handout course cxl vienna 2011 1 - official escrs · corneal cross-linking for ectasia after...

$: Handout Course CXL Vienna 2011 1 - Official ESCRS · Corneal Cross-Linking for Ectasia After Excimer Laser Refractive Surgery: One-Year Results ... BELIN /AMBROSIO INDICES BFS Enhanced$
Course IC-99 – Cross-Linking – Vinciguerra - 1

XXIX Congress of The ESCRS

17 - 21 September, 2011 Vienna, Austria

Course IC-99

Successful Cross-Linking: Patient Selection, Management

of Complications, Long-Term Follow-Up, and

Understanding Corneal Response to Treatment

Senior Instructor: Paolo Vinciguerra, MD

Associate Instructors:

Theo Seiler, MD Fabrizio I. Camesasca, MD

Scipione Rossi, MD Elena Albè, MD

20 September 2011

14.30 – 16.30

Room 2


INDEX

I. Patient Selection Elena Albè, MD

Page 3

II. Surgical Technique Fabrizio I. Camesasca, MD

Page 8

III. Topo-aberrometric, refractive and pachymetric analysis of Keratoconics eyes undergoing CXL Paolo Vinciguerra, MD

Page 11

IV. Corneal Cross-Linking for Ectasia After Excimer Laser Refractive Surgery: One-Year Results Paolo Vinciguerra, MD

Page 23

V. Complication and failure rates after corneal crosslinking Theo Seiler, MD

Page 29

VI. Pediatric Patients: Two Years Results Elena Albè, MD

Page 34

VII. Evaluation of Crystalline Lens Opacity Induced by Corneal Cross-Linking with Scheimpflug Imaging Fabrizio I. Camesasca, MD

Page 37

VIII. Anterior and Posterior Corneal Surface Scipione Rossi, MD

Page 40

ADDRESSES……………………………………………………………………………….. Page 45 Special thanks to Pietro Rosetta, MD Ophthalmology Dept. – Istituto Clinico Humanitas


I. Patient selection

Collagen Cross Linking

TRADITIONAL USE

PROGRESSIVE CORNEA ECTASIA

• Keratoconus

• Pellucid Marginal Degeneration

• Post iatrogenic ectasia

RECENTLY…

• CXL and corneal infection

• CXL with INTACTS

• CXL and PTK

1. How to diagnose ectasia2. How to assess progression of

ectasiain KC, PMD, ectatic corneas

3. Inclusion CXL criteria4. Exclusion CXL criteria

Collagen Cross Linkingin progressive corneal ectasia

AIM

1.Corneal Topography2.Corneal Tomography3.Endothelial Microscopy

Collagen Cross Linkingin progressive corneal ectasia

METHODS

1. HOW TO DIAGNOSE ECTASIA

ectasia or pseudo‐ectasia?

Risk Factor or Hot Spots: Risk Factor or Hot Spots: RED on RED

Coincidence of hot spots: Coincidence of hot spots:

Maximum curvature Maximum curvature –– max ant.& post. max ant.& post. elevation elevation -- minimum minimum pachymetrypachymetry

Interlocking relationships on Holladay Report

ECTASIAECTASIA RED on RED

TANGENTIAL TANGENTIAL MAP MAP

SteepestSteepestpointpointREDRED

PACHYMETRY PACHYMETRY MAPMAP

ThinnestThinnestpointpointREDRED

ELEVATION ELEVATION MAPMAP

MostMost ElevatedElevatedpointpointREDRED

PSEUDOECTASIAPSEUDOECTASIA RED on BLUE

TANGENTIAL TANGENTIAL MAPMAP

FlattestFlattestpointpointBLUEBLUE

PACHYMETRY PACHYMETRY MAPMAP

ThickestThickestpointpointBLUEBLUE

ELEVATION ELEVATION MAPMAP

LessLess elevatedelevatedpointpointBLUEBLUE


1. HOW TO DIAGNOSE ECTASIA

ectasia or pseudo‐ectasia?

Coincidence and displacement of Coincidence and displacement of maximum ant.& post. Elevationmaximum ant.& post. Elevation

Anterior elevation values > 12-15 µ

Posterior elevation values > 20 µ

Eccentricity of thinnest pointEccentricity of thinnest point

Map patterns (eccentric, asymmetric Map patterns (eccentric, asymmetric pattern/hot spots)pattern/hot spots)

Interlocking relationships on Holladay Report

BLUE on BLUEBLUE on BLUERED on RED on RED on REDRED on RED BLUEBLUE

Thinnest point located centrally

Thicker nasally and superiorly

Flatter nasally

Pachymetrygradient is predictable

Map patterns

BLUE on BLUEHolladay reportNormal cornea

+1,75 –6.75@170

ASTIGMATISM: tipical pattern ! BLUE on BLUE

IRREGULAR ASTIGMATISM BLUE on BLUE

PSEUDOECTASIAPSEUDOECTASIA

CicatrixCicatrixPerforatingPerforating woundswoundsHostHost--donordonor interfaceinterface

Highest curvature does not correspond

to thinnest cornea

Post refractive ablation

RED on BLUE


ECTASIAECTASIACorneal thinning corresponds to

highest curvature point

SteepestSteepest, , thinnestthinnest, , mostmostelevatedelevated pointspointscoincidencecoincidence

BFS

HYPERCURVATUREHYPERCURVATURE

PELLUCID MARGINAL DEGENERATION

RED on RED

POST LASIK ECTASIA RED on RED

TAKE HOME MESSAGE 1. HOW TO DIAGNOSE ECTASIA

• Interlocking relationships are a safer and more sensitive tool for ectasia diagnosis than single maps

• ECTATIC CORNEA •• RED RED on REDRED

• NON ECTATIC CORNEA •• BLUE BLUE on BLUEBLUE

Slit lamp: subjective but not repeatable

Endothelium and Vogt striae: late changes

Confocal microscopy: not sensitive

Refraction: HOA, and LOA

Ectasia outside the pupillary area does not change refraction : false negative

Progression of myopia: false positive

2. HOW TO ASSESS ECTASIA PROGRESSION

These are not reliable indicators of ectasia progression

How can progression be monitored?

Follow up with DIFFERENTIAL MAPS Curvature: Tangential map

Elevation: Elevation Maps

Thickness: Pachymetry Map

…… MethodMethod : : toto evaluateevaluate changechange

ABSOLUTEABSOLUTE

VALUEVALUEPATTERNPATTERN


When differential maps are notavailable we should compare

pattern & absolute value & indices

200155,22D

200558,10D

When differential maps are notavailable we should compare

pattern & absolute value & indices

TANGENTIAL MAPPattern change

Increased cone area

Absolute keratometrychange

11 months

O month

3.16 D

63,12 D

59,97 D

B B prepre

ELEVATION INCREASE ABSOLUTE VALUE

AA--BB

ANTERIOR ELEVATION MAP

A postA post

PATTERN VARIATION

INCREASE IN ELEVATION

POSTERIOR ELEVATION MAP

B B prepre AA--BBA postA post

PATTERN VARIATION

THICKNESS REDUCTION

PACHYMETRY MAP

B B prepre AA--BBA postA post


TAKE HOME MESSAGE 2Only progression indicates ectasia

• Single topographic map is not a safe diagnostic instrument

• Differential maps allow soon progression assessment

• Differential maps allow earlier ectasia diagnosis in border‐line cases

• Early diagnosis is important for successful application of cross linking

WHAT TO DO IN CASE OF DOUBTFUL WHAT TO DO IN CASE OF DOUBTFUL ECTASIA? ECTASIA?

FALSE POSITIVE = WARPAGEFALSE POSITIVE = WARPAGE

OSV 0.8 +3.25 (-3.25)180 OSV 0.7 +2.0(-3.25)170 OSV 1.0 +2.0(-3.25)170

+49.80 +50.07 +45.59

2005 2006 2009

OSV 0.8 -1.00(-1.00)0 OSV 0.8 -2.00(-1.50)170 OSV 0.8 -1.50(-1.25)170

OSV 0.8 -2.00(-1.50)170 OSV 0.6 -2.00(-1.50)170

2/2005 07/2005 2/2006

05/2007 09/2008

False warpage: Progression of kc

SUSPECT KERATOCONUS RED on RED

WHAT TO DO IN CASE OF WHAT TO DO IN CASE OF DOUBTFUL ECTASIA? DOUBTFUL ECTASIA?

TOPO AND TOMOGRAPHIC INDICESTOPO AND TOMOGRAPHIC INDICES Corneal Navigator OPDCorneal Navigator OPD

BelinBelin AmbrosioAmbrosio Indices PENTACAMIndices PENTACAM

Corneal Hysteresis ORACorneal Hysteresis ORA

KERATOCONUS

NORMAL

ORACORNEAL NAVIGATOR

BELIN /AMBROSIO INDICES

BFSBFS

EnhancedEnhancedBFSBFS

DifferenceDifferenceElevation Elevation

MapsMaps

<6<6 >12>1266--1212


TAKE HOME MESSAGE TAKE HOME MESSAGE EARLY DIAGNOSES IS IMPORTANT!

Avoid PK, DALK.

Soon CXL.

Preserve best VA .

Preserve good CL tolerance.

3. CXL TO TREAT OR NOT TO TREATINCLUSION CRITERIA

Ectatic corneal disease

Ectasia progression documented by serial differential corneal topographies and optical pachymetries

pt’age over 9 years

signed informed consent

Adequate corneal thickness

CORNEAL THICKNESS at its thinnest point

at least 400μin degenerative ectaticcorneal diseases

At least 380μin most severe cases

Expansion technique

At least 350μ in post refractive ectasia

…REMEMBER

First stages KC and pediatric patients havebetter topographical and visual recovery.

CL tolerance

CCT/Kmax

Kmax 87,44D Kmax 46,47D

CCT 332µin botheyes

1° Pt KC 2° Pt post LASIK ectasia

4. EXCLUSION CRITERIA

ABSOLUTE

Loss endothelial cell count

Severe corneal opacities

pregnant or nursing ♀

RELATIVE

history HSV,HZV

severe eye dryness

corneal infections

autoimmune diseases

previous ocular surgery

poor compliant pt

Thank you for your attention !

Elena AlbéIstituto Clinico Humanitas

[email protected]


II. Surgical Technique

Organized Surgical Approach

• Check‐List

•Eye

•Patient data

•Activities by:

•Attending physician

•Nurse

•Surgeon

•Alert

• Same‐day control of clinical situation

• Antipain meds 30 min before CXL

Surgical Approach ‐ Sterility Day Surgery

Sterile conditions in the operating suite

Preop disinfection

Scrub

Surgical gown and gloves

Disposable medication

Single‐set surgical instruments

Patient draping

Rama P et al. J Cataract Refract Surg 2009; Apr

Preoperative Medications

2% Pilocarpine drops

pilocarpine reduces the thermal and photochemical

Ultraviolet A (UVA) light irradiation potentially

harmful to the lens and retina

amount of light rays reaching the retina is

proportional to the square of the pupil diameter

i.e., 6 mm pupil = 36 units, 4 mm pupil = 16

units, 2 mm pupil = 4 units

Topical anesthesia with two applications of 4%

lidocaine drops and oxybuprocaine hydrochloride 0.2%

Available UVA Devices

UV light from a solid‐state UVA source

UV‐X ™ System Peschke Meditrade GmbH, Huenenberg,

Switzerland

The UV‐X ™ System was developed by

Theo Seiler, MD and Eberhard Spoerl,

PhD (Zuerich / Dresden).

It consists of a radiator which

emits highly homogenized UV‐light

at 365 nm and a table mount.

irradiance of 3 mW/cm2 or 5.4 J/ cm2

Available UVA Devices

UV light from a solid‐state UVA source

VEGA CBM X Linker, Oofta HT, Montegiorgio, Italy

diode UV‐A emitting source with a wavelight of 370 nm,

with diaphragm, fixation point, double light aiming

system, LCD camera

Standard Surgical Procedure

• Corneal epithelium is abraded in a central, 9‐mm

diameter area with an Amoils brush.

• Photosensitizing riboflavin 0.1% solution ( 10 mg

riboflavin‐5‐phosphate in 20% dextran‐T‐500 10 ml

solution) is applied onto the cornea every minute

for 30 minutes to achieve adequate penetration of

the solution

• Using a slit lamp with the blue filter, presence of

riboflavin in the anterior chamber is confirmed

before UV irradiation


Surgical Procedure• A calibrated UVA meter (LaserMate‐Q; Laser 2000,

Wessling, Germany) used before treatment to check the

irradiance at a 1.0 cm distance. Laser 370±5 nm, Power

3 mW/cm2 (= 5.4 j/cm2)

• UV source exposition for 30 minutes

• leave untreated zone of at least 1.5 mm from the limbus

(stem cells protection)

● Do not shorten treatment time

● Do not use home‐made solutions

● Surface must remain moist to avoid haze formation

• Riboflavin solution is applied again, but only once every

5 minutes

• Focusing is very important: out‐of‐focus can result in

dangerous or ineffective dosage

Postoperative Medication

• Cyclopentolate 2% eyedrops

• Levofloxacin eyedrops

• Soft bandage contact lens until re‐

epithelialization is complete.

• Topical levofloxacin 4 times daily for 7 days

• Dexamethasone 21‐phosphate 0.15% drops 3 times

daily for 20 days

• 0.15 % sodium hyaluronate drops 6 times daily for

45 days

• Oral aminoacid supplement

Postoperative Period

• 1, 3, 6, 12 month‐controls

• Complete ophthalmological examination

• Corneal topography

• Pentacam

• Haze monitoring

• 0.15 % sodium hyaluronate drops

• CL use is allowed one month after surgery

if corneal epithelium appears healthy and

regular

Good Medical Practice

• Accurate preoperative patient information

(i.e., course of visual acuity)

• Standardized informed consent

• In Italy, one IC for the whole nation,

approved by the national

ophthalmological society (SOI)

• Documenting ectasia progression over at

least 6 month‐period:

• Corneal topography

• Pentacam

Good Medical Practice

• Documenting Surgery

• Surgical logbook

• Surgical report

• Use of product adhesive labels (i.e,

riboflavin)

• Documenting follow‐up:

•Visual Acuity

•Corneal topography

•Pentacam



III. Topo-aberrometric, refractive and pachymetric analysis

of Keratoconics eyes undergoing CXL

Part 1

Cross‐linking (CXL) tecnique2% Pilocarpine drops (protection of lens and retina)

The light reaching the internal structures of the eye is decreased by the square of the reduction of the pupil diameter

(For example : a 6‐mm pupil = 36 units, a 4‐mm pupil = 16 units, 2‐mm pupill = 4 units)

Antipain meds 30 min before CXL.

Oxybuprocaine hydrochloride 0.2% + Lidocaine 5 min before CXL.

Cross‐linking (CXL) tecnique Laser test ((UVA meter)

Laser 370±5 nm

Power 3 mW/cm2 (= 5.4 j/cm2)

Calibration should be extremely precise: +/‐0.1 mW/cm2

Focusing is very important

out‐of‐focus can result in dangerous or ineffective dosage

Diaphragm adjusts size of treatment area

Laser plus camera enabling monitoring of focus, beam size and corneal surface

Monitor with view of cornea,beam, and treatment time


Cross‐linking (CXL) tecnique

● A 9‐mm Ø central epithelial abrasion with Amoils brush

● Riboflavin 0.1% solution, 2 drops every minute for 30 minutes (commercially available®)● Do not be tempted to shorten treatment time

● Do not use home‐made solutions

● Surface must remain moist to avoid haze formation

● Riboflavin absorption check (anterior chamber flare)

● UVA irradiation, leaving an untreated zone of at least 1.5 mm from the limbus (stem cells protection)

● Riboflavine again, 1 drop every 2‐3 minutes during treatment

Cross‐linking (CXL) tecnique

At the end of treatment

● Cyclopentolate 0.5%

● Hyaluronic acid + antibiotics (till re‐epithelization)

● Bandage contact lens

545 treated eyes Preop.evaluated eyes:344 28 pediatric; 21 ectatic (lasik,prk,intacs); 3 PMD

Demographic

age@OP average 30 years (from 10 to 67)

sex female 27,1% or 95 eyes

male 72,4% or 254 eyes

pre SR equiv: mean ‐3,95 D ± 4,35 D (from ‐24,75 to 5,50)

pre SR sph: mean ‐2,49 D ± 4,20 D (from ‐23,00 to 6,00)

pre SR cyl: mean ‐2,92 D ± 1,97 D (from ‐10,00 to 0,00)

9%5%5%5%

21%22%

25%

42 %50%

51%50%

74%

59%

66%

75%79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

<=1D

<=2D

<=4D

<=5D

pre op (351)

1 y (170)

2 y (40)

3 y (19)

month(eyes)

Defocus equivalent‐%

12%8%

3%5%

23%

26%

10%5%

27%

21%

20%

21%

13%

19%

28%

5%

16%

20%

38%

63%

0%

10%

20%

30%

40%

50%

60%

70%

lost 1 unchanged gained 1 gained 2 gained > 2

6 (200)

12 (168)

24 (40)

36 (19)

month(eyes)

Change in BSCVA ‐ %“Safety”

7% 6% 5%

10%

14%12%

9%

25%25%

23%

27%

47%

41%

42%44%

63%

0%

10%

20%

30%

40%

50%

60%

70%

Vin

cig

ue

rra

Pa

olo

+- 0,25 +- 0,5 +- 1,0 +- 2,0

pre op (351)

1 y (170)

2 y (41)

3 y (19)

month (eyes)

Refractive outcomerefractive variation / preop


8%

14%18%

21%

10%

16%

30%

5%

14%

23%

13%

42%

13%15%

13%16%

55%

29%28%

16%

0%

10%

20%

30%

40%

50%

60%

1,0 0,9 0,8 0,7 0,6 or worse

1 m (280)

1 y (170)

2 y (40)

3 y (19)

month(eyes)

BSCVA ‐ %

BSCVA over time

0,62 0,64

0,42 0,42

0,490,52

0,580,63

36170202160281351 40 190,0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

1,0

pre op 1 m 3 m 6 m 1 y 1,5 y 2 y 3 y

Vin

cigu

erra

Pao

lo

Achieved Correction SEQ over time“STABILITY”

-1,96-2,90

-2,88-3,28

-3,95-4,00

-4,50-3,95

1940351 281 160 202 170 35-10,00

-8,00

-6,00

-4,00

-2,00

0,00

2,00

pre op 1 m 3 m 6 m 1 y 1,5 y 2 y 3 y

Vin

cigu

erra

Pao

lo

Diopters

Normalized Double Angle Minus Cyl - Scatter Plot (351 eyes)

-5

-4

-3

-2

-1

-0

-1

-2

-3

-4

-5

-5 -4 -3 -2 -1 -0 -1 -2 -3 -4 -5

Mean Cyl -2,92 @ 0,0°

Vinciguerra Paolo

0°

45°

90°

135°

177.7°‐2.163 yrs post cxl

2°‐1.762 yrs poscxl

179.9°‐1.651 yr post cxl

0°‐2.92Pre cxl

@Meancyl

2,92

1,651,76

2,16

0

0,5

1

1,5

2

2,5

3

mean cyl (-)

pre cxl

1 yr post cxl

2 yrs post cxl

3 yrs post cxl

Dio

pte

r

PentacamChamber volume mm3

PRE PRE 224,17224,17±± 37.3 mm37.3 mm33

POSTPOST 3 m3 m 223.,37 223.,37 ±± 27 mm27 mm33

POST 6 m 221,17POST 6 m 221,17±±45.39mm45.39mm33

POST 12 m 238,50 POST 12 m 238,50 ±± 30 mm30 mm33

POST 24 m 236,29POST 24 m 236,29 ±± 26.3626.36 mmmm33

POST 36 m 239,05POST 36 m 239,05±± 17,3 mm17,3 mm33

mm

mm

33

mos

Anterior chamber dept mm3PRE PRE 3,45 3,45 ±± 0,24 mm0,24 mm33

POSTPOST 3 m 3 m 3,3,47 47 ±± 0,27 mm0,27 mm33

POST 6 m 3.45 POST 6 m 3.45 ±± 0.30 mm0.30 mm33

POST 12 m POST 12 m 3,3,53 53 ±± 0,19 mm0,19 mm33

POST 24 m 3.49 POST 24 m 3.49 ±± 0.21 mm0.21 mm33

POST 36 m 3,51 POST 36 m 3,51 ±± 0,2 mm0,2 mm33

mm

mm

33

mos


THINNEST POINT PRE 429 ± 48.15 µm POST 3 m 401 ± 59.03 µm POST 6 m 417 ± 64.03 µm POST 12 m 429 ± 45,10 µm POST 24 m 428 ±35.6 µm POST 36 m 429 ± 33.03 µm

Result pentacam‐‐pachymetry

micron

Result pentacam‐‐pachymetry PUPIL CENTER

PRE 440 ± 45,18 µm POST 3 m 410 ± 60,98 µm POST 6 m 435 ± 59,17 µm POST 12 m 432 ± 31,51 µm POST 24 m 438 ± 29.12 µm Post 36 m 439 ± 34 µm

440

410

435432

438 439

395

400

405

410

415

420

425

430

435

440

pupil center

pre op

3 mos post cxl

6 mos pos cxl

12 mos post cxl

24 mos pos cxl

36 mos post cxl

micron

PentacamCentral corneal thickness µm

micron

351PRE

170POST 12 m

40POST 24 m

19POST 36 m

ACP 44.75 43.6 42.08 40,5

CYL 2,57 1.98 1.75 1,68

CVP 73.14 60.12 57 55

SDP 4.12 2.7 2.5 1,9

AA% 85,68 82.75 80.03 78,2

CEI 0,37 0.1 0.09 0,06

LogMAR 0,17 0.1 0.14 0,09

DSI 8,7 5.9 5.5 4,9

SRI 1.34 1.22 1.21 1,19

SRC 1,19 1.10 1.07 1,02

SAI 1,88 1.3 1.26 1,26

IAI 5,86 0.56 0.58 0,58

OSI 7,18 4.2 3.95 3,94

CSI 0.9 0.02 0.03 0,02

KCI 8,9 0.25 0.24 0.23

KPI 0,43 0.27 0.28 0.25

EDP 2,67 2.40 2.45 2.39

EDD 10.01 6.5 5.1 4,9

OPD

OPD

CO

RN

EA

L N

AV

IGA

TO

RC

OR

NE

AL

NA

VIG

AT

OR

KL

YC

E IN

DE

XE

SK

LY

CE

IND

EX

ES

IMPROVED

UNCHANGED

WORSED

N =

1,26

0,58

isv iva ki cki iha ihd rmin

PRE CXL

77,4 0,78 1,13 1,02 19,12 0,08 6,57

POST 3 mos

79,0 0,8 1,17 1,12 19,1 0,065 6,66

POST6 mos

86 1,19 1,07 0,89 19,6 0,075 6,67

POST 1 yrs

61,27 0,76 1,09 1,01 14,56 0,04 6,89

POST2 yrs

59.07 0.55 1.03 1.02 13.12 0.023 5.9

POST 3 yrs

52,9 0.38 0.76 0.87 11.5 0.020 5.6

Indici di Ambrosio

Topo classifier map

GRAFICA Klyce classification

Le Le classiclassi di di probabilitprobabilitàà sonosono ottenuteottenute da da unauna correlazionecorrelazione tratra indiciindicicheratometricicheratometrici e le e le corrispondenticorrispondenti patologiepatologie o o distrofiedistrofie cornealicorneali, e , e sonosonobasatebasate sullesulle deviazionideviazioni standardstandard provenientiprovenienti dalladalla reterete neuraleneurale NidekNidek..


OPD corneal navigator %

KCS KC PMD PKP KSI

PRE XL(351)

6,64 32.03 15,10 0 17,33

POST 3 M (160) 9.72 32.6 12,1 0 12

POST 6 M(202)

0 32 0 0 23

POST 1 Y(170) 0,3 35.95 0 0 5.03

POST 2 Y(40)

0.27 34.78 0 0 3.79

POST 3 Y(19)

0.18 35.2 0 0 3.7

K max 3‐5‐7 mmD

K min 3‐5‐7 mmD

Ambrosio’sIndexes

ISV:index surface variance—this index is elevated in all types of irregularity of the corneal surface (astigm, warpage,kc, etc).

IVA:Ind of vertical Asymmetry: this index is elevated in case of oblique astigmatism, in kc or in ectasiae

KI:kc index

CKI:center keratoconus index:increases with severity of central kc

IHA: ind of Height Asimmetry: this index is analogous of IVA, this index but it is more sensitive

IHD: index of Height Decentration is elevated in keratoconus

Rmin: Minimum Sagittalcurvature in 8 mm‐zone

TKC:topographical Keratoconus Classification only based on anterior corneal data

Part 2

Intra‐operative findings

Why dealing with intra‐operative findings?

To understand the real shape of the cornea without the masking effect of the epithelium

To determine the changes occurring after epithelial removal

To document the changes induced by CXL

To explain why topography and BCVA do deteriorate during the first 3 months after CXL


PRE sine epithelium

PRE con

PRE with epithelium

POST sine

Note the increased power and diameter of the cone and the flattening of the surrounding area

PRE sine epithelium

PRE con

PRE with epithelium

POST sine epithelium

Note the decreased power and diameter of the cone and the steepening of the surrounding

area immediately after CXL

1 month post CXL

7 days post CXL

PRE with epithelium

At 7 days cone looks steeper, larger

At 1 mos cone even steeper, larger

Now first signs of

flattening/shrinkage

PRE with epithelium

3 mos after CXL

Why these late cone changes? The epithelium in a keratoconic cornea is arranged according to the law of surface tension: thinner at the apex and thicker at the edge of the cone

This masks the real ( keratoconic) shape of the stroma

Why these late cone changes?

After any epithelial abrasion, the physiological rearrangement of the layers takes weeks to complete

Only when the epithelium is back to normal, and its masking function is re‐established, does the flattening effect of CXL begin to appear ( at about 3 mos)


Other intra‐operative findigs

Apparent corneal thinning

Biomechanical changes

BSCVA is better even if there is an apparent corneal thinning

474 µ -176 µ +94 µ

1 mos post cxl

0,6 +7,00 ‐1,00@90

pre cxl

0,8 – 1,25@94

6 mos post cxl0,9 nat

1 mos post cxl

0,6 +7,00 ‐1,00@90

pre cxl

0,8 – 1,25@94


+28 µ + 23 µ (-5 µ) +28 µ (-14 µ)

Differential elevation anterior map: -14 µ

Reduction of the elevation anterior of the keratoconus overtime

1 mos post cxl

0,6 +7,00 ‐1,00@90

pre cxl

0,8 – 1,25@946 mos post cxl0,9 nat

+63.5 D + +58 D (-5.4 D) +53.9(-9.6 D)

Reduction of the area/power of the keratoconus overtime

Differential tangential map: -9.6 D

Pachymetry distribution 6 mos after CXL

1 mos post cxl

0,6 +7,00 ‐1,00@90

pre cxl

0,8 – 1,25@94


- 44.20 % -38.4 % (+ 5.8 %) -21.4 % (+ 22.8%)

+22.8%

Differential Pachymetry relative map

Apparent corneal thinning

“Thinning” is only temporary because:

Riboflavine solution contain dextrane that together with the exposure to air of the denuded cornea dehydrates the stroma

Collagen fibers and lamellae are packed by CXL


Corneal thickness normalization Epithelium takes weeks to return to normal

thickness

Stroma rehydrates

Increase of fiber diameter due to CXL

Corneal thickness can even increase with time (1‐2 years)

Pachymetrymap shows a more physiological distribution with time

Courtesy of Rita Mencucci, M.D.

CONTROL KC CXL

Packing of lamellae in normals, keratoconus and after CXL

Return to normal thickness

Pre cxl 12 mos post cxl 18 mos post cxl

430 μ437 μ 423 μ

Normalization of pachymetry distribution 18 mos after CXL

Differential pachymetry mapfrom pre op to 18 mos post cxl

0.7 -3.50 -1.00 (90) 0.9 -4.25 -1.50(130) 0.9 -3.50 -2.00(110)

Pre op 1 mos post cxl 8 mos post cxl

447µ 375µ 446µ

Normalization of pachymetry distribution 8 mos after CXL

Return to normal thickness


Fluctuation of the corneal thickness pachymetry overtime :

+11µ

433µ

450µ 422µ

0µ

373µ

Pre cxl

6 mos post cxl

1 examination

-54µ

2 mos post cxl

Fluctuation of pachymetryfrom pre op to6 most after cxl

Return to normal thickness: minimal thickness decrease(‐9µ) and early regularization (+28µ) after 4 mos

1 examination Pre cxl 1 mos post cxl

4 mos post cxl

498µ 476µ

515µ

487µ

Differentialpachimetry map+ 28 micron



Normalization of pachymetrydistribution 1 year after CXL

Pre‐CXL relative pachymetry Post‐ CXL relative pachymetry

Normalization of pachymetry distributiononly 3 mos after cxl

-8 % at only 3 mos post cxl!!

Pre cxl 3 mos post cxl

Biomechanical properties of cornea (ORA)

Biomechanical improvement immediately after CXL

CRFCRF Corneal ResistanceCorneal Resistance FactorFactor

9,05 9,42

14,15

0

2

4

6

8

10

12

14

16

CRF

StatisticalStatistical significancesignificance pp<0.05<0.05

PRE XLWITH EPI

PRE XLWout EPI

POST XLWout EPI

RESULTS RESULTS CHCH Corneal HysteresisCorneal Hysteresis

9,68 10,32

15,18

0

2

4

6

8

10

12

14

16

CH

StatisticalStatistical significancesignificance pp<0.05<0.05

PRE XLWITH EPI

PRE XLWout EPI

POST XLWout EPI

Reduction of the area/power of the keratoconus overtime

1°examination pre cxl 1 mos post‐op 3 mos post

6 mos post 12 mos post 24 mos post

+3.65 D -6.18 D

-5.17 D -6.08 D -6.61 D

-4.15 D

pt n° 138 Differential map from pre cxl to 24 mos post cxl

Cxl over time: from keratoconus toirregular astigmatism

1.0 -2.25@7 0,9 -0,75 -2.00@20 0,9 -2,50@156 mos post cxl (-0,14 D) 1 yrs post cxl (-3,42 D)

Pre cxl (44,57 D) 1 mos post cxl (+1,02 D) 3 mos post cxl (-0,37 D)

0,9 con -2,50 @15 1.0 con -2.00@10

DifferentialTangential map

from pre op to 1yrs post cxl-3,42 D


BSCVA is better with minimal decrease of the curvature

3 mos post cxl

0.4 -3.00 sph

8 mos post cx

0.9 +0.75 33.00(115)

Pre cxl

0.4 -3.00 sph

1 mos post cxl

0.4 -3.00 sph

52,9 D 55,0 (+2,1) D 51,8 (-0,9) D 52,4 (-0,5) D

Differential tangential map: only – 0,5 D!!!

pt n° 154

( Differential Tru net power map +1.1D )

Curvature reduction ofkeratoconus post Cxl over time

0.2 -23sf -3.50 @55 0,4 -15,25 (-5,25)50 0.5 con -16sf -4.50@40

Differentialaxial map-11,23D

Pre cxl 6 mos post cxl 1 yrs post cxl

54,42 D 46,59 D 43,19 D

Reduction of the TRUE NET power of the keratoconus

overtime

Pre op cxl 1 mos post cxl 3 mos post cxl 6 mos post cxl

12 mos post cxl 24 mos post cxl

Differential map from pre op cxl to 2 yrs post cxlpt n° 75

49.3 D 48.8 D 46.0 D 46.3 D

46.8 D 46.1 D

Coma reduction overtime

Pre op cxl 1 mos post cxl 3 mos post cxl

6 mos post 12 mos post cxl 24 mos post cxl

coma reduction of the 44.57 %

1.685 µ 1.096 µ 1.029 µ

1.079 µ 1.013 µ 0.934 µ

pt n° 75

Reduction of elevation anterior map overtime of the keratoconus

Pre cxl 3 mos post cxl 6 mos post cxl 1 yrs post cxl

DifferentialElevation anterior

map-8 micron

Reduction of elevation posterior mapover time of the keratoconus


DifferentialElevation

posterior map-19+ micron

pt n° 250


Reduction of elevation anterior map overtime of the keratoconus

DifferentialElevation

anterior map-13 micron


pt n° 250

Reduction of pachimetry map over time of the keratoconus post cxl with expansion (<400 µ)

385µ 272µ 287µ 275µ

Pre cxl 1 mos post cxl 3 mos post cxl 9 mos post cxl

0.3 +2.50 (-4.25)80 0.3 -2.00 (-5.00) 80 0.4 -1.50 (-4.50)80 0.6 -1.50 (-4.50)80

-110 µDifferential pachimetry map

pt n° 305

Pre cxl 1 mos post cxl 3 mos post cxl 9 mos post cxl

0.3 +2.50 (-4.25)80 0.3 -2.00 (-5.00) 80 0.4 -1.50 (-4.50)80 0.6 -1.50 (-4.50)80

62.81 D 68.47 D 59.69 D 59.77 D

Reduction of area/power over time ofthe keratoconus post cxl with expansion

pt n° 305

-5.99D of flattening

Lasik : zo ricentrata molto visibile con

riduzione dell’ametropia

PRE PRE cxlcxl 4 4 mosmos post post cxlcxlKmax 39.0.2 D Kmax 33.12 D

0,7 +3.50 -2.00 (80) 1,0 +3.50 sph

1 32

Pentacam Nucleus Staging

0

Precxl

Post cxl1yrs

Post cxl2yrs

Post cxl3yrs (19)

0 0 0 0

Staging example

Cirrus vs Pentacam

Cirrus

Pentacam

1 mos after cxlSame patient

328μ in cornea

315μ in cornea


Transition line of keratoconuspost cxl over time



256μ in cornea

260μ in cornea 308μ in cornea

328μ in cornea

Transition line of keratoconus post cxlover time

in different pts

2 yrs post cxl

3 yrs post cxl3,5 yrs post cxl

1 yrs post cxl

340μ in cornea

404μ in cornea

292μ in cornea

328μ in cornea

keratoconus

Keratoconus is a degenerative disorder of the eyein wich structural changes within the cornea cause it to thin and change to a more conical shape thanits normal gradual curve.

The exact cause of the kc is uncertain, but hasbeen associated with detrimental enzyme activitywithin the cornea and with disorder of thyroid(altered value of T3, T4, FTSH) and hipofisy.

Total 91 asintomatic pts

•65, 9% male (18,3 % alterated value)

•34,1 % female (16,12 % with alterated value)

• Patologies checked:• Struma plurinodulare

• Tiroidite cronica su base autoimmunitaria

• Tiroidite cronica con noduli solidi

• Iperplasia nodulare dx/sx

• Tiroidite (assenza di noduli)

• Noduli isoecogeni

Study

•FT3‐ pg/ml (tri‐iodo‐tironina)= 1%

•FT4 ng/dl (tiroxina) = 1%

•TSHmicro U/L (thyroid stimulating hormone) = 4,39%

•Ab HTG Ul/ml =5,49%

•HTG ng/ml (normal value)

•Ab Rec TSH U/L (value normal)

•AbTPOUI/ml = 8,79%

conclusions

Thank you for your attention


IV. Corneal Cross-Linking for Ectasia After Excimer Laser Refractive Surgery:

One-Year Results

CausesCauses of Ectasiaof Ectasia

Flap thicker than planned

Insufficient bed thickness

LASIK flap cuts 200 million stromal fibers

(PRK 5 millions)

Interface infiammation/infection, S.O.S. etc.

Pre‐operative overlook of risk factors

[email protected]@camesasca.com

• Patients that underwent refractive surgery

• After looking for a permanent solution for an

unpleasant situation, such as high myopia…

•…find themselves with an even worst life quality !

• Instability and an apparently endless progression of

bad visual acuity, heading towards PK…

• Often these patients come to our office when CXL is

not anymore possible, due to extreme corneal thinning

• Astonished and diffident patients …

CrossCross‐‐LinkingLinking and Ectasia and Ectasia After After RefractiveRefractive SurgerySurgery



A A GrowingGrowing PhenomenonPhenomenon ?? Effects are visible only over the long period

Inefficient interpretation of topographymaps

Unsufficient use of pachymetric mapsduring patient evaluation

Wide‐diameter flap e O.Z. (large pupil) sever a larger number of fibers


Materials And MethodsMaterials And Methods

INCLUSION CRITERIA

corneal thickness of at least 350μm, at thinnest point

Age: 30 to 59

Signed informed consent.

Ectatic cornea (post‐LASIK, post‐PRK)

EXCLUSION CRITERIA

history of HSV, HZV

severe eye dryness

corneal infections

corneal opacities

autoimmune diseases

poorly compliant pt

pt wearing RGP CL 4 weeks before baseline examination.


CORNEAL THICKNESS CORNEAL THICKNESS at its thinnest pointat its thinnest point

at least 400μ in degenerative ectaticcorneal diseases

At least 340μ in most severe cases

Expansion technique

At least 300μ in post refractive ectasia


MaterialsMaterials And And MethodsMethods

13 eyes with ectasia after refractive surgery 3 prk 10 lasik

9 patients: 6 women, 3 men, mean age 42.2 years

pre SR equiv: mean ‐4,13 D ± 5,24 D (from ‐18,50 to 5,50)

pre SR sph: mean ‐2,97 D ± 4,68 D (from ‐16,00 to 6,00)

pre SR cyl: mean ‐2,32 D ± 2,06 D (from ‐8,75 to 0,00)

Ectasia progression documented in the last 6 months by:

differential topography

Scheimpflug optical pachimetry

Minimal corneal thickness: 350 µm

MEAN CCT 412 microns

Follow up: 1, 3, 6 and 12 months.


28%

19%

5%

11%

28%

44%

20%

28%

13%15%

22% 22%

13%

30%

11%

6%

13%

25%22%

0%

10%

20%

30%

40%

50%

60%

70%


1 (18)

3 (16)

6 (20)

12 (18)

month(eyes)

Change in BSCVA ‐ %“Safety”


BSCVA over TIMEBSCVA over Time

0,77

0,610,680,67

0,480,48

30 18 16 20 18 50,0

0,2

0,4

0,6

0,8

1,0

1,2

1,4

pre op 1 m 3 m 6 m 1 y 1,5 y

Vin

cigu

erra

Pao

lo


Achieved Correction SEQ over Time 'STABILITY'

-2,60-2,49-2,06-2,94-2,98

-4,13

30 18 16 20 18 5-10,00

-8,00

-6,00

-4,00

-2,00

0,00

2,00

pre op 1 m 3 m 6 m 1 y 1,5 y

Vin

cigu

erra

Pao

lo

Achieved Correction over time ‐SE ‐ “STABILITY”

UCVA: unchanged

preop BSCVA 0.75

12 mos: 0.9 (p<.05), SE: reduced at 6 mos (p> .05)

6 mos: Subjective UCVA improvement

6 to 12 mos continuous improvement in BSCVA.

3 mos postoperatively:

Klyce CVP, LogMAR and SRC indexes increased (p<.05)

SDP index decreased (p<.05).

6 mos postoperatively:

Ambrosio IVA index increased

KCI index, on the opposite, was significatively decreased

12 mos :

mean corneal coma, SA and high order astigmatism were decreased (p> .05)

CrossCross‐‐LinkingLinking and Ectasia and Ectasia AfterAfter RefractiveRefractive SurgerySurgery

ResultsResults


Indexes of Indexes of

AmbrosioAmbrosio

ISV:index surface variance—this index is elevated in all types of irregularity of the corneal surface (astigm, warpage,kc, etc).

IVA:Ind of vertical Asymmetry: this index is elevated in case of oblique astigmatism, in kc or in ectasiae

KI:kc index

CKI:center keratoconus index:increases with severity of central kc

IHA: ind of Height Asimmetry: this index is analogous of IVA, this index but it is more sensitive

IHD: index of Height Decentration is elevated in keratoconus

Rmin: Minimum Sagittalcurvature in 8 mm‐zone

TKC:topographical Keratoconus Classification only based on anterior corneal [email protected]@camesasca.com

PentacamPentacam OpticalOpticalPachymetryPachymetry

PUPIL CENTER PRE 437 ± 45,28 µm POST 3 m 404 ± 64,89 µm POST 6 m 426 ± 64,25 µm POST 12 m 432 ± 31,51 µm

THINNEST POINT PRE 427 ± 47,33 µm POST 3 m 389 ± 66,42 µm POST 6 m 413 ± 66,01 µm POST 12 m 422 ± 43,61 µm

µm


Optical Pachymetry with Pentacam

3 mos

• Mean central pupil pachymetry and mean pachymetry at

the thinnest corneal point were decreased (p< .05)

• total corneal volume at was decreased (p< .05)

• Corneal thickness at 0 and 2 mm: decreased (‐9,0%)

(p<.01)

CrossCross‐‐LinkingLinking and Ectasia and Ectasia AfterAfter RefractiveRefractive SurgerySurgery

ResultsResults


PREPRE

PPostost 4 m 4 m

At 4 months the STEEPEST POINTcurvature value is greatly reduced

Post-lasik-5.99D of flattening


20012001Case 13. 35 35 y.o.y.o. woman, woman, PhysicianPhysician

VOD 20/VOD 20/2020 ––4.00 D4.00 D

VOS 20/VOS 20/2020 ––4.00 D4.00 D

2001, OU 2001, OU successfulsuccessful LASIKLASIK

AllAll wentwent wellwell forfor twotwo yearsyears, , thenthen……

Progressive Progressive decreasedecrease in VA, in VA, withwith returnreturn totospectaclespectacle useuse..


20032003

20052005

VOD 20/25 VOD 20/25 ––0.75 0.75 ––1.00 (65)1.00 (65)

VOS 20/35 VOS 20/35 ––1.50 1.50 ––3.25 (110)3.25 (110)

PentacamPentacam:: 2nd 2nd orderorder topographicaltopographical astigmatismastigmatism

NormalNormal pachimetrypachimetry

OD 12 OD 12 mumu suspectsuspect elevationelevation on on altimetricaltimetric mapmap

ContactContact lenslens correctioncorrection


20052005


20082008

VOD 20/30 –3.00 –3.75 (80)

VOS 20/40 –2.75 –3.75 (95)

OO apparent central cornealthinning

LAC withdrawal

Pentacam

OPD


20082008


LE, 2005 vs. 2008LE, 2005 vs. 2008



20082008LELE 404 404 μμ

+19 mu +29 mu

RE, 2008 vs. 2005RE, 2008 vs. 2005


20082008RERE 435 435 μμ

+14 mu +30 mu

…Patient Selection !……PatientPatient SelectionSelection !!

LELE

RERE


LE, CXL 10.14.08: 3 mos post CXLLE, CXL 10.14.08: 3 mos post CXL

Note central flattening


CrossCross‐‐LinkingLinking and Ectasia and Ectasia

After After RefractiveRefractive SurgerySurgery

Case 13. LE, 04.03.2005, first examination, four years after LASIK for ‐4.00 –0.50 (125). BSCVA is 20/35 with ‐1.50 ‐3.25 (110).

LE, 09.03.2008, immediately before cross‐linking, BSCVA is 20/50 with ‐2.75 ‐6.00 (95). Note worsening of ectasia.

LE, 04.07.2009, 6 months after cross‐linking, BSCVA is 20/30 with ‐2.50 ‐4.00 (105). Note central flattening.



Upper right, LE 04.03.2005, first examination, the cross indicates a central point with 43.01 D of curvature. Upper left, LE 09.03.2008, immediately before cross‐linking, the same, cross‐marked, point now has 47.17 D of curvature. Differential map showing that the progression of ectasia was of 4.15 D.

Upper right, 09.03.2008, immediately before cross‐linking, the cross is on the central point with 47.17 D of curvature. Upper left, 04.07.2009, 6 months after cross‐linking, the same, cross‐marked, point now has 43.90 D of curvature. Differential map

shows that ectasia regressed of 3.27 [email protected]@camesasca.com

CrossCross‐‐LinkingLinking and Ectasia and Ectasia

AfterAfter RefractiveRefractive SurgerySurgery

ConclusionsConclusions 11

Perform regular topo‐ and tomographicexaminations using differential maps

Always suspect that a LASIK patient may develop ectasia at some future point

Perform CXL early, before cornea becomes too thin, with greatest refractive changes


ConclusionsConclusions 22

No complications

All patients display stability

OZ apparently recentered

Mild reduction of refractive error

Improvement continues long after CXL

Corneas thinner than 400 μ are still treatable

Paolo Vinciguerra [email protected]@camesasca.com


Reprinted with permission from Elsevier


VI. Pediatric Patients: Two Years Results

AFTER 4 MONTHS…

-186 MICRON!!!!!!

PROGRESSION OF KCPROGRESSION OF KC

PZ 12 years

NO CXL

NO CL fitting

ExpulsiveExpulsive ChoroidalChoroidal HemorrageHemorrage 22‐‐3%3%

WoundWound leakleak or or dehiscencedehiscence 22‐‐10%10%

InadvertentInadvertent lenslens loss 1loss 1‐‐2%2%

CornealCorneal ulcerulcer and/or and/or infectioninfection 44‐‐9 %9 %

EndophthalmitisEndophthalmitis 2%2%

New New onsetonset glaucoma 5glaucoma 5‐‐9%9%

CataractCataract 22‐‐7%7%

RetinalRetinal DetachmentDetachment 33‐‐5%5%

PhthisisPhthisis 44‐‐13%13%

PK PK ComplicationsComplicationsin in PediatricsPediatrics

Stulting RD et al: Penetrating keratoplasty in children, Ophthalmology 91:1222-1230, 1984

Demographic

number of eyes : 57 stage II KC(Amsler‐Krumeich Classif)

Age average 14 years (from 9 to 18)

female 22,8% or 13 eyes

male 77,2% or 44 eyes

pre SR equiv:

mean ‐3,17 D ± 3,74 D (from ‐13,75 to 2,00)

KC progression documented by serial

differential corneal topographies and optical pachymetries.

Controlateral not‐treated eyes stage I‐II used as control.

PATIENT'S AGE DISTRIBUTION

3% 8%5%

10%

13%

17%14%

22%

5% 3% 9101112131415161718

2% Pilocarpine drops and antipain meds 30 min before CXL.

Oxybuprocaine hydrochloride 0.2% 5 min before CXL.

LASER TEST UVA meter Laser 370±5 nm

Power 3 mW/cm2 (= 5.4 j/cm2)

RICROLIN riboflavin 0.1% solutioninstillation each minute for 30 min

Riboflavin check absorption in anterior chamber (flare).

UVA Light Corneal irradiation CBM CSO 7.5 mm Ø.

RICROLIN instillation 6 times of 5 min each

Bandage soft CL application and levofloxacin eyedrops


SAFETY:ENDOTHELIAL CELL COUNT

32013089

3189

1500

1700

1900

2100

2300

2500

2700

2900

3100

3300

3500

PRE 6m 24m

ECC cell/mm2

p>0.05

0,25

0,320,35

0,380,35

0,00

0,05

0,10

0,15

0,20

0,25

0,30

0,35

0,40

0,45

PRE 1m 3m 12m 24m

UCVA

p<0.05

0,570,63

0,670,72 0,7

0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

PRE 1 3 12 24

BSCVA

p<0.05

UCVAUCVA

BSCVABSCVA

p<0.05

p<0.05

,PRE 1m 3m 12m 24m

Change in BSCVA% SAFETY

6%

3%

11%

34%

17%16%

31%

34%

32%

9%

14%

11%13%

21%

26%

50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%


1 6 12 24month(eyes)

CORRECTIONsphere and cylinder

P>0.05

1,98

3,37

2,27

2,9

0,62

2,38

3,56

2,25

3,24 3

3,44

3,32

0

0,5

1

1,5

2

2,5

3

3,5

4

PRE 1m 3m 6 m 12 m 24 m

Dio

pte

rs

SPHERE

CYLINDER

p<0.05

P>0.05

SEQ correction over timeSTABILITY

-1,88

-3,10-5,10-4,89

-2,84

-5,03-3,17

257 32 19 29 19 6-12,00

-10,00

-8,00

-6,00

-4,00

-2,00

0,00

2,00

4,00

pre op 1 m 3 m 6 m 1 y 1,5 y 2 y

COMA REDUCTION

POST 2Y

PRE

RESULTS

PENTACAM TOMOGRAPHY

494,15

471,15414,64

420,36

463,80

447,00

459,83

435,00

522,00

481,00

0,00

100,00

200,00

300,00

400,00

500,00

600,00

Pupil Center Pachimetry

Thinnest Point Pachimetry

p<0.05

p<0.05

p>0.05

p>0.05

20082008 20102010 FASTER RECOVER

PEDs /ADULTs1 year

instead of 2

reductionequalityincrease

PRE XL Treat PED Eye

POST XL 6 m PED Eye

POST XL 2y PED Eye

PRE XL ADULT Eye

POST XL 6m ADULT Eye

POST XL2y ADULT Eye

ACP 50,86 49,27 49,08 50,75 52,01 49,01CYL 6,05 6,05 5,57 4,38 4,59 4,5CVP 100,99 99,04 99,37 106,42 108,02 97,02SDP 4,97 4,78 4,8 5,24 5,31 4,82CEI 1,05 0,9 0,84 1,19 1,21 1,02LogMAR 0,29 0,28 0,27 0,28 0,29 0,26DSI 11,1 11,2 12,05 12,87 12,92 12,61SRI 1,66 1,67 1,58 1,53 1,54 1,52SRC 1,46 1,48 1,44 1,53 1,55 1,5SAI 2,68 2,61 2,58 3,25 3,28 3,21IAI 0,63 0,63 0,62 0,63 0,64 0,63OSI 8,87 8,81 8,51 10,29 10,32 10,27CSI 3,21 2,68 2,45 3,45 3,62 3,15KCI 0,79 0,75 0,74 0,92 0,89 0,86KPI 0,41 0,4 0,39 0,46 0,48 0,43EDP 3,69 3,88 3,64 4,18 4,32 4,13EDD 14,88 14,49 13,59 17,01 17,52 16,75

OPDOPD CORNEAL NAVIGATORCORNEAL NAVIGATORKLYCE INDEXESKLYCE INDEXES

EQUAL BEHAVIOUR PEDs /ADULTs


RESULTSTOPOGRAPHY

47,01

53,05

43,59

45,8

51,84

42,24

45,36

50,93

41,458

40

50

60

SIMK flat SIMK steep Min K

PRE

12m

24m

p<0.05

p<0.05

KERATOCONUS IRREGULAR ASTIGMATISM

PRE ODV 1.0 con -2.25@7

8 months post cxlODV 1.0 con -2.00@10

pre cxl 1 m post cxl

6 m post cxl 12 m post cxl

0.7 ‐13.25(‐8.00)0

0.7 ‐12.00(‐4.00)0 0.8 ‐6.25 (‐6.00)130

0.7 ‐12.00(‐4.00)0

DifferentialInstantaneusmap-5.48D

59.08D 56.65D

53.87D 53.60D

Only after 1 mos!!Reduction of the area/power of the keratoconusovertime

Evaluation pachymetry map over time in Pediatric cxl

Contenuta perdita di

Spessore post cxl

‐46 micron

post 1 yr!!





Only after 1 month

Reduction of the true net power of the keratoconusovertime

pre cxl 1 m post cxl 7 m post cxl

0.6 ‐8.00(‐4.00)0 0.9 ‐4.25(‐4.75)250.7 ‐7.00(‐4.00)0

Differentialaxial map-6.23D

Only after 1 month

57.95D 52.48D 51.72D

Reduction of the area/power of the keratoconusovertime

Conclusions

CXL is indicated in PEDs with progressive KC.

CXL appears to be effective in improving UCVA and BSCVA by reducing corneal asimmetry and cornealwavefront aberrations at two years follow‐up.

CXL is a safe treatment for KC, with faster reepithelialization and faster recovery of CCT in pediatric pt.

Careful screening and closer followup needed in pediatricage to avoid faster and more dramatic progression of the disease.


Elena AlbéIstituto Clinico Humanitas

[email protected]


VII. Evaluation of Crystalline Lens Opacity Induced by Corneal Cross-Linking

with Scheimpflug Imaging


EvaluationEvaluation of of CrystallineCrystalline LensLens OpacityOpacityInducedInduced byby CornealCorneal CrossCross--LinkingLinking withwith

ScheimpflugScheimpflug ImagingImaging

FI Camesasca, P Vinciguerra, S FI Camesasca, P Vinciguerra, S TrazzaTrazza

Department of OphthalmologyDepartment of Ophthalmology

IRCCS IRCCS IstitutoIstituto ClinicoClinico HumanitasHumanitas

RozzanoRozzano, Milano, Italy, Milano, Italy

Chairman: Prof. P. VinciguerraChairman: Prof. P. Vinciguerra

I have no financial interest to discloseI have no financial interest to disclose


•• CornealCorneal CrossCross--linkinglinking (CXL):(CXL):•• stabilizesstabilizes progressive progressive keratoconuskeratoconus

•• inhibitsinhibits some some physiopathologicalphysiopathological mechanismmechanism ofof

cornealcorneal ectasia ectasia

•• increasesincreases biomechanicalbiomechanical strenghtstrenght ofof cornea cornea ofof

300%300%

•• preventsprevents PKPK

((WollensakWollensak G, Am J G, Am J OphthalmolOphthalmol 2003)2003)

ScheimpflugScheimpflug, Cristalline , Cristalline LensLens andand

CornealCorneal CrossCross--LinkingLinking


•• ObjectiveObjective evaluationevaluation ofof crystallinecrystalline lenslens opacityopacity::•• ComplexComplex

•• LOCS III, LOCS III, AgeAge--RelatedRelated EyeEye DiseaseDisease StudyStudy

•• ClinicalClinical measurementmeasurement: : subjectivesubjective

ScheimpflugScheimpflug, Cristalline , Cristalline LensLensand and CornealCorneal CrossCross--LinkingLinking

(McCarty CA, Dev Ophthalmol 2002)


•• OculusOculus PentacamPentacam HR Software (HR Software (OculusOculus

OptikgerOptikgeräätete, , WetzlarWetzlar, Germania) , Germania) •• information information fromfrom the the anterioranterior cornealcorneal surfacesurface

toto the the posteriorposterior crystallinecrystalline capsulecapsule

•• objectiveobjective system system measuringmeasuring densitometrydensitometry

•• full full scanscan toto reconstructreconstruct the the lenslens

ScheimpflugScheimpflug, Cristalline , Cristalline LensLensand and CornealCorneal CrossCross--LinkingLinking


ScheimpflugScheimpflug, , LensLens andandCrossCross--LinkingLinking

PentacamPentacam software software evaluatesevaluates::•• volumevolume•• 3D 3D opticaloptical densitydensity•• meanmean opticaloptical density density

DensitometryDensitometry Software :Software :•• comparescompares density density withwith anan advancedadvanced nomogramnomogram•• assignesassignes a a lenslens density density gradegrade•• quantifiesquantifies density and area density and area ofof lenslens opacificationopacification

Measures the lens density in an objective, reppoducible and accurate way


UV UV raysrays: a : a wellwell--knownknown etiologicaletiological agentagent ofof cataractcataract

The The ocularocular structurestructure mostmost exposedexposed toto UV UV raysrays duringduringcrosscross--linkinglinking, , afterafter the the cornealcorneal endotheliumendothelium, , isis the the crystallinecrystalline lenslens

Ectasia Ectasia patientspatients are are oftenoften veryvery youngyoung::•• progressive progressive keratoconuskeratoconus•• ectasia ectasia followingfollowing refractiverefractive surgerysurgery



•• 18 18 eyeseyes ofof 18 18 patientspatients withwith progressive progressive keratoconuskeratoconus, , documenteddocumented

•• CXL CXL performedperformed betweenbetween AprilApril and and JuneJune 20062006

•• meanmean patientpatient ageage: 34.9 : 34.9 ±± 6.5 6.5 yrsyrs ((rangerange: 26 : 26 toto 50)50)

•• CXL: CXL: wellwell--establishedestablished and and describeddescribed techniquetechnique

•• PreoperativelyPreoperatively and 1, 2, 3 and 1, 2, 3 yearsyears postoperativelypostoperatively


MaterialsMaterials e e MethodsMethods

Vinciguerra P, Ophthalmology 2009


••EvaluationEvaluation ::

•• complete complete ophthalmologicalophthalmological examinationexamination

•• endothelialendothelial cellcell countscounts

•• cornealcorneal topographytopography

•• aberrometryaberrometry

•• centralcentral pachimetrypachimetry and /or topo/and /or topo/tomographytomography withwith ScheimpflugScheimpflug system system

((PentacamPentacam))

•• ScheimpflugScheimpflug system system usedused forfor the the objectiveobjective evaluationevaluation ofof lenslens transparencytransparency

•• lenslens opacitiesopacities gradedgraded withwith a system a system rangingranging fromfrom 0 0 toto 33





•• InclusionInclusion criteriacriteria

••Progressive Progressive keratoconuskeratoconus ((seriesseries ofof topotopo--tomographiestomographies))

••AgeAge aboveabove 1818

•• ExclusionExclusion criteriacriteria::

•• cornealcorneal thicknessthickness < 400 < 400 mumu at at thinnestthinnest pointpoint

•• historyhistory ofof herpeticherpetic keratitiskeratitis

••SvereSvere dry dry eyeeye

•• ConcurrentConcurrent cornealcorneal infectionsinfections

•• CornealCorneal opacitiesopacities

•• ConcomitantConcomitant autoimmune autoimmune diseasedisease






The The PentacamPentacam--basedbased lenslensopacityopacity evaluationevaluation system on system on

providesprovides gradesgrades rangingrangingfromfrom 0 0 toto 33

ScheimpflugScheimpflug, , LensLens andandCrossCross--LinkingLinkingMaterialsMaterials and and MethodsMethods

1 32

Pentacam Nucleus Staging

0

StagingStaging exampleexample

Time Interval

Preoperative

1 year 2 years 3 years

Crystalline lens opacity (mean)

0.18 ± 0.39(0 -1)

0.21 ±0.53

(0 -2)

0.04 ±0.20(0 -1)

0.17 ± 0.39 (0 -1)


MeanMean UCVA and BSCVA:UCVA and BSCVA:

preoperativepreoperative :180/20 and 20/40:180/20 and 20/40

3 3 yearsyears afterafter CXL: 20/50 and 20/25 (p<.05)CXL: 20/50 and 20/25 (p<.05)

SE: SE: reductionreduction ofof 0.96 D 0.96 D

MeanMean simulatedsimulated keratometrykeratometry: : reducedreduced (p<.05)(p<.05)

EndotelialEndotelial CellCell CountsCounts : : unchangedunchanged ((p=p=.13). .13).

LensLens transparencytransparency::

measuredmeasured withwith the the ScheimpflugScheimpflug system, system, threethree yearsyears afterafter CXL CXL

remainedremained unchangedunchanged

LensLens alwaysalways transparenttransparent


ResultsResults



22.34 ±9.38

(9.4 –41.6)

18.19 ±6.32

(8.2 –32.2)

ns18.4 ±3.92

(11.4 –26.3)

24.99 ± 7.9(13.7 – 37.6)

Min (%)(mean ± SD)(range: min to max)

22.34 ±9.38

(9.4 –41.6)

ns18.19 ±6.32

(8.2 –32.2)

ns18.4 ±3.92

(11.4 –26.3)

24.99 ± 7.9(13.7 – 37.6)

Max (%)(mean ± SD)(range: min to max)

3.10 ±2.29

(0.6 –7.8)

ns2.12 ±1.31

(0.3 –4.8)

ns1.93 ±0.60

(0.9 –2.9)

3.14 ± 1.21(1.3 – 5.2)

ST Dev (%)(mean ± SD)(range: min to max)

10.41 ±2.44

(7.8 –17.2)

ns9.90 ±1.64

(87.4 –14.7)

ns10.48 ±

1.79(8.30 –13.7)

11.51 ± 1.70(8.50 – 17.2)

Average opacity (%)(mean ± SD)(range: min to max)

0 -1ns0 -1ns0 -20 -1Crystalline lens opacity grading scale value (range: min to max)

0.17 ±0.39

ns0.04 ±0.20

ns0.21 ±0.53

0.18 ± 0.39Crystalline lens density (mean ± SD)

3 yearsp2 yearsp1 yearPreoperativeTime Interval


Young Young meanmean ageage ofof the the studystudy cohortcohort: : completelycompletely

transparenttransparent lenslens

LensLens persistentlypersistently trasparenttrasparent 36 36 monthsmonths afterafter CXL: CXL:

the procedure the procedure diddid notnot induce induce anyany lenslens changechange

measurablemeasurable withwith PentacamPentacam and the and the dedicateddedicated

densitometrydensitometry softwaresoftware

Grewal DS, Ophthalmology 2009


ConclusionsConclusions


PentacamPentacam dedicateddedicated software can software can measuremeasure lenslens density in density in

anan accurate, accurate, objectiveobjective and and reproduciblereproducible wayway

AfterAfter CXL, CXL, wewe diddid notnot observeobserve anyany side side effecteffect involvinginvolving

the the lenslens or the or the cornealcorneal endotheliumendothelium at at anyany timetime intervalinterval..

Grewal DS, Ophthalmology 2009


ConclusionsConclusions


VIII. Anterior and Posterior Corneal Surface

Scipione Rossi,MDDirector of Ocular Microsurgey Unit

San Carlo Hospital-IDIRome, Italy

POSTERIOR CORNEAL HIGH-ORDER ABERRATIONS

AFTER CORNEAL CROSS LINKING

To evaluate the posterior corneal surface high-order aberrations (HOAs) outcomes 4 years after corneal collagen cross-linking

(CXL) in eyes with progressive keratoconus

OBJECTIVE

WHY POSTERIOR CORNEAL SURFACE?

The cornea does not exhibit uniform biomechanical strength

– The collagen fibrils of the anterior lamellae are smaller (50 µm to 100 µm) and more densely packed and interweave.

– the posterior lamellae are larger and more loosely packed and do not interweave

– This lamellae arrangement allows for the cornea to be divided into strong and weak zones, both anterior-posterior and peripheral-central.

the posterior corneal surface is a “weak zone”

IN NORMAL EYES:

Marshall J.ESCRS ,2007.

STRONG CORNEA

160 µm

1. the posterior corneal surface, its elevation and curvature have been shown to be screening factors for keratoconus

• For cut-off of 35 µm, sensitivity 93% & specificity 95%,

2. Mean posterior corneal elevation significantly higher compared to mean anterior corneal in keratoconus eyes

Nilforoushan MR, Speaker M, Marmor M, Abramson J, Tullo W, Morschauser D, Latkany R. Comparative evaluation of refractive surgery candidates with Placido topography, Orbscan II, Pentacam, and wavefront analysis. J Cataract Refract Surg 2008; 34: 623–631.Schlegel Z, Hoang-Xuan T, Gatinel D.Comparison of and correlation between anterior and posterior corneal elevation maps in normal eyes and Keratoconus suspecteyes. J Cataract Refract Surg 2008; 34:789–795De Sanctis U, Loiacono C, Richiardi L,Turco D, Mutani B, Grignolo FM. Sensitivity and specificity of posterior corneal elevation measured by Pentacam in discriminating keratoconus/subclinical keratoconus.Ophthalmology 2008; 115: 1534–1539..Tomidokoro A, Oshika T, Amano S, HigakiS, Maeda N, Miyata K. Changes in anterior and posterior corneal curvatures in

keratoconus. Ophthalmology 2000; 107: 1328–1332.Dubbleman M, Sicam VADP, Van der Heijde RGL. The contribution of the posterior corneal surface to the coma aberration of the human cornea. J Vision 2007; 7:1–8.

IN KERATOCONIC EYES:the posterior corneal surface is a “critical zone”

POSTERIOR CORNEAL ELEVATION

Table 1. The sensitivity and specificity of different posterior corneal elevation levels to distinguish between keratoconic eyes and controls.

Keratoconus Controls

Cut-off point (µm) Sensitivity Specificity

10 100 0

15 100 12.3

20 100 53.4

25 100 66.2

30 96.4 84.5

35 93.2 94.9

40 89.0 98.9.

45 86.2 100

posterior elevation optimal cutoff point to discriminate

keratoconus and keratoconus suspect versus normal corneas

35 µm

Rao SN, Raviv T, Majmudar PA, Epstein RJ. Role of Orbscan II in screening keratoconus suspects before refractive corneal surgery. Ophthalmology 2002; 109:1642–1646


the posterior corneal surface profile is

more irregular than that of the anterior corneal surface in advanced KC eyes.

anterior and posterior asymmetric corneal protrusion induces irregular astigmatism

(pseudo-astigmatism)

Elevated High Order Aberrations

COMA-LIKE and SPHERICAL aberrations

leading to impared visual function

OPTICAL EFFECT OF ANTERIOR AND POSTERIOR CORNEAL SURFACE IN KC

ANTERIOR APEX TILTING ANTERIOR-COMAPSEUDO-ASTIGMATISM

ANTERIOR CORNEAL RAY DECREASING

INCREASED CORNEAL POWER(Myopic shift)

POSTERIOR CORNEAL PROTRUSION

REDUCED CORNEAL POWER(Hyperopic shift)

POSTERIOR CORNEAL RAY DECREASING

PSEUDO-ASTIGMATISMPOSTERIOR-COMA

Anterior Corneal

Aberration

“inferior slow pattern”

Posterior Corneal

Aberration

“superior slow pattern”

Total Corneal

Aberration

+ =

Nagawa T., Maeda N., Kosaki R. et al.: Higher –Order aberrations due to the posterior corneal surface in patients with keratoconus. IOVS., 2009Chen M., Yoong.G.:Posterior Corneal Aberrations and Their Compensation Effects on Anterior Corneal Aberrations in Keratoconic

Eyes.Invest Ophthalmol Vis Sci. 2008;49:5645–5652

ANTERIOR AND POSTERIOR CORNEAL WAVEFRONT ABERROMETRY

Exist an aberration compensation effect

between the anterior and posterior corneal surface if their irregular surface profiles had the same direction.

METHODS

• 300 eyes with progressive keratoconus were treated with UVA riboflavin CCL from 2007 to 2010

• Clinical and instrumental progression (Refractive, Tomographic , Aberrometric) in the last 6-12 months

• We performed a retrospective study in 40 eyes (follow-up 4 years ) to evaluate the HAOs of corneal posterior surface

METHODS

Group I (28 eyes)

• Maximum Posterior Corneal Elevation <50 µm• Corneal Thickness between 400 - 520µm

Group II (12 eyes)

•Maximum Posterior Corneal Elevation Value > 50 µm• Minimum Corneal Thickness between 380-400

• CORNEAL TOMOGRAPHY1. Anterior and posterior curvature/power maps2. Enhanced anterior and posterior elevation best fit

sphere (BFS)3. Pachymetric maps

• CORNEAL WAVEFRONT ABERRATIONS

1. Anterior/posterior aberrations maps2. Total corneal aberrations

Koller T., Iseli H.P., Hafezi F.,Vinciguerra P. et al.: Scheimpflug imaging of corneas after collagen cross-linking.Cornea,2009 ;28(5):510-5

Dual Scheimpflug Analyzer :PLACIDO + SCHEIMPFLUG

THECNOLOGIES

METHODS

RAY-TRACING

CORNEAL WAVEFRONT ABERRATIONS

• the wavefront maps of the total cornea using the Zernike Polynomial function – HOAs for 6 mm pupils were calculated from the difference between the height

data and best –fit sphere (BSF)

– The reference axes of the measurements were aligned with the primary line of

sight.

• Trefoil, coma, fourth-order astigmatism, spherical aberration all differ both anteriorly and posteriorly

• For both anterior and posterior surfaces, vertical coma most important HOAs


Correlation the mean RMS of coma like aberration to the Amsler-Krumeich classification :

Stage I

• Eccentric steeping• Myopia and astigmatism < 5.00 D•Mean central K readings < 48.00 D•RMS of coma-LIKE from 1,50 to 2,50 µm

Stage II

• Myopia and astigmatism from 5.00 to 8.00 D• Mean central K readings < 53.00 D•Absence of scarring • Minimum corneal thickness >400 µm•RMS of coma-LIKE from > 2,50 to ≥ 3.50 µm

Stage III

•Myopia and astigmatism from 8.00 to 10.00 D• Mean central K readings >53.00 D•Absence of scarring • Minimum corneal thickness 300 to 400 µm•RMS of coma-LIKE from 3,50 to ≤4,50 µm

Stage IV

• Refraction not measurable• Mean central K readings >55.00 D• Central corneal scarring• Minimum corneal thickness 200 µm•RMS of coma-LIKE from > 2,50 µm

Aliò J.L., Shabayek M.H.: corneal higher order aberration: a method to grade keratoconus. Journal of refractive surgery., 2006;22:539-545

RESULTS AFTER 4 YEARS

• UVA: 3 mW/cm2

• Exposure time: 30 min

• Depth: 300 mm

ORDER ABERRATIONPRE OPERATIVE

MEAN (µm)POST OPERATIVE

MEAN (µm)

Mean aberration coeficient 1.75 ( 0.48198) 1.8925 ( 0.62936)

3rd Coma 2,3597 ( 1.18623) 1,0233 ( 1.925109)

3rd Trefoil -0.0548 ( 0.35627) -0.0963 ( 0.51242)

4th High order astigmatism -0.0491 ( 0.48198) 0.1524 ( 0.77456)

4th Tetrafoil -0.0294( 0.60129) -0.0543 ( 0.52224)

4th Spherical Aberration 0.3513 ( 0.73449) 0.6033 ( 1.08027)

5th High order coma 0.0488 ( 0.28599) -0.0643 ( 0.38893)

5th High order trefoil -0.0035 ( 0.20314) -0.061 ( 0.23362)

5th Pentafoil -0.0121 ( 0.19826) -0.0234 ( 0.40602)

Summary of total HOA s mean before and 4 years after corneal CXL treatment (GroupI)

Coma aberration reduction was statistically significant

ORDER ABERRATIONPRE OPERATIVE

MEAN (µm)POST OPERATIVE

MEAN (µm)

Mean aberration coeficient 1.95 ( 0.56298) 2.0925 ( 0.7336)

3rd Coma 4,895 ( 1.14623) 3,082( 1.925109)

3rd Trefoil -0.0548 ( 0.25627) -0.5478 ( 0.36242)

4th High order astigmatism -0.1091 ( 0.58198) 0.5524 ( 0.25456)

4th Tetrafoil -0.0494( 0.30129) -0.0643 ( 0.53424)

4th Spherical Aberration 0.5513 ( 0.83449) 0.8033 ( 1.09127)

5th High order coma 0.0588 ( 0.68599) -0.0843 ( 0.38893)

5th High order trefoil -0.00345 ( 0.50314) -0.071 ( 0.22562)

5th Pentafoil -0.01521 ( 0.39826) -0.0634 ( 0.42302)

Summary of total HOA s mean before and 4 years after corneal CXL treatment (GroupII)

Coma and Trefoil aberrations reduction was statistically significant

GROUP I

(28 eyes)

GROUP II

(12 eyes)Pre-CXL 4 years

Post-CXL

Pre-CXL 4 years

Post-CXL

Anterior Elevation

(µm)12,10

0,043

8,98 0,023

24,3

0,087

20,4

0,045

Posterior elevation (µm)

23,8

0,072

28,8

0,064

57,1

0,052

50,2

0,087

Total

Corneal Wavefront (COMA-RMS)

2,35

0,012

1.83

0,015

4,59

0,032

3,13

0,043

Anterior

Corneal Wavefront

(COMA-RMS)

2,40

0,027

2,35

0,038

5,62

0,068

3,24

0,0027

Posterior

Corneal Wavefront

(COMA-RMS)

-0,50

0,015

-0,80

0,013

-1,02

0,020

-0,40

0,002

Pre germano

PosteriorElevation

BFS

Thinnest point 547

PRE-CXL

27 µm

AnteriorElevation

BFS 18 µm

18

GROUP I:

Pre germano)

PosteriorElevation

BFS 33 µm

4 years POST-CXL

Thinnest point 550

AnteriorElevation

BFS 14 µm

PRE-CXL

RMS Total COMA

2,35µm

RMS Anterior COMA

2,40 µm

≥

GROUP I:


RMS Total COMA

1,83 µm

RMS Anterior COMA

2,35 µm

4 years POST-CXL

> >

GROUP I:

PRE-CXL

62 micron

PosteriorElevation

BFS

Thinnest point 376

AnteriorElevation

BFS 26 micron

GROUP II:

4 years POST-CXL

Thinnest point 385

AnteriorElevation

BFS

GROUP II:

24 micron 45 micron

PosteriorElevation

BFS

PRE-CXL

RMS Total COMA

4,59µm

RMS Anterior COMA

5,62 µm

>

GROUP II:

RMS Total COMA

3,13 µm

RMS Anterior COMA

3,24 µm

4 years POST-CXL

≥

GROUP II:

Outcomes:

• In the Group I after CXL

1. The total corneal HAOs aberrations decreasedsignificantly

2. The anterior corneal HAOs aberrations decreased

3. The posterior corneal HAOs aberration increased

Outcomes:

• In the Group II after CXL

1. The total corneal HAOs aberrations decreasedsignificantly

2. The anterior corneal HAOs aberrations decreased

3. The posterior corneal HAOs aberration decreased

What Happens after Cross Linking?CONCLUSION

Demarcation line

485µ

If we treat keratoconic cornea with high tickness(450/500μm) :

The 300 μm of anterior cornea are cross-linked andthe posterior cornea (weak cornea) continue ectasic evolution

with no evidence of anterior progression ?The cross-linked anterior lamellae produce an increase of post.

elevation due too biomecanical effects ( transport effect) ?


What Happens after Cross Linking?

CONCLUSION:

Does the treatment in low pachimetry cornea ( around 400 ) allow the cross-linking in the posterior corneal stroma?

390 µm

CONCLUSION

• Total Corneal HAOs, especially coma-like aberrations, always decrease significantly

• The posterior surface HOAs are related with posterior elevation and initial pachimetry.

What Happens after Cross Linking regarding HAOs?

• We observe : in our series the age of the first Group waslower than the second one but this data are notsignificative (a few cases)

• We think that also the age play a role in changing the posterior HAOs aberrations after CXL

Now our goal is follows the posterior corneal elevation and HOAs in pediatric cases

FUTURE PLANNING

THANKS FOR YOUR ATTENTION


Addresses

Paolo Vinciguerra, MD Chairman, Ophthalmology Dept. Istituto Clinico Humanitas Office: Via Ripamonti, 205 20100 Milano - Italy ph + 39 02 55211388 fax +39 02 57410355 [email protected] www.paolovinciguerra.com www.refractiveonline.it

Scipione Rossi, MD [email protected]

Fabrizio I. Camesasca, MD Ophthalmology Dept. Istituto Clinico Humanitas Office: P.za Maria Adelaide, 1 20129 Milano - Italy Ph +39 02 29529396 Fax +39 02 29529396 [email protected] www.camesasca.com

Theo Seiler, MD IROC AG Institute fur Refractive und Ophthalmo-Chirurgie Stockerstrasse, 37 CH-8002 Zurich Ph. +41 43 488 38 00 Fax + 41 43 488 38 09 [email protected] www.iroc.ch

Elena Albè, MD Ophthalmology Dept. Istituto Clinico Humanitas Via Manzoni, 56 20089 Milano - Italy Ph + 3902 8824 4680 Fax +3902 8224 4694 [email protected]

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