Dr Waleed Al-Tuwairqi, MD Dr Omnia Sherif, MD

Dr Waleed Al-Tuwairqi, MD Dr Omnia Sherif, MD

By
Dr Waleed Al-Tuwairqi, MD
Dr Omnia Sherif, MD
Ophthalmology Consultants,
Elite Medical & Surgical Center
Riyadh -KSA
Rome, Italy
2013
‫بسم الرحمن الرحيم‬
In the name of Allah,
Most Gracious,
Most Merciful
2
Saudi Desert
Riyadh
Mecca
Elite
3
4
In recent years,
the technique of corneal collagen cross-linking
(CXL)
Revolutionized the management of
Keratoconus.
5
Needs epithelial removal
Does not correct refractive error
Needs long time for UV exposure (30 min.)
If combined with PRK, can give refractive surprises
6
LASIK is well established as the most commonly performed
refractive surgical procedure.
One of the most feared complications of LASIK is post operative
ectasia.
Hyperopic LASIK is associated with higher rate of regression
compared to myopic LASIK
7
The combination of CXL therapy with the LASIK
procedure has potential of ameliorating regression.
Since corneal biomechanical response has been
implicated in the patho-physiology of regression following
hyperopic LASIK, modifying the corneal biomechanical
properties might be beneficial.
8
Regression is a considerable clinical problem warranting
retreatment in a significant proportion of cases and
restricting the effective range of treatment. The
concurrent use of CXL with LASIK may also allow
treatment of a broader range of cases at risk of ectasia
from LASIK alone.
9
In this study,
we evaluated
the refractive outcomes, safety, and efficacy of
simultaneous LASIK and CXL
in hyperopic cases
&
in KC suspects
10
Vast majority of cases requesting refractive surgery have normal
topography & tomography and they are cleared easily for LASIK.
Small group of patients requesting refractive surgery have an
established diagnosis of KC.
Another small group do not have enough criteria to confirm the
diagnosis of KC (KC Suspect).
Management of this group is controversial.
11
Ankylosing Spondylitis
HLA-B27
12
No KC
F-LASIK
ICL
KC suspect
LASIK X
E. KC
PRK + CXL
ICL ± CXL
13
KC suspect
PRK
LASIK X
ICL
14
15
Identify any additional risks or complications induced by CXL.
Exclude any obvious effect of CXL on refractive outcome in
hyperopic LASIK.
Evaluate the possibility that the treatment modifies the
occurrence of regression.
Evaluate the possibility that the treatment can prevent ectasia in
KC suspects.
16
17
32
63
18
KC suspects
Hypermetrope
(40 eyes)
(23 eyes)
19
All underwent FS LASIK technique with immediate CXL
with:
riboflavin application under the flap for 1 minute and 30 seconds
followed by UV light irradiation, power of 3.6 j/cm2 for 1 minute and
30 seconds.
Follow up was done on:
2nd day postoperatively
1 month postoperatively.
20
1.
Mild superior inferior asymmetry of 1.5 – 3D
2.
Coma >0.3
3.
Anterior elevation <10µ
Posterior elevation <15
4.
Against the rule astigmatism with family history of KC
5.
One case had a superior corneal scarring due to
pannus and the topography was inconclusive.
21
Mean
25.95 ± 5.5 y
Males
11
Minimum
19 y
Females
9
Maximum
38 y
Patients
20
Patients
20
Eyes
40
22
Compound myopic astigmatism
37 eyes
Mixed astigmatism
2 eyes
Simple astigmatism
1 eye
40 eyes
23
Mean average K
44.28 ± 1.89
Mean steep K
45.24 89˚
Mean flat K
43.4 93˚
24
Mean Refraction
-2.7 -1.8 89˚
Mean corneal astigmatism
-1.95 ± 1.29
Mean coma
0.25 ± 0.16
Mean thinnest pachymetry
514.75 µ ± 31.19 µ
(468µ - 585µ)
Mean maximum ablation depth
57.6 µ ± 18.5 µ
Mean central ablation depth
56.85 µ ± 18.7 µ
25
Mean
0.21 ± 0.17
Mean
1.04 ± 0.15
Minimum
0.05
Minimum
0.05
Maximum
0.70
Maximum
1.20
Count
40 Eyes
Count
40 Eyes
26
27
Mean UCVA
(Log Mar)
Pre-Operative
2nd Day
1 M.
0.21 ± 0.17
0.87 ± 0.19
0.95 ± 0.17
28
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.95
0.87
Mean
0.21
Pre-Op
2nd day Post-Op
1M. Post-Op
29
Mean BCVA
(Log Mar)
Pre-Operative
1 M.
1.04 ± 0.15
0.98 ± 0.09
30
1.05
1.04
1.03
1.02
1.01
1.00
0.99
0.98
0.97
0.96
0.95
1.04
Mean
0.98
Pre-Op
1M. Post-Op
31
Mean
Refraction
Pre-Operative
Post-Operative
-2.7 -1.8 89˚
+0.16 -0.5 64˚
32
0.50
0.16
0.00
-0.50
-1.00
-1.50
Mean
-2.00
-2.50
-2.70
-3.00
Pre-Op
1M. Post-Op
33
1.00
0.50
0.50
0.00
-0.50
Mean
-1.00
-1.50
-1.80
-2.00
Pre-Op
1M. Post-Op
34
1.
High hypermetropia beyond the LASIK limits with shallow
anterior chamber or if pt. not interested in ICL
2.
Preoperative assessment that raised the possibility of
suboptimal outcome (based on a clinical composite
determination of corneal thickness, topography and
magnitude of refraction).
3.
Hypermetropia and high astigmatism
35
Mean
24.7 ± 5.5 y
Males
2
Minimum
19 y
Females
10
Maximum
45 y
Patients
12
Patients
12
Eyes
23
36
Compound hyperopic astigmatism 11 eyes
Mixed astigmatism
10 eyes
Simple hyperopia
2 eyes
37
Mean average K
41.87 ± 1.61
Mean steep K
42.95 86˚
Mean flat K
40.78 111˚
38
Mean Refraction
+3.4 - 1.8 109˚
Mean corneal astigmatism
-2.17 ± 1.1
Mean coma
0.25 ± 0.07
Mean thinnest pachymetry
559.13 µ ± 31.3 µ
(503µ - 596µ)
Mean maximum ablation depth
63.64 µ ± 22.67 µ
Mean central ablation depth
7.23 µ ± 9.5 µ
39
Mean
0.52 ± 0.20
Mean
0.97 ± 0.18
Minimum
0.20
Minimum
0.04
Maximum
0.90
Maximum
1.20
Count
23 Eyes
Count
23 Eyes
40
Mean UCVA
(Log Mar)
Pre-Operative
2nd Day
0.52 ± 0.20
0.87 ± 0.14
1 M.
0.9 ± 0.11
41
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
0.90
0.87
0.52
Mean
Pre-Op
2nd day Post-Op
1M. Post-Op
42
Mean BCVA
(Log Mar)
Pre-Operative
1 M.
1.04 ± 0.15
0.98 ±0.08
43
1.05
1.04
1.03
1.02
1.01
1.00
0.99
0.98
0.97
0.96
0.95
1.04
Mean
0.98
Pre-Op
1M. Post-Op
44
Mean
Refraction
Pre-Operative
Post-Operative
+3.4 -1.8 109˚
-0.07 -0.66 85˚
45
4.00
3.50
3.40
3.00
2.50
2.00
1.50
Mean
1.00
0.50
0.00
-0.07
-0.50
Pre-Op
1M. Post-Op
46
0.00
-0.20
-0.40
-0.60
-0.66
-0.80
-1.00
Mean
-1.20
-1.40
-1.60
-1.80
-1.80
-2.00
Pre-Op
1M. Post-Op
47
48
We had 5 cases with SPK (3 in the KC group) (2 in the hyperopic group).
One case of DLK in the hyperopic group resolved within 1 month.
One case of persistent CXL effect in the KC group resolved within 2
months.
None of these complications affected the visual recovery.
None of our patients lost any line of BCVA
49
50
The primary finding in our study is that the addition of
simultaneous CXL therapy to LASIK in hyperopic patients or KC
suspects does not affect the safety of the procedure.
There was no clinical or topographic evidence of flap-related
complications.
There was some early stromal haze (CXL effect), but this did not
seem to significantly affect visual recovery and resolved within a
month. Only one case persisted for 2 months but still did not limit
the visual recovery.
51
Our study indicates that UCVA quickly reaches the target levels in
both groups, without inducing any significant side effects or
compromising visual safety.
Group 1
Group 2
52
We found no significant over- or under-correction attributable to
the combination of CXL and LASIK. There was also no
suggestion of increased variability.
No alteration of the regular LASIK treatment nomogram could be
addressed in either group.
Our goal is to minimize the risk of ectasia in the KC suspect
cases and reduce risk of regression in hyperopic cases, so
longer follow up periods are required for our patients to evaluate
the incidence of long term adverse effects if any.
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Saudi Desert
Riyadh
Mecca
Elite
54