represent 65% of sold lenses </li></ul></ul>
    31. 31. For a 8.70mm diam.
    32. 32. Axial Ege Lift (AEL)  Edge Lift (EL) <ul><li>Rather than talking about AEL in mm which is difficult to evaluate for the fitter, Paul Rose simplified and reduced this notion to a simple number without unit : Edge Lift (EL) </li></ul><ul><ul><li>EL = 0 = standard corresponds to the AEL associated to the curve </li></ul></ul><ul><ul><li>EL > 0 correspond to lenses that are flatter in periphery than standard </li></ul></ul><ul><ul><li>EL < 0 correspond to lenses that are steeper in periphery than standard </li></ul></ul>
    33. 33. available EL +3.00 à -1.3 / 0.1 <ul><li>EL Standard “0” 65% </li></ul><ul><li>EL “quick” +1.0 20% </li></ul><ul><li>EL “slow” -0.5 10% </li></ul><ul><li>Others 5 to 10% </li></ul>The majority of Rose K are done with 3 EL
    34. 34. Trial Box <ul><li>Std EL for all lenses (but AEL unique for each BC) </li></ul><ul><li>Powers increase in steep curves : the more advanced is the cone, the more myopia there is  important for assessing precisely centration and mobility . </li></ul><ul><li>Diameter decreases when the cone is getting advanced (difficult for large lenses to follow the very flat periphery) </li></ul>
    35. 36. Fitting steps <ul><li>Keratometry from a keratometer or a topograph </li></ul>7,00 mm 12 ⁰ 6,60 mm 102⁰ Km. 6.80 Cyl. 3,00
    36. 37. <ul><li>In the trial box, choose the lens according to the rule : </li></ul><ul><li>BC = av.K -0.10 </li></ul><ul><li>Assess the contact at the apex of the cone </li></ul><ul><ul><li>If too much contact (Flat)  decrease BC </li></ul></ul><ul><ul><li>If not enough contact (Steep)  increase BC </li></ul></ul>STEEP FLAT OPTIMALE
    37. 38. Remarques <ul><li>Wait 1 minute before evaluation </li></ul><ul><li>Analyze fluo pattern, lens centered </li></ul>
    38. 39. <ul><li>After finding the best BC </li></ul><ul><ul><li>If too thin periphery (< 0.6 mm)  EL « quick » +1.0 </li></ul></ul><ul><ul><li>If too wide periphery (> 0.8mm)  EL « slow » -0.5 </li></ul></ul>Too thin Optimal Too wide
    39. 40. <ul><li>Centration and mobility </li></ul>Up riding .steep the lens .and/or reduce diameter .and/or reduce EL Low riding .Flatten the lens .and/or increase diameter .and/or increase EL Optimal
    40. 41. <ul><li>This is not the central fitting that involves discomfort but the periphery </li></ul><ul><li>Too steep periphery involves discomfort ++, physiology -- </li></ul><ul><li>Too flat periphery involves discomfort +, decentration, mobility + </li></ul><ul><li> With Rose K, good control of this periphery </li></ul>
    41. 42. <ul><li>Find the best sphere giving the best </li></ul>
    42. 43. Spherical Aberrations <ul><li>Peripheral rays are more refracted than central rays. </li></ul><ul><li>Ex : -7.00 in the center, -7.75 in periphery </li></ul>
    43. 44. <ul><li>Those aberrations induced by the lens are higher when : </li></ul><ul><ul><li>Pupil is large </li></ul></ul><ul><ul><li>Power of the lens is high </li></ul></ul><ul><ul><li> More benefits for high myopic patients </li></ul></ul>
    44. 45. Rose K2 Advantages <ul><li>Easy to fit </li></ul><ul><ul><li>Only 1 trial box : one lens name </li></ul></ul><ul><ul><li>Lens changes with the cone (AEL changes with BC) </li></ul></ul><ul><ul><li>Std EL works in main cases </li></ul></ul><ul><ul><li>2 other EL slow and quick cover most of the modifications </li></ul></ul><ul><ul><li>6 steps fitting </li></ul></ul><ul><li>Maximum physiological respect </li></ul><ul><ul><li>Material Z </li></ul></ul><ul><ul><li>Special Geometry for the best compromise physiology/vision </li></ul></ul><ul><li>Vision </li></ul><ul><ul><li>Control of the spherical aberrations </li></ul></ul>
    45. 47. Indications <ul><li>Pellucid Marginal Degeneration - PMD </li></ul><ul><li>Keratoglobus </li></ul><ul><li>P ost lasik ectasy, Post Graft </li></ul>PMD DMP Globus Lasik
    46. 48. <ul><li>reversed design for BC > 7.20 </li></ul><ul><li>flatter the BC is, more reversed the design is </li></ul><ul><li>Larger optical zone </li></ul><ul><li>OZ decreases with BC </li></ul><ul><li>EL steeper than Rose K </li></ul><ul><li>Total diameter larger than graft diameter </li></ul><ul><li>Also used on post lasik ectasy </li></ul>
    47. 50. 5 Edge Lift +0.6 /+1.2 / -0.5 / -1.0
    48. 51. 1st lens: BC = K’ +0.30 mm Fitting: 1. Keratometry 2. BC 3. central Fitting 4. peripheral fitting 5. Centration/Mobility (=>Diameter) 6.Power Ex. 6.80/5.50  5.50 +0.30 = 5.80
    49. 52. BC plat OK / serré serré
    50. 53. EL périphérie très serrée EL Lent (-) périphérie serrée EL standard Périphérie ok EL rapide (+)
    51. 54. Mobility Look for enough mobility to insure enough tear flow Mobility ++ Mobility -- increase diameter Decrease diameter decrease BC Flatten BC 0 decrease l’Edge Lift increase l’Edge Lift
    52. 55. 1st lens = Km - 0.30 mm Fitting : 1. Keratometry 2. BC 3. central fitting 4. peropheral fitting 5. Centration / mobility 6. Power Ex. 6.80/5.50  6.15 - 0.30 = 5.85
    53. 56. ROSE K2 Post Graft: Rose K2 PG <ul><li>the hardest fitting </li></ul><ul><li>irregular cornea shape </li></ul><ul><li>High astigmatism, often irregular </li></ul><ul><li>sensitives eyes </li></ul>
    54. 57. <ul><li>Optimal </li></ul>
    55. 58. www.mencon.fr [email_address] [email_address] [email_address] Thank you for your attention

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