Intrastromal corneal ring Kyriakidou Nantia M.D. Diathlasis Day Care Unit Scienti1ic Workshop of Diathlasis Day Care Unit 18-19 November, 2016 The Met Hotel Thessaloniki, Greece DAY CARE UNIT DIATHLASIS, THESSALONIKI, GREECE
I have no :inancial interest
Intrastromal corneal ring 1987 Fleming and Reynold Early myopia 1994 CE - Myopia (- 1,0 D to 3,0D) 1999 FDA - Myopia (- 1,0 D to 3,0D) 2004 FDA Keratoconus, Ectasia
Types of CRS Intacs Kerarings (Mediphacos, Inc, Belo Horizonte, Brazil ) Ferrara (Ferrara Ophthalmics, Inc, Belo Horizonte, Brazil) Bisantis (Opticon 2000SpA and Soleclo SpA, Rome, Italy) MyoRing (Dioptex GmbH, Linz, Austria)
Indications for CRS implantation Keratoconus Pellucid Marginal Degeneration Iatrogenic Ectasia Ectasia (Post Lasik, PRK) Irregular astigmatism after PKP Irregular astigmatism after RK Treatment of post- trauma corneal irregularities
Indications for CRS implantation in patients suffer from keratoconus Unsatisfactory VA with glasses Contact lens intolerance Mild and moderate keratoconus K reading less than 58D Clear cornea and optical zone with no corneal scarring Corneal thickness greater than 450μm in the area of the proposed tunnels
Contraindications Acute keratoconus (K 70D) possibly poor visual outcome Hydrops Corneal scarring Endothelial cell count 1000cel/μm
Contraindications Severe atopic patients eye rubbing can cause complications e.g. ring migration Decentered PKP complications during surgery Recurring Corneal Erosion Syndrome possible melting, extrusion and infection
Theory of ICRS Mechanism of Action
Surgical Planning Topography (sagittal curvature map, axial map, anterior elevation map) Pachymetry map (large and detailed) Manifest Refraction (subjective) BCVA LO, HO, Coma map/axis
Surgical Planning
DAY CARE UNIT DIATHLASIS, THESSALONIKI, GREECE
Data Male Age 46 5/10( - 3,25*10 ) 10/10 (- 1,00-0,50*80) 12 months follow up
Data Male Age 24 CXL + Keraring 3months follow up 5/10 (- 2,00-4,00*60) 10/10 (- 0,50)
Intraoperative Complications Mechanical procedure Segment decentration Asymmetry of the implants Inadequate depth of channel Super1icial channel dissection with anterior Bowman s layer perforation Femtosecond procedure Incomplete channel formation. Incorrect entry of the channel Mechanical epithelial defects at the keratotomy site Posterior cornea perforation during channel creation
Postoperative Complications Anterior chamber perforation Corneal in1iltrate Segment migration Corneal melting Mild infection Cornea neovascularization Epithelial plug at the incision site Night halos Chronic pain Focal edema around segments
Materials and method A complete ophthalmic examination was performed preoperatively including: Visual acuity (UCVA) Keratometric readings (K) HO aberration, LO aberration, Coma Follow up (10 months)
Statistical analysis of CRS (Keraring) based on a sample from diathlasis day care unit A total of 17 patients (24 eyes) suffer from clinical keratoconus were selected for investigation All surgical procedures were performed by the same surgeon Age (31.083 ± 8.505 years) Range 22-47 years 92% of total eyes are male and 8% eyes are female 17 eyes undergone CXL therapy 1 eye undergone CXL therapy+ Keraring implantation guided by femtosecond laser
Statistical analysis of ICRS (Keraring) based on a sample from diathlasis day care unit Age distribution Gender distribution Cross Linking (CXL) therapy distribution Comparison of preoperative and post operative outcome (UDVA, SE)
Age distribution n = 24 eyes Age = (31.083 ± 8.505) years 22 years Age range 47 years Mode = 23 years
Gender distribution Total numper of eyes (n) Female Male 24 2 22 100% 8% 92%
CXL therapy distribution Total numper of eyes (n) Numper of patients undergone CXL Numper of patients did not undergone CXL 24 17 7 100% 71% 29%
Comparison of pre- operative and 1 month post- operative UDVA n = 24 eyes UDVApre- operative = 0.467 ± 0.181 0.2 UDVApre- operative range 0.8 Mode = 0.40 (4/10) UDVApost- operative = 0.700 ± 0.184 0.4 UDVApost- operative range 1.0 Mode = 0.80 (8/10)
Comparison of pre- operative and 6 month post- operative UDVA n = 24 eyes UDVApre- operative = 0.467 ± 0.181 0.2 UDVApre- operative range 0.8 Mode = 0.40 (4/10) UDVA6month- post = 0.746 ± 0.182 0.4 UDVA6month- post range 1.0 Mode = 0.80 (8/10)
Comparison of pre- operative and 1 month post- operative SE n = 24 eyes SEpre- operative = (- 3.823 ± 2.645)D - 11.38D SEpre- operative range - 0.50D Mode = - 2.00D SE1month- post = (- 2.130 ± 1.826)D - 6.38D SE1month- post range 1.88D Mode = - 3.50D
Comparison of pre- operative, 1month and 6 month post- operative SE n = 24 eyes SEpre- operative = (- 3.823 ± 2.645)D - 11.38D Sepre- operative range - 0.50D Mode = - 2.00D SE6monthpost- operative = (- 1.964 ± 1.794)D - 5.55D SE6monthpost- operative range 2.00D Mode = 0.00D
Comparison of pre- operative, 1month and 6 month post- operative K1 (Corneal dioptric power in the :lattest meridian in the central zone) n = 24 eyes K1pre- operative = (45.079 ± 3.334)D 37.9D K1pre- operative range 51.3D Mode = 52.70D K11month post = (44.292 ± 2.793)D 38.8D K11month post range 49.5D Mode = 46.80D K16month post = (44.321 ± 2.799)D 38.7D K16month post range 49.5D Mode = 42.10D
Comparison of pre- operative, 1month and 6 month post- operative K2 (Corneal dioptric power in the steepest meridian in the central zone) n = 24 eyes K2pre- operative = (48.533 ± 3.210)D 41.8D K2pre- operative range 54.10D Mode = 50.0 D K21month post = (46.388 ± 3.012)D 40.6D K21month post range 52.5D Mode = 44.80D K26month post = (46.233 ± 3.042)D 40.5D K26month post range 53.8D Mode = 45.7D
Comparison of pre- operative, 1 month and 6 month post- operative Kmax (Mean corneal dioptric power) n = 24 eyes Kmaxpre- op. = (55.683 ± 7.139)D 48.6D Kmaxpre- op. range 50.4D Mode = 50.40 D Kmax1month post = (52.421 ± 5.104)D 46.0D Kmax1month post range 67.7D Mode = 50.30D Kmax6month post = (51.292 ± 4.981)D 44.2D Kmax6month post range 61.8D Mode = 54.0D
Comparison of pre- operative, 1 month and 6 month post- operative LO n = 24 eyes LO pre- op. = (4.947 ± 3.413)μm 0.0μm LOpre- op. range 9.01 μm Mode = 0.0 μm LO 1month post = (2.854 ± 1.828) μm 0.0μm LO 1month post range 7.95μm Mode = 0.0 μm LO 6month post = (2.775 ± 1.802)μm 0.0μm LO 6month post range 8.08μm Mode = 0.0 μm
Comparison of pre- operative, 1month and 6 month post- operative HO n = 24 eyes HO pre- op. = (1.535 ± 1.064)μm 0.0μm HOpre- op. range 3.64 μm Mode = 0.0 μm HO 1month post = (1.097 ± 0.792) μm 0.0μm HO 1month post range 3.48μm Mode = 0.0 μm HO 6month post = (1.092 ± 0.786)μm 0.0μm HO 6month post range 2.95μm Mode = 0.0 μm
Comparison of pre- operative, 1 month and 6 month post- operative COMA n = 24 eyes COMA pre- op. = (1.322 ± 0.978)μm 0.0μm COMApre- op. range 3.11 μm Mode = 0.0 μm COMA 1month post = (0.819 ± 0.657) μm 0.0μm COMA1month post range 2.40μm Mode = 0.0 μm COMA 6month post = (0.763 ± 0.621)μm 0.0μm COMA6month post range 2.40μm Mode = 0.0 μm
Conclusion Keraring implantation guided by femtosecond laser is a safe and a high ef:icacy method. It is provided signi1icant improvement in visual acuity, spherical equivalent, and keratometry results. The CRS is an effective treatment for managing keratoconus and might delay or even avoid the need for penetrating keratoplasty.
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