Advanced Use of Intacs and Holcomb C3-R

Advanced Use of Intacs
and Holcomb C3-R
Brian S. Boxer Wachler , MD
Beverly Hills, CA
New Intacs Discovery!
Two segments produce global flattening
Single segment produces inferior flattening
and superior steepening
Single segment better for peripheral KC
 
Sharma S, Chan CCK, Boxer Wachler BS. American
Journal of Ophthalmology, 2006.
Two segments better for central KC
Postop Day 1
elevation of shelf
flattening of cone
Preop
Intacs
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Postop Day 1
-4.75 -2.50 X 90 20/20
Preop
-3.50 -4.50 X 85 20/20
Photophobia
Responds to 2 week tapering dose of
NSAID
Rule out iritis
Rule out epi ingrowth in channel
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May require surgical epi removal
There Can be Trouble in Paradise
Setting Patient Expectations
Expect to gain on average of 2 lines of
BSCVA (range 1 to 6 lines)
If preop BSCVA on MRx:
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20/20 to 20/50
20/50 to 20/80
20/80 or worse
SCTLs, Synergeyes,glasses
SCTLs, Synergeyes, RGPs
Synergeyes,RGPs
Expect reduction in astigmatism
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Some residual astigmatism typical though
Contact Lens Fitting Expectations
Soft Lenses - after 2 weeks
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Proclear Compatible Toric (XR)
HydraKone
Hydrasoft XW
Piggy-Back or Scleral - after 1 month
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RGP designs: Dyna Z, Rose K, Rose K2
Scleral desgin: 18.2 Jupiter from Medlens Innovations
RGP or Synerges - after 6 months
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Too early fit can cause FBS and photophobia
Will require multiple visits – 5-6 visits expected
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Charge global fee - i.e. $1600 includes visits over 6 mos
Lens cost: $300 - $800/per eye a year
®
Holcomb C3-R
(corneal collagen crosslinking with riboflavin)
30 minute treatment time
I have been performing nearly
7 years now
Indications
Unstable/Progressing Corneas
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Keratoconus
Forme Fruste
Ectasia
RK (radial keratotomy)
Combined with other surgical procedures
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Intacs for keratoconus
CK and LTK
Safety Profile
®
Holcomb C3-R®
Mechanism
UVA
Riboflavin
Corneal Collagen
Cross-linking
Biomechanical
Stiffness
Stability
Technique
Technique
Technique
Crosslinked
Safety Profile
Holcomb C3-R – Transepithelial Epi On Crosslinking
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No complications reported (Boxer Wachler, Pinelli, Ertan)
No infection, No Scar/haze, No cornea denervation
No cataracts
No endothelial loss
No retinal pathology
Crosslinking with Removal of Epithelium
Complications can occur
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1-3% corneal infection rate (FDA study)
5.5% corneal infection rate (Seiler s study)
1% corneal scarring (same)
100% Uniform corneal nerve denervation (Pallikaris)
1-2% delayed epithelization (FDA study, Selier s IROC group)
Net flattening
Preop
Postop
Another Case
Postop 2 months
Preop C3-R
Prevent Progression
19 year old woman
Wearing soft contact lenses
Newly diagnosed with keratoconus
Sept 2003
September 2003
-0.50 -0.75 x 55 20/20
+1.00 – 2.25 x 129 20/25
Progression Right Eye – 1.5 yrs
April 2005
+1.00 -4.25 x 69
20/25
-0.50 -0.75 x 55
20/20
Sept 2003
Progression Left Eye – 1.5 yrs
April 2005
+6.50 -8.75 x 114
20/30
Sept 2003
+1.00 - 2.25 x 129 20/25
®
C3-R
Holcomb
alone
could have easily
prevented this
We treat referred patients
www.KeratoconusInserts.com
®
C3-R
Holcomb
Aids Intacs Effect
+
C3-R
(Same Day)
Postop Day 1
-1.50 -1.50 X 095 20/20
Preop
+0.50 -3.0 X 176 20/30
Postop Day 1
UCVA 20/20
Preop
+2.5 -4.50 x 73 20/25
Postop Day 1
UCVA 20/25
+1.50 -3.00 x 101 20/25
Postop 1 Month
BCVA 20/40
Preop
BCVA 20/160
Postop 1 Month
Preop
Intacs + C3-R
Intacs and C3-R
27 eyes of 23 patients with keratoconus and
LASIK-induced ectasia (keratectasia) were
evaluated
Single segment used to flatten peripheral cone
Axis of incision was on steepest axis on manifest
refraction (Boxer Wachler et al. Ophthalmology 2003)
Outcomes: UCVA, BCVA, manifest refraction,
keratometry (steep, flat and average), L-U ratio
Mean follow up was 99.0 ± 37.5 days
Preoperative Matching
Preoperative
measurements
Intacs+C3-R
12 eyes of 9 patients
Intacs
15 eyes of 14 patients
UCVA (Log Mar)
1.12 (20/250) ± 0.93
1.31 (20/400) ± 0.81
BCVA (Log Mar)
0.23 (20/32) ± 0.16
0.27(20/40) ± 0.18
Sphere
-1.03 ± 2.75
-0.93 ± 3.39
Cylinder
-4.82 ± 1.79
-3.61 ± 1.43
K steep (D)
48.31 ± 3.20
49.84 ± 5.02
K flat (D)
44.11 ± 2.56
45.44 ± 3.12
K average (D)
46.22 ± 2.61
47.73 ± 3.89
MRx L-U (D)
33.83 ± 18.18
23.02 ± 19.13
Matched with p>0.05
Lower-Upper (L-U) Ratio
I-S ratio
L-U ratio
(more accurate)
Change in Cylinder
5.0
2.52 ± 1.38
1.48 ± 1.17
4.0
3.0
2.0
1.0
Intacs +C3-R
Intacs only
p = .04
Change in K Steep (D)
50
2.33 ± 1.33
0.89 ± 2.07
47.5
45
42.5
40
Intacs +C3-R
Intacs only
p = .03
Change in K Average (D)
50
1.69 ± 1.05
0.21 ± 2.70
47.5
45
42.5
40
Intacs +C3-R
Intacs only
p = .03
Change in LU ratio
50
40
11.69 ± 15.97
6.87 ± 14.90
30
20
10
Intacs +C3-R
Intacs only
p = .04
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