Slides do curso avançado de atualização em implante de Anel de Ferrara, elaborado por Ferrara Ophtalmics. Para material completo, acesse www.aneldeferrara.com.br

1. Curso de Implante deCurso de Implante de

2. 19501950 -- Barraquer, J., Intracorneal implantsBarraquer, J., Intracorneal implants
19661966 -- BlavatskayaBlavatskaya -- Corneal rings from corneal tissueCorneal rings from corneal tissue
19861986 -- Simon, G.Simon, G. -- Silicon RingsSilicon Rings
19871987 -- FlemingFleming -- Adjustable ringsAdjustable rings
19911991 -- NosNoséé, W, W -- Single piece rings for low myopiaSingle piece rings for low myopia
19911991-- Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia19911991-- Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia
19961996 -- Ferrara, P.Ferrara, P. -- Ring segments for KeratoconusRing segments for Keratoconus
19971997 -- Colin, J.Colin, J.-- Ring segments for KeratoconusRing segments for Keratoconus
Barraquer, J., Intracorneal implantsBarraquer, J., Intracorneal implants
Corneal rings from corneal tissueCorneal rings from corneal tissue
Silicon RingsSilicon Rings
Adjustable ringsAdjustable rings
Single piece rings for low myopiaSingle piece rings for low myopia
Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia
Ring segments for KeratoconusRing segments for Keratoconus
Ring segments for KeratoconusRing segments for Keratoconus

3. BARRAQUERBARRAQUER’’ss
MYOPIA CORRECTIONMYOPIA CORRECTION
Remove tissue of the center of the cornea;Remove tissue of the center of the cornea;
Add tissue to the periphery of the cornea.Add tissue to the periphery of the cornea.
HYPEROPIA CORRECTIONHYPEROPIA CORRECTION
Add tissue to the center of the corneaAdd tissue to the center of the cornea
Remove tissue from the periphery of the corneaRemove tissue from the periphery of the cornea
THICKNESS LAWTHICKNESS LAW
MYOPIA CORRECTIONMYOPIA CORRECTION
Remove tissue of the center of the cornea;Remove tissue of the center of the cornea;
Add tissue to the periphery of the cornea.Add tissue to the periphery of the cornea.
HYPEROPIA CORRECTIONHYPEROPIA CORRECTION
Add tissue to the center of the corneaAdd tissue to the center of the cornea
Remove tissue from the periphery of the corneaRemove tissue from the periphery of the cornea

4. BLAVATSKAYABLAVATSKAYA
The larger (diameter) the ring the lesser theThe larger (diameter) the ring the lesser the
correctioncorrection
The thicker the ring the greater the correctionThe thicker the ring the greater the correctionThe thicker the ring the greater the correctionThe thicker the ring the greater the correction
BLAVATSKAYABLAVATSKAYA’’S LAWS LAW
The larger (diameter) the ring the lesser theThe larger (diameter) the ring the lesser the
correctioncorrection
The thicker the ring the greater the correctionThe thicker the ring the greater the correctionThe thicker the ring the greater the correctionThe thicker the ring the greater the correction

6. Material PMMAMaterial PMMA
YELLOW FILTERYELLOW FILTER
Apical Diameter 5mmApical Diameter 5mm
Triangular cross section= prismaticTriangular cross section= prismatic
effecteffect
Flat Basis width 0,6 mmFlat Basis width 0,6 mm
Variable arch lengh and thicknessVariable arch lengh and thickness
Triangular cross section= prismaticTriangular cross section= prismatic

7. Variable thicknessesVariable thicknessesVariable thicknessesVariable thicknesses

8. Asphericity (Q)Asphericity (Q)Asphericity (Q)Asphericity (Q)

10. CORNEAL ASPHERICITYCORNEAL ASPHERICITY
OblateOblate
0,50,5
CORNEAL ASPHERICITYCORNEAL ASPHERICITY
HyperpHyperpProlateProlate
00 --11 --22--0,230,23

11. INDICATIONSINDICATIONS
CORNEAL IRREGULARITIESCORNEAL IRREGULARITIES
PRIMARYPRIMARY
KERATOCONUSKERATOCONUS
PELUCID MARGINAL DEGENERATIONPELUCID MARGINAL DEGENERATION
IATROGENYIATROGENY
PKPPKPPKPPKP
PRK; LASIK; RKPRK; LASIK; RK
TRAUMATRAUMA
REFRACTIVEREFRACTIVE
INDICATIONSINDICATIONS
CORNEAL IRREGULARITIESCORNEAL IRREGULARITIES
PELUCID MARGINAL DEGENERATIONPELUCID MARGINAL DEGENERATION

12. INDICATIONSINDICATIONSINDICATIONSINDICATIONS

13. CONTRAINDICATIONSCONTRAINDICATIONS
11.. VeryVery advancedadvanced keratoconuskeratoconus11.. VeryVery advancedadvanced keratoconuskeratoconus
andand significantsignificant apicalapical opacityopacity
22.. HydropsisHydropsis;;
33.. ThinThin corneas,corneas, withwith thicknessthickness
ckck;;
44.. PatientsPatients withwith intenseintense
oreore thethe
implant)implant)
CONTRAINDICATIONSCONTRAINDICATIONS
keratoconuskeratoconus withwith curvaturescurvatures overover 6060 diodiokeratoconuskeratoconus withwith curvaturescurvatures overover 6060 diodio
opacityopacity andand scarringscarring;;
thicknessthickness belowbelow 300300 micramicra inin thth
atopiaatopia (these(these shouldshould bebe tt

14. FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Evolution of the NomogramEvolution of the Nomogram
First generation (1997First generation (1997
Second generation (2002Second generation (2002
equivalentequivalent
Third generation (2006Third generation (2006
Evolution of the NomogramEvolution of the Nomogram
(criteria for ring selection)(criteria for ring selection)
Third generation (2006Third generation (2006
astigmatismastigmatism
Fourth generation (May 2009 to now):Fourth generation (May 2009 to now):
FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Evolution of the NomogramEvolution of the Nomogram
-- 2002): keratoconus gra2002): keratoconus gra
Second generation (2002Second generation (2002 -- 2006): spherical2006): spherical
-- 2009): topographic2009): topographic
Evolution of the NomogramEvolution of the Nomogram
-- 2009): topographic2009): topographic
Fourth generation (May 2009 to now):Fourth generation (May 2009 to now): asphericitasphericit

15. FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Second generation (2002Second generation (2002
equivalentequivalentequivalentequivalent
Eye 1Eye 1
Refraction:Refraction: --10.00 D10.00 D
Are these the same?Are these the same?
NO !NO !
FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Second generation (2002Second generation (2002 -- 2006): spherical2006): spherical
Eye 2Eye 2
Refraction:Refraction: --10.00 D10.00 D
Are these the same?Are these the same?
NO !NO !

16. FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
Third generation (2006Third generation (2006 --
astigmatismastigmatismastigmatismastigmatism
Eye 1Eye 1
ratometry: 42.00 x 47.00 Dratometry: 42.00 x 47.00 Dratometry: 42.00 x 47.00 Dratometry: 42.00 x 47.00 D
Are these the same ?Are these the same ?
NO !NO !
FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM
2009): topographic2009): topographic
Eye 2Eye 2
Keratometry: 52.00 x 57.Keratometry: 52.00 x 57.
Are these the same ?Are these the same ?
NO !NO !
Keratometry: 52.00 x 57.Keratometry: 52.00 x 57.

17. Asphericity (Q)Asphericity (Q)
NOMOGRAMNOMOGRAM
Concept related to the shape of the cornea;Concept related to the shape of the cornea;
““NormalNormal”” cornea: mild prolate;cornea: mild prolate;
Range: oblate (hiperopesRange: oblate (hiperopes
Asphericity (Q)Asphericity (Q)
Range: oblate (hiperopesRange: oblate (hiperopes
to prolate (myopesto prolate (myopes -- keratoconus)keratoconus)
Q values:Q values: tt --0.230.23 ±± 0.080.08
GonzGonzáálezlez--MMééijome JM, Cerviijome JM, Cerviñño A, ET AL. Asfericidad corneal en una poblo A, ET AL. Asfericidad corneal en una pobláá
2004;79:3852004;79:385--392.392.
Asphericity (Q)Asphericity (Q)
NOMOGRAMNOMOGRAM
Concept related to the shape of the cornea;Concept related to the shape of the cornea;
cornea: mild prolate;cornea: mild prolate;
Range: oblate (hiperopesRange: oblate (hiperopes -- post myopic ablation)post myopic ablation)
Asphericity (Q)Asphericity (Q)
Range: oblate (hiperopesRange: oblate (hiperopes -- post myopic ablation)post myopic ablation)
keratoconus)keratoconus)
0.080.08 (young adults, at 4,5 mm)(young adults, at 4,5 mm) YebraYebra--PimentePimente
áácion de adultos jcion de adultos jóóvenes. Implicaciones clvenes. Implicaciones clíínicas. Arch Soc Esp Oftalmonicas. Arch Soc Esp Oftalmo

18. HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
phericity law
Addition in the cornea
ange – frequently without
ncomitant significant corneal
Ring diameter = how
attened, the astigmatism
phericity will be changed
HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
cornea periphery = aspherici
without
corneal flattening;
much the cornea will
astigmatism and
changed

19. HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
phericity lawphericity law
Ring arc length = how
ratometry and astigmatism
anged. The shorter theanged. The shorter the
tigmatic correction, the
phericity change.
HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS
how much the asphericit
astigmatism will be
segment, the greater tsegment, the greater t
the lesser the

20. NOMOGRAMNOMOGRAM
The asphericity is the best parameter, at theThe asphericity is the best parameter, at the
present moment, for ring selection;present moment, for ring selection;
There is a tendency to implantThere is a tendency to implant
achieve the same (or better) correction than wasachieve the same (or better) correction than was
achieved in the past;achieved in the past;
QQ value =value = QQuality of visionuality of vision
NOMOGRAMNOMOGRAM
The asphericity is the best parameter, at theThe asphericity is the best parameter, at the
present moment, for ring selection;present moment, for ring selection;
There is a tendency to implantThere is a tendency to implant ““lessless”” tissue totissue to
achieve the same (or better) correction than wasachieve the same (or better) correction than was
uality of visionuality of vision

21. 40 arc = PMD40 arc = PMD
-- Q 0 or positiveQ 0 or positive
10 arc = Nipple10 arc = Nipple
-- Q negative (hyperprolateQ negative (hyperprolate
cornea)cornea)
90% of keratoconus (90% of keratoconus (““standardstandard”” ring)ring)
--
hyperprolate cornea)hyperprolate cornea)
Q negative (hyperprolateQ negative (hyperprolate
ring)ring)
Q negative (prolate toQ negative (prolate to

22. General GuidelinesGeneral Guidelines
NOMOGRAMNOMOGRAM
MUST BE DETERMINED:
The type of keratoconus:
Central
ple
Oval (paracentral)Oval (paracentral)
PMD
The corneal asphericity (Q)
The pachymetry at the corneal steepest axis and
General GuidelinesGeneral Guidelines
NOMOGRAMNOMOGRAM
Central
Oval (paracentral)Oval (paracentral)
The corneal asphericity (Q)
The pachymetry at the corneal steepest axis and

23. Type of keratoconusType of keratoconus
NOMOGRAMNOMOGRAMNOMOGRAMNOMOGRAM

24. Type of keratoconusType of keratoconus
NOMOGRAMNOMOGRAM
CentralCentral
(Nipple(Nipple))
NOMOGRAMNOMOGRAM
OvalOvalOvalOval

25. NOMOGRAMNOMOGRAMNOMOGRAMNOMOGRAM

26. -0,07
-0,569999993
-0,340000004
-0,310000002
150 200 250 150-150
-0,800000012
-0,730000019
-0,99000001
-1,019999981
-0,860000014
150-200 150-250 200-200 200-250 250-250

27. variation according to ring thicknessvariation according to ring thickness
Single Segments (Single Segments (µµm)m) ∆∆QQ
150150 -- 0.070.07
200200 -- 0.310.31
250250 -- 0.340.34
Paired Segments (Paired Segments (µµm)m)
150150 –– 150150 -- 0.570.57
150150 –– 200200 -- 0.730.73
150150 –– 250250 -- 0.800.80
200200 –– 200200 -- 0.860.86
200200 –– 250250 -- 1.021.02
variation according to ring thicknessvariation according to ring thickness
QQ ∆∆KK pp valuevalue
0.070.07 0.78 D0.78 D 0.0420.042
0.310.31 1.82 D1.82 D < 0.001< 0.001
0.340.34 2.74 D2.74 D < 0.001< 0.001
0.570.57 3.40 D3.40 D < 0.001< 0.001
0.730.73 4.35 D4.35 D < 0.001< 0.001
0.800.80 3.86 D3.86 D 0.0010.001
0.860.86 5.65 D5.65 D < 0.001< 0.001
1.021.02 6.27 D6.27 D < 0.001< 0.001

28. NOTENOTE:: (THIS(THIS ISIS VALIDVALID FORFOR
segmentsegment oror pairpair ofof segmentssegments
ostoperativeostoperative corneacornea asphericityasphericityostoperativeostoperative corneacornea asphericityasphericity
thisthis happenshappens soso itit isis advisableadvisable
choosechoose aa pairpair ofof segmentssegments
tsts thisthis conditioncondition eveneven ifif
hievedhieved KERATOMETRICKERATOMETRIC
rrectionrrection isis smallersmallerrrectionrrection isis smallersmaller
anan thethe desireddesired oneone..
FORFOR ALLALL MAPS)MAPS)
segmentssegments SHOULDSHOULD notnot turnturn thethe expecexpec
asphericityasphericity (Q)(Q) significantlysignificantly belowbelow --00..22asphericityasphericity (Q)(Q) significantlysignificantly belowbelow --00..22
advisableadvisable
segmentssegments thatthat
ifif thethe

29. NippleNipple
NOMOGRAMNOMOGRAM
NippleNipple
NOMOGRAMNOMOGRAM
Q change induced by the 2Q change induced by the 2
ringring

30. Nipple ConesNipple Cones
NOMOGRAMNOMOGRAM
Nipple ConesNipple Cones
NOMOGRAMNOMOGRAM

31. Nipple ConesNipple Cones
The 210 ringThe 210 ring
Nipple ConesNipple Cones
The 210 ringThe 210 ring

32. Pellucid Marginal DegenerationPellucid Marginal Degeneration
NOMOGRAMNOMOGRAM
Pellucid Marginal DegenerationPellucid Marginal Degeneration
NOMOGRAMNOMOGRAM

33. ITIT MUSTMUST BEBE DETERMINEDDETERMINED::
NOMOGRAMNOMOGRAM
ITIT MUSTMUST BEBE DETERMINEDDETERMINED::
TheThe pachymetrypachymetry atat thethe cornealcorneal
probableprobable ringring tracktrack
((55 mmmm opticaloptical zone)zone)
IncisionIncision ((8080%% depth)depth)::
11 segmentsegment:: atat 9090
ringring atat thethe steepeststeepest axisaxis
NOMOGRAMNOMOGRAM
cornealcorneal steepeststeepest axisaxis andand
909000 axisaxis –– thethe tiptip ofof thethe
axisaxis

34. WHYWHY THETHE INCISIONINCISION SHOULDSHOULD BEBE ATAT
NOMOGRAMNOMOGRAM
SuperficialSuperficial stromastroma
8080%% DEPTH?DEPTH?
NOMOGRAMNOMOGRAM
DeepDeep stromastroma

35. TETE::(THIS(THIS ISIS VALIDVALID FORFOR ALLALL
CHYMETRYCHYMETRY’’SS LAWLAW
ee thickestthickest segmentsegment ofof aa
segmentssegments cannotcannot exceedexceed
thicknessthickness ofof thethe corneacornea
bedbed..
thisthis happenshappens soso oneonethisthis happenshappens soso oneone
choosechoose aa pairpair ofof segmentssegments
tsts thisthis conditioncondition eveneven
achievedachieved correctioncorrection isis smallersmaller
ALLALL MAPS)MAPS)
aa pairpair ofof
exceedexceed halfhalf
corneacornea inin itsits
oneone hashas totooneone hashas toto
segmentssegments thatthat
eveneven ifif thethe
smallersmaller

37. IncisionIncision
544 micra544 micra

38. superiorsuperior inferiorinferior

39. SUMMARYSUMMARY
GENERAL RULESGENERAL RULES
NOMOGRAMNOMOGRAM
Q preoperativeQ preoperative -- Q change induced by the ringQ change induced by the ring
-- 0.23 (TARGE FINAL Q VALUE)0.23 (TARGE FINAL Q VALUE)
SUMMARYSUMMARY
GENERAL RULESGENERAL RULES
NOMOGRAMNOMOGRAM
Q change induced by the ringQ change induced by the ring ==
0.23 (TARGE FINAL Q VALUE)0.23 (TARGE FINAL Q VALUE)

40. ASPHERICITY _ RING SELECTIONASPHERICITY _ RING SELECTION
VI. NOMOGRAMVI. NOMOGRAM
ate corneas (Q < -0.23):
gle 140 or 160 (arc) segments
erately prolate corneas
gle or paired 160 (arc)
erprolate corneas
red 160 (arc) segments or
ASPHERICITY _ RING SELECTIONASPHERICITY _ RING SELECTION
VI. NOMOGRAMVI. NOMOGRAM
:
segments
corneas (- 0.23 < Q < -1
segments
(Q > - 1
or 210 segment if nipple

41. VII. SURGICAL TECHNIQUEVII. SURGICAL TECHNIQUE
ManualManual
FemtosecomdFemtosecomd
VII. SURGICAL TECHNIQUEVII. SURGICAL TECHNIQUE
ManualManual
FemtosecomdFemtosecomd

42. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um
descompressor
são necessários para ver esta imagem.
DP, Alio JL, El Kady B, Coskunseven E, Morbelli H
ve and aberrometric outcomes of intracorneal ri
ond-assisted procedures. Ophthalmology. 2009 Sep;116(9):1675
MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um
Codec YUV420 descompressor
são necessários para ver esta imagem.
Morbelli H, Uceda-Montanes A, Maldonado MJ, Cuevas D, Pa
ntracorneal ring segments for keratoconus: mechanical versus
assisted procedures. Ophthalmology. 2009 Sep;116(9):1675-87.

43. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER

44. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER

45. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER

46. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um
descompressor
são necessários para ver esta imagem.

47. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um
descompressor
são necessários para ver esta imagem.

48. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER
O QuickTime™ e um
descompressor
são necessários para ver esta imagem.

49. MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER

50. FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL
O QuickTime™ e um
DV/DVCPRO - NTSC descompressor
são necessários para ver esta imagem.
FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL
O QuickTime™ e um
DV/DVCPRO - NTSC descompressor
são necessários para ver esta imagem.

51. FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL

52. FERRARA RING +TORIC ICLFERRARA RING +TORIC ICL
O QuickTime™ e um
Codec YUV420 descompressor
são necessários para ver esta imagem.
FERRARA RING +TORIC ICLFERRARA RING +TORIC ICL
O QuickTime™ e um
Codec YUV420 descompressor
são necessários para ver esta imagem.

53. FERRARA RING +TORIC IOLFERRARA RING +TORIC IOLFERRARA RING +TORIC IOLFERRARA RING +TORIC IOL

55. VIII . CLINICAL CASESVIII . CLINICAL CASES
/200/200 --6.006.00--2.50x102.50x10
PREOPPREOP
POSTOPPOSTOP
0/40 pl0/40 pl--5.000x505.000x50
RGICAL PLANNING ?RGICAL PLANNING ?
0/40 pl0/40 pl--5.000x505.000x50
VIII . CLINICAL CASESVIII . CLINICAL CASES

56. VIII . CLINICAL CASESVIII . CLINICAL CASES
/400 +3.00/400 +3.00--6.00x856.00x85
Cataract + PMDCataract + PMD
PREOPPREOP
POSTOPPOSTOP
/30 +0.50/30 +0.50--3.00x853.00x85
RGICAL PLANNING ?RGICAL PLANNING ?
/30 +0.50/30 +0.50--3.00x853.00x85
VIII . CLINICAL CASESVIII . CLINICAL CASES

57. VIII . CLINICAL CASESVIII . CLINICAL CASES
NippleNipple
/60/60 --8.508.50--1.50x1401.50x140
PREOPPREOP
POSTOPPOSTOP
/40/40 ----0.500.50--1.50x401.50x40
RGICAL PLANNING ?RGICAL PLANNING ?
/40/40 ----0.500.50--1.50x401.50x40
VIII . CLINICAL CASESVIII . CLINICAL CASES

58. •• -- RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
COMPLICATIONSCOMPLICATIONS
•• -- RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
•• -- RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM
-- RELATED TO THE RINGRELATED TO THE RING•• -- RELATED TO THE RINGRELATED TO THE RING
RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
COMPLICATIONSCOMPLICATIONS
RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE

59. •• RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
-- Extrusion 0.1%Extrusion 0.1%•• -- Extrusion 0.1%Extrusion 0.1%
•• -- Infection 0.08%Infection 0.08%
•• -- Bad centration of the segmentBad centration of the segment
•• -- MigrationMigration
•• -- RotationRotation•• -- RotationRotation
•• -- Misplacement or asimmetry of theMisplacement or asimmetry of the
segmentssegments
RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE
Bad centration of the segmentBad centration of the segment
Misplacement or asimmetry of theMisplacement or asimmetry of the

60. EXTRUSIONEXTRUSION
ExtrusionExtrusion
EXTRUSIONEXTRUSION
Shallow tunnelShallow tunnel

61. EXTRUSIONEXTRUSIONEXTRUSIONEXTRUSION

62. INFECTIONINFECTIONINFECTIONINFECTION

63. MIGRATIONMIGRATIONMIGRATIONMIGRATION

64. ASYMMETRY of SEGMENTSASYMMETRY of SEGMENTSASYMMETRY of SEGMENTSASYMMETRY of SEGMENTS

65. WRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RING

66. RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM
(corneal bio(corneal bio
11--OvercorrectionOvercorrection
22--UndercorrectionUndercorrection
RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM
(corneal bio(corneal bio--mechanics)mechanics)
OvercorrectionOvercorrection
UndercorrectionUndercorrection

70. RELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RING
Halos and GlareHalos and Glare
Periannelar depositsPeriannelar deposits
NeovascularizationNeovascularizationNeovascularizationNeovascularization
RELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RING
Halos and GlareHalos and Glare
Periannelar depositsPeriannelar deposits
NeovascularizationNeovascularizationNeovascularizationNeovascularization

73. YELLOW RINGYELLOW RING
Preop CPreop C
YELLOW RINGYELLOW RING
Preop CPreop C--QuantQuant

74. YELLOW RINGYELLOW RING
Postop CPostop C
YELLOW RINGYELLOW RING
Postop CPostop C--QuantQuant

76. METHODSMETHODS
SampleSample:: 10731073 eyeseyes ofof 810810 patientspatients consecutivelyconsecutively
toto JulyJuly 20082008
TwoTwo groupsgroups (type(type ofof ringring implanted)implanted)
GroupGroup II –– patientspatients implantedimplanted withwith
GroupGroup IIII –– patientspatients implantedimplanted
StudiedStudied parametersparameters::
UncorrectedUncorrected visualvisual acuityacuity (UCVA)(UCVA)
BestBest--correctedcorrected visualvisual acuityacuity (BCVA)(BCVA)
KeratometryKeratometry (K)(K)
AsphericityAsphericity (Q)(Q)AsphericityAsphericity (Q)(Q)
PachymetryPachymetry atat thethe thinnestthinnest pointpoint
METHODSMETHODS
consecutivelyconsecutively operatedoperated fromfrom JanuaryJanuary
implanted)implanted)::
withwith thethe 160160--degreedegree ofof arcarc ringring (n=(n=9797
withwith thethe 210210--degreedegree ofof arcarc ringring (n=(n=11
(UCVA)(UCVA)
(BCVA)(BCVA)
pointpoint (PTP)(PTP) ofof thethe corneacornea.. (Pentacam)(Pentacam)

77. METHODSMETHODS
MeanMean patientpatient ageage:: 2929..22 ±± 99..44 (Group(GroupMeanMean patientpatient ageage:: 2929..22 ±± 99..44 (Group(Group
FollowFollow--upup:: 2323..88 ±± 1212..22 (Group(Group I)I) andand
llll patientspatients completedcompleted atat leastleast sixsix monthsmonths
StatisticalStatistical analysisanalysis::StudentStudent´´ss tt testtest
SPSS,SPSS, Chicago,Chicago, IL)IL)..
METHODSMETHODS
(Group(Group I)I) andand 3030..22 ±± 88..77 (Group(Group II)II);;(Group(Group I)I) andand 3030..22 ±± 88..77 (Group(Group II)II);;
andand 2222..99 ±± 1515..11 monthsmonths (Group(Group II)II)..
monthsmonths ofof followfollow--upup;;
testtest forfor pairedpaired datadata -- SPSSSPSS softwaresoftware

78. GROUP IGROUP IGROUP IGROUP I
PreopPreop PostopPostop
UCVAUCVA 20/22020/220 20/8020/80 0.0000.000
BCVABCVA 20/10020/100 20/4020/40 0.0000.000
Sph. Eq. (D)Sph. Eq. (D) --3.993.99 --2.262.26 0.0000.000
AsphericityAsphericity --0.880.88 --0.350.35 0.0000.000
Keratometry (D)Keratometry (D) 49.1849.18 45.7245.72 0.0000.000Keratometry (D)Keratometry (D) 49.1849.18 45.7245.72 0.0000.000
Pachymetry (Pachymetry (m)m) 448448 465465 0.0000.000
GROUP IIGROUP IIGROUP IIGROUP II
pp PreopPreop PostopPostop pp
0.0000.000 20/35020/350 20/13020/130 0.0010.001
0.0000.000 20/11020/110 20/6020/60 0.0000.000
0.0000.000 --8.528.52 --4.144.14 0.0000.000
0.0000.000 --1.171.17 --0.560.56 0.0000.000
0.0000.000 51.9251.92 48.1048.10 0.0000.0000.0000.000 51.9251.92 48.1048.10 0.0000.000
0.0000.000 418418 435435 0.0000.000

79. RESULTSRESULTS
Preoperative and postoperative UCVAPreoperative and postoperative UCVA
350
400
210
220
150
200
250
300
60
80
0
50
100
I II
RESULTSRESULTS
Preoperative and postoperative UCVAPreoperative and postoperative UCVA
400
250
200 Pre
Pos
100
III IV

80. 800
RESULTSRESULTS
Preoperative and postoperative BCVAPreoperative and postoperative BCVA
300
400
500
600
700
60
35
94
40
0
100
200
I II
800
RESULTSRESULTS
Preoperative and postoperative BCVAPreoperative and postoperative BCVA
400
Preo
Post
55
90
III IV

81. Complications (treatment)Complications (treatment)
Undercorrection (implantation of additional segment)Undercorrection (implantation of additional segment)
Overcorrection (segment removal followed for reimplantation)Overcorrection (segment removal followed for reimplantation)
Extrusion (segment removal)Extrusion (segment removal)
Malposition (segment repositioning)Malposition (segment repositioning)
Progressive corneal steepening (keratoplasty)Progressive corneal steepening (keratoplasty)
Ring neovascularization (bevacizumab)Ring neovascularization (bevacizumab)
TOTALTOTAL
Complications (treatment)Complications (treatment) Eyes (%)Eyes (%)
Undercorrection (implantation of additional segment)Undercorrection (implantation of additional segment) 16 (1.49)16 (1.49)
Overcorrection (segment removal followed for reimplantation)Overcorrection (segment removal followed for reimplantation) 11 (1.02)11 (1.02)
Extrusion (segment removal)Extrusion (segment removal) 6 (0.56)6 (0.56)
Malposition (segment repositioning)Malposition (segment repositioning) 4 (0.37)4 (0.37)
Progressive corneal steepening (keratoplasty)Progressive corneal steepening (keratoplasty) 2 (0.18)2 (0.18)
Ring neovascularization (bevacizumab)Ring neovascularization (bevacizumab) 2 (0.18)2 (0.18)
41 (3.82%)41 (3.82%)

82. PreoperativePreoperative 1 month1 month 1 year1 year
KKMAXMAX
52.9552.95 ±± 6.786.78 49.3649.36 ±± 6.666.66 47.6947.69 ±± 5.435.43
KKMINMIN
47.8647.86 ±± 5.195.19 45.2745.27 ±± 5.395.39 44.0344.03 ±± 4.524.52
KKMEANMEAN
50.3650.36 ±± 5.685.68 47.2947.29 ±± 5.915.91 45.7945.79 ±± 4.854.85
UCVAUCVA 0.120.12 ±± 0.140.14 0.250.25 ±± 0.190.19 0.330.33 ±± 0.230.23
2 years2 years 3 years3 years 4 years4 years 5 year5 year
5.435.43 47.7747.77 ±± 5.265.26 47.8147.81 ±± 5.875.87 48.0748.07 ±± 6.266.26 48.0948.09 ±± 5.5.
4.524.52 44.2944.29 ±± 4.464.46 44.0444.04 ±± 4.854.85 44.8244.82 ±± 5.575.57 44.4544.45 ±± 5.5.
4.854.85 45.9645.96 ±± 4.654.65 45.8345.83 ±± 5.085.08 46.4446.44 ±± 5.905.90 46.2446.24 ±± 5.5.
0.290.29 ±± 0.180.18 0.340.34 ±± 0.230.23 0.420.42 ±± 0.310.31 0.310.31 ±± 0.20.2

83. errara intrastromal corneal ring segments implantation
keratoconus patients: 10
Leonardo Torquetti, Guilherme Ferrara, Paulo Ferrara
errara intrastromal corneal ring segments implantation
keratoconus patients: 10-year follow-up.
Leonardo Torquetti, Guilherme Ferrara, Paulo Ferrara

84. KERATOMETRY
errara intrastromal corneal ring segments implantation
keratoconus patients: 10
KERATOMETRY
errara intrastromal corneal ring segments implantation
keratoconus patients: 10-year follow-up.

85. VISUAL ACUITY (UCVA
errara intrastromal corneal ring segments implantation
keratoconus patients: 10
VISUAL ACUITY (UCVA – BCVA)
errara intrastromal corneal ring segments implantation
keratoconus patients: 10-year follow-up.

86. errara intrastromal corneal ring segments implantation
keratoconus patients: 10
errara intrastromal corneal ring segments implantation
keratoconus patients: 10-year follow-up.

87. errara intrastromal corneal ring segments implantation
keratoconus patients: 10
errara intrastromal corneal ring segments implantation
keratoconus patients: 10-year follow-up.

89. culated exponential cell loss rate over tculated exponential cell loss rate over t
mean interval of followmean interval of follow
1.4% per year1.4% per year
culated exponential cell loss rate over tculated exponential cell loss rate over t
mean interval of followmean interval of follow--up (4 years):up (4 years):
1.4% per year1.4% per year
Endothelial Cell Loss (per yeEndothelial Cell Loss (per ye

91. PreoperativePreoperative
UCVAUCVA 20/18520/185
BCVABCVA 20/12520/125BCVABCVA 20/12520/125
Apex PachymetryApex Pachymetry 457.7457.7
Asphericity (Q)Asphericity (Q) --0.950.95
PreoperativePreoperative PostoperativePostoperative
20/6620/66 p = 0.005p = 0.005
20/4020/40 p = 0.008p = 0.00820/4020/40 p = 0.008p = 0.008
466.2466.2 p =0.025p =0.025
--0.230.23 p = 0.006p = 0.006

92. WAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RING

93. Easy procedureEasy procedure
Topical anesthesiaTopical anesthesia
Quick recoveryQuick recovery
X. CONCLUSIONX. CONCLUSION
Reversible and reajustableReversible and reajustable
Do not interfere with PKPDo not interfere with PKP
Improves contact lens toleranceImproves contact lens tolerance
Independent of tissue donationsIndependent of tissue donations
Low rate of complicationsLow rate of complicationsLow rate of complicationsLow rate of complications
Improves UCVA and BSCVAImproves UCVA and BSCVA
Reduces ocular aberrationsReduces ocular aberrations
X. CONCLUSIONX. CONCLUSION

94. •• -- The surgical technique is safe andThe surgical technique is safe and
X. CONCLUSIONX. CONCLUSION
•• -- The surgical technique is safe andThe surgical technique is safe and
reproducible;reproducible;
•• -- The technique has a longThe technique has a long
•• -- There is stabilization of the disease afterThere is stabilization of the disease after
Ferrara ring implantation.Ferrara ring implantation.
The surgical technique is safe andThe surgical technique is safe and
X. CONCLUSIONX. CONCLUSION
The surgical technique is safe andThe surgical technique is safe and
The technique has a longThe technique has a long--lasting effect;lasting effect;
There is stabilization of the disease afterThere is stabilization of the disease after
Ferrara ring implantation.Ferrara ring implantation.

95. THANK YOU!THANK YOU!THANK YOU!THANK YOU!