CXL and topo-guided PRK or toric phakic intraocular lens implantation after Keraring implantation. Wwhen and how to combine the treatments

1. ESCRS 2013 Amsterdam
KERARING USER 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 COMBINED TREATMENT ?
Improve
Vision
+
Stop
Progression

3. COMBINED TREATMENT OPTIONS
+

4. COMBINED TREATMENT OPTIONS
+
+

5. COMBINED TREATMENT OPTIONS
+
+
+

6. COMBINED TREATMENT OPTIONS
+
+
+
+

7. TRIPLE PROCEDURES
+
+
+
+
+
+

8. TRIPLE PROCEDURE
TOPO-GUIDED TRANSEPITHELIAL PRK AFTER
INTRACORNEAL RING SEGMENT IMPLANTATION
AND COLLAGEN CROSSLINKING FOR THE
TREATMENT OF KERATOCONUS

9. METHODS


16 eyes of 10 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 FS 60): 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

11. 0.8
0.74
0.7
0.58
0.6
0.48
0.5
0.44
UCVA
0.4
BCVA
0.3
0.3
0.25
0.21
0.2
0.1
0.1
UCVA BCVA
Pre-Op 0,1
Post-ICR
Pre-Op
0,21
Post-ICR
0,25
0,44
Post-ICR+CCL
0,3
0,48
Post-TopoPRKPTK
0,58
0,74
0
Post-ICR+CCL
Post-TopoPRK-PTK

12. -6
-5
-5.66
-4,34
-4
-3
-3.05
-2.63
CYL
SEQ
-2.44
-2
-2
-0,98
-0.98
-1
0
Pre-Op
Post-ICR
Post-ICR+CCL
CYL
-4,34
-2,63
-2,44
SEQ
-5,66
-3,05
-2
Post-TopoPRK-PTK
-0,98
-0,98

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=3,2 D
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= 11 D
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
3.8 D 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

19. PREOP
POSTOP

20. Post-ICR
Pre-op
Kmax-Kmin: 55,5-44,5= 11 D
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+Topo PRK-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

27. 18/03/2010
~K2: 47,2-46,9=
06/10/2012
-0,3
~K2: 46,9-47,5=
27/09/2013
+0,6

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 implantation is 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 effect of 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 of both 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

32. COMBINED TREATMENT OPTIONS
+
+

33. TORIC ICL FOR
CORRECTION OF 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
0.89 0.88
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

36. METHODS
+
Stop Progression
<1,5D Irregularity
Sph<-18 D
Cyl<5 D

37. COMBINED TREATMENT OPTIONS
+
+
+
+

38. TORIC ICL IMPLANTATION AFTER
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 of 9 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 FS 60): 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

41. UCVA & BCVA
0.58
0.6
0.48
0.46
0.5
0.46
0.4
0.3
0.16
0.2
0.1
0.08
0.06
0.01
0
Pre-OP
Post-ICR
Post-ICR+CXL
UCVA
Pre-Op
Post-ICR
Post-ICR+CCL
Post-ICL
UCVA
0,01
0,06
0,08
0,46
BCVA
0,16
0,46
0,48
0,58
BCVA
Post-ICL

42. CYLINDER & SEQ
-18
-16.4
-16
-14
-12
-9.81
-9.56
-10
-8
-6
-4.73
-4
-2
-2.36
Pre-OP
Post-ICR
-1.88
Post-ICR+CXL
0
CYL
CYL
Pre-Op
Post-ICR
Post-ICR+CCL
Post-ICL
SEQ
SEQ
-4,73
-2,36
-1,88
-0,96
-16,4
-9,81
-9,56
-0,8
-0.96 -0.8
Post-ICL

43. Mean K
59
58
58,36
57
56
55,77
55
54
54.07
54.03
Post-ICR+CXL
Post-ICL
53
52
51
Pre-OP
Post-ICR
Mean K
Pre-Op
Post-ICR
Post-ICR+CCL
Post-ICL
58,36
55,77
54,07
54,03

44. K1
57
56,16
56
56,1-54,7=1,4 D
55
54,78
54
53.54
53
53.57
52
Pre-OP
Post-ICR
Post-ICR+CXL
K1
Pre-Op
Post-ICR
Post-ICR+CCL
Post-ICL
56,16
54,78
53,54
53,57
Post-ICL

45. K2
62
60
60,57
60,5-56,7=3,8 D
58
56,76
56
54
54.61
54.48
Post-ICR+CXL
Post-ICL
52
50
Pre-OP
Pre-Op
Post-ICR
Post-ICR+CCL
Post-ICL
Post-ICR
K2
60,57
56,76
54,61
54,48

47. METHODS
7M
<7 D
Irregularity
8,4 M
 Stop Progression
 <1,5D
Irregularity
Sph<-18 D
Cyl<5 D

48. COMBINED TREATMENT
+
+
+

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

50. 11/13/2008 PREOP FEMALE, 18 Y

51. 11/13/2008 PREOP FEMALE, 18 Y

52. ICR SURGERY 14/11/2008
POSTOP ICR 22/11/2008

53. ICR SURGERY 14/11/2008
POSTOP ICR 22/11/2008

54. PREOP
POSTOP ICR

55. CCL SURGERY 06/01/2009
POSTOP CCL 30/03/2009

56. PREOP ICL 24/02/2012
Man Ref:-4.00(-6.00x 80)
UCVA: 0.1
BCVA: 0.5

57. ICL SURGERY 03/07/2012
PREOP ICL 24/02/2012
Man Ref:-4.00(-6.00x 80)
UCVA: 0.1
BCVA: 0.5

58. POSTOP ICL /
PREOP TOPO 28/02/2013
Man Ref:-1.75(-2.00x 35)
UCVA: 0.3
BCVA: 0.5

59. TOPO SURGERY 05/03/2013
POSTOP TOPO 19/09/2013
Man Ref:-0.75(-1.00x 30)
UCVA: 0.7
BCVA: 0.8

60. 5 Years
PREOP
2008
POSTOP ICR
2008
POSTOP CCL
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
POSTOP SEPT/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
 Stop Progression
<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

64. THANK YOU
efekan.coskunseven@dunyagoz.com