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UUpdate on Keratoconuspdate on Keratoconus Diagnosis and Diagnosis and TreatmentTreatment

Mahdavi MDMahdavi MD

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““Keratoconus is a Keratoconus is a clinical term to clinical term to describe a describe a condition in which condition in which the cornea the cornea assumes a conical assumes a conical shape because of shape because of thinning and thinning and protrusion”protrusion”

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Keratoconus HistoryKeratoconus History

Blurred visionBlurred vision

Distortion Distortion

PhotophobiaPhotophobia

Monocular polyopiaMonocular polyopia

HalosHalos

Patient presents with frequent eyeglass Patient presents with frequent eyeglass changeschanges

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KCN HISTORYKCN HISTORY

Non-inflammatoryNon-inflammatory

1/2000-50001/2000-5000

Central 2/3Central 2/3

AR/AD InheritanceAR/AD Inheritance

Females =MalesFemales =Males

Presents initially at Presents initially at puberty & puberty & progression varies, progression varies, stability in 30sstability in 30s

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““Why don’t we see elderly Why don’t we see elderly patients with keratoconus”patients with keratoconus”

Do they die youngerDo they die youngerNONO

Do they not visit Do they not visit POSSIBLEPOSSIBLE

Have they CE/PKPHave they CE/PKP POSSIBLEPOSSIBLE

THEORY BY KRACHMERTHEORY BY KRACHMER The eye becomes more rigid as the patient The eye becomes more rigid as the patient

ages and therefore the condition stabilizesages and therefore the condition stabilizes

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ASSOCIATED SYSTEMIC ASSOCIATED SYSTEMIC CONDITIONSCONDITIONS

Vernal KC Vernal KC Atopic DermatitisAtopic DermatitisDown’s SyndromeDown’s SyndromeFloppy Eyelid SyndromeFloppy Eyelid SyndromeMitral Valve ProlapseMitral Valve ProlapseEhlers-Danlos SyndromeEhlers-Danlos SyndromeOsteogenesis ImperfectaOsteogenesis ImperfectaLawrence-Moon-Biedl Lawrence-Moon-Biedl SyndromeSyndromeNeurofibromatosisNeurofibromatosisPsuedoxanthoma Psuedoxanthoma ElasticumElasticum

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ETIOLOGY OF KCNETIOLOGY OF KCN

History of trauma that causes weaknessHistory of trauma that causes weaknessRecurrent trauma due to rubbing fromRecurrent trauma due to rubbing from Blepharitis, CL/lids, 53% have atopic dxBlepharitis, CL/lids, 53% have atopic dx

Inflammatory component !!!Inflammatory component !!! Decrease proteinase inhibitorsDecrease proteinase inhibitors Increase collagenaseIncrease collagenase Premature keratocytic apoptosisPremature keratocytic apoptosis Increase cytokine bindingIncrease cytokine binding

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Basic Science ResearchBasic Science Research

KCN have higher # of mitochondrial DNA KCN have higher # of mitochondrial DNA deletions that leads to decrease oxidative deletions that leads to decrease oxidative phosphorylation… increase Hphosphorylation… increase H220022

Causes leakage, damages proteins, and Causes leakage, damages proteins, and results in oxidative stressresults in oxidative stress

Leads to apoptosis, abnormal healing, Leads to apoptosis, abnormal healing, inflammation.inflammation.

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Basic Science ResearchBasic Science Research

Yaron Rabinowitz, MD UCLAYaron Rabinowitz, MD UCLAKCN have suppressed Aquaporin 5 KCN have suppressed Aquaporin 5 (AQP5)(AQP5)AQP5 is the water transport gene that is AQP5 is the water transport gene that is responsible for cell migration and wound responsible for cell migration and wound healing.healing.Quantitative PCR testing (epithelial cells) Quantitative PCR testing (epithelial cells) could diagnose thiscould diagnose this

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RESEARCH MAY RESEARCH MAY INDICATE NEW THERAPIESINDICATE NEW THERAPIESKCN is unlikely a single gene defectKCN is unlikely a single gene defect Chromosome 5, 21 Chromosome 5, 21

Multiple genes in a common pathwayMultiple genes in a common pathwayThose with the defect may develop KCN Those with the defect may develop KCN naturally or only if exposed to factors that naturally or only if exposed to factors that induce oxidative stress: CL over-wear, UV, induce oxidative stress: CL over-wear, UV, allergy or refractive surgeryallergy or refractive surgeryTX: Anti-inflammatory, Anti-oxidantTX: Anti-inflammatory, Anti-oxidant

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RETINOSCOPYRETINOSCOPY

Scissors ReflexScissors Reflex

Against motion that Against motion that breaks apartbreaks apart

Represents multiple Represents multiple refractive powers refractive powers within the optic zonewithin the optic zone

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KERATOCONUS-SLIT LAMP FINDINGSKERATOCONUS-SLIT LAMP FINDINGS

FLEISCHER RING FLEISCHER RING abrupt change in curvature 50%abrupt change in curvature 50%

VOGT’S STRIAE VOGT’S STRIAE 11stst Sign 65% Sign 65%

STROMAL THINNINGSTROMAL THINNING

STROMAL SCARSSTROMAL SCARS

ENLARGED CORNEAL NERVESENLARGED CORNEAL NERVES

ACUTE HYDROPS 5%ACUTE HYDROPS 5%

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FLEISCHER RINGFLEISCHER RING

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VOGT’S STRIAEVOGT’S STRIAE

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STROMAL SCARSSTROMAL SCARS

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ACUTE HYDROPSACUTE HYDROPS

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EXTERNAL FINDINGSEXTERNAL FINDINGS

MUNSONS SIGNMUNSONS SIGN RIZZUTIS SIGNRIZZUTIS SIGN

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Keratoconus- KeratometryKeratoconus- Keratometry

Steepening begins infero-Steepening begins infero-temporally and progresses temporally and progresses clockwiseclockwise

TOPOGRAPHY- more sensitiveTOPOGRAPHY- more sensitive

PLACIDO RINGS- get closerPLACIDO RINGS- get closer

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PLACIDO RING IMAGESPLACIDO RING IMAGES

Rings that are Rings that are closer together closer together represent areas represent areas of steeper of steeper curvaturecurvature

May indicate a May indicate a tight suture tight suture applicableapplicable

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ELEVATION (FLOAT) MAPSELEVATION (FLOAT) MAPS

Predicts the relativePredicts the relative

elevation or depressionelevation or depression

of the cornea (in mm)of the cornea (in mm)

using a computerusing a computer

generated BEST FITgenerated BEST FIT

SPHERE as a referenceSPHERE as a reference

and fit at the steepestand fit at the steepest

pointpoint

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ELEVATION MAPS PREDICT ELEVATION MAPS PREDICT Na-FL PATTERNNa-FL PATTERN

+ VALUES- warm colors + VALUES- warm colors points higher than sphere = elevation Areas of bearing or touch points higher than sphere = elevation Areas of bearing or touch

- VALUES- cool colors- VALUES- cool colorspoints lower than sphere = depression Areas of poolingpoints lower than sphere = depression Areas of pooling

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PELLUCID MARGINAL PELLUCID MARGINAL

Tear meniscus can creates pseudo-PMD Tear meniscus can creates pseudo-PMD

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PMD vs. KCNPMD vs. KCN

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PSEUDOKERATOCONUSPSEUDOKERATOCONUS

Corneal warpage topography can mimic KC Corneal warpage topography can mimic KC

Repeat topography must be performed and a Repeat topography must be performed and a measurable change would indicate pseudo-measurable change would indicate pseudo-KCKC

Evaluation of elevation maps at steep zone:Evaluation of elevation maps at steep zone:

Predicts the elevation or depression of the Predicts the elevation or depression of the cornea if the best fit sphere was on corneacornea if the best fit sphere was on cornea

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POSTERIOR KERATOCONUSPOSTERIOR KERATOCONUS

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KCN Effects on VisionKCN Effects on Vision

Tim McMahon, ODTim McMahon, OD60% reduction in VA is 60% reduction in VA is due to curvature, not just due to curvature, not just high cylinderhigh cylinderRGP corrects cylinder RGP corrects cylinder however HOA remainhowever HOA remainCOMACOMAMay consider reverse May consider reverse geometry CLSgeometry CLSReduced low contrast VAReduced low contrast VAReads chart slowerReads chart slower

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COMA ZCOMA Z3311

Similar to SA except that Similar to SA except that it concerns off axis it concerns off axis peripheral rays that cause peripheral rays that cause a comet-shaped image a comet-shaped image deformity to non-axial deformity to non-axial portions of the image.portions of the image.

MinimalMinimal

Post refractive surgery Post refractive surgery “Potato chip” due to flap “Potato chip” due to flap hinge and shows the hinge and shows the most dynamic change.most dynamic change.

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Refractive SurgeryRefractive Surgery Corneal laser refractive Corneal laser refractive

surgery: pre-op, surgery: pre-op, enhancement optionsenhancement options

Phakic IOLsPhakic IOLs Corneal refractive Corneal refractive

implants: Intacsimplants: Intacs

Anterior Segment Imaging Anterior Segment Imaging and Surgeryand Surgery

Corneal Imaging and Corneal Imaging and MeasurementMeasurement

Iris Imaging and Iris Imaging and EvaluationEvaluation

Trauma AssessmentTrauma Assessment

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Visante ApplicationsVisante ApplicationsAnterior Segment Imaging and Anterior Segment Imaging and

SurgerySurgery

Corneal Imaging and Corneal Imaging and MeasurementMeasurementimaging and evaluation of imaging and evaluation of corneal pathologiescorneal pathologiespenetrating keratoplastypenetrating keratoplastylamellar keratoplastylamellar keratoplastyendothelial keratoplastyendothelial keratoplastykeratoconus imaging and keratoconus imaging and assessmentassessmentanterior segment imaging anterior segment imaging through opaque corneasthrough opaque corneas

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Terrien‘s Marginal DegenerationTerrien‘s Marginal Degeneration

image courtesy of Dr. M. Packer

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Evolution of KCN: Ectasia to HydropsEvolution of KCN: Ectasia to Hydrops

image courtesy of Prof. G. Baikoff

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KCN/Open Angle (ML)KCN/Open Angle (ML)

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KCN- Thinning (ML)KCN- Thinning (ML)

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Indications for Intra-Limbal LensesIndications for Intra-Limbal Lenses

KCN RGP dropoutsKCN RGP dropouts

Pellucid MarginalPellucid Marginal

Post-PKPPost-PKP

Astigmatic corneasAstigmatic corneas

SCL failures: due to SCL failures: due to neovascularization neovascularization

or poor visual acuity.or poor visual acuity.

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Large Diameter LensesLarge Diameter Lenses

Corneo- ScleralCorneo- Scleral

12.9 mm- 13.5 mm12.9 mm- 13.5 mm

Semi- ScleralSemi- Scleral

13.6 mm- 14.9 mm13.6 mm- 14.9 mm

Mini- ScleralMini- Scleral

15.0 mm-18.0 mm15.0 mm-18.0 mm

Scleral Bearing, minimum Scleral Bearing, minimum corneal clearancecorneal clearance

Full ScleralFull Scleral

18.1 mm- > 24+ mm18.1 mm- > 24+ mm

Scleral Bearing, maximum Scleral Bearing, maximum corneal clearancecorneal clearance

Dyna Intralimbal Dyna Intralimbal (Lens Dynamics)(Lens Dynamics)

Macrolens Macrolens

(C&H)(C&H)

Jupiter Jupiter

(Innovations in Sight)(Innovations in Sight)

GBL GBL

(Con-Cise)(Con-Cise)

Robert Breece, OD

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Intra-Limbal FittingIntra-Limbal Fitting

BC is Flatter than expectedBC is Flatter than expected K @ 4-5mm temporal vs. K @ 4-5mm temporal vs. Average Mid K +.2mmAverage Mid K +.2mm

GoalGoal Light feather touchLight feather touch .2mm < corneal diameter .2mm < corneal diameter

(11.3 OAD)(11.3 OAD) .1-.2 mm movement.1-.2 mm movement .2mm edge clearance.2mm edge clearance Menicon Z or ExtremeMenicon Z or Extreme Unique ph or ClarisUnique ph or Claris

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SOFT LENS OPTIONS FOR SOFT LENS OPTIONS FOR KERATOCONUSKERATOCONUS

Soft SpheresSoft Spheres

Soft ToricsSoft Torics

X-cel Flexlens TricurveX-cel Flexlens Tricurve Basecurve 6.0 - 9.9Basecurve 6.0 - 9.9 Diameter 10.0-15.0Diameter 10.0-15.0 Center Thickness .45Center Thickness .45 dK 13.2dK 13.2 Continental, Gelflex USA, Ocu-Ease Continental, Gelflex USA, Ocu-Ease

(Ocuflex K)(Ocuflex K)

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Benz 5x material,Glycerol Benz 5x material,Glycerol MethacrylateMethacrylate Less dehydration, Less dehydration,

flexure,better opticsflexure,better optics

Fit the normal peripheral Fit the normal peripheral cornea & sclera like cornea & sclera like standard SCL. The standard SCL. The central posterior curve central posterior curve provides sagittal depth to provides sagittal depth to touchtouch

POSTERIORPOSTERIOR: :

Steep central curve, flatter Steep central curve, flatter paracentral peripheral curveparacentral peripheral curve

all asphericall aspheric

ANTERIORANTERIOR: :

Central optical surface that Central optical surface that quickly tapers to maximize quickly tapers to maximize 0202

Low ridingLow riding

More movementMore movement

Innovations in SightSUPER NOVA HydroKone™

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Innovations in SightInnovations in Sight

SUPER NOVA HydroKoneSUPER NOVA HydroKone™™ Base Curves: 4.1 to 9.3 Base Curves: 4.1 to 9.3 (5.3-8.5)(5.3-8.5)Diameters: 12.0 to 17.0Diameters: 12.0 to 17.0 (14.8)(14.8)Paracentral: 8.0-9.2Paracentral: 8.0-9.2 (8.6)(8.6)Sphere: +50.00 to -75.00Sphere: +50.00 to -75.00Cylinder: -0.25 to -50.00Cylinder: -0.25 to -50.00Axis: 1 to 180 in 1 degree stepsAxis: 1 to 180 in 1 degree steps

Mean K + 1mmMean K + 1mmDo not use H2O2 due to thicknessDo not use H2O2 due to thicknessEXPECT MORE MOVEMENTEXPECT MORE MOVEMENT

SynergEyes™ SynergEyes™ AA High Dk Hybrid High Dk Hybrid

MaterialMaterial Paragon HDS 100 GP Center Paragon HDS 100 GP Center 27% Water Non Ionic Skirt (Group 27% Water Non Ionic Skirt (Group

I)I)

DesignDesign 14.5 mm over all diameter14.5 mm over all diameter 8.4 mm rigid center8.4 mm rigid center 7.8 mm optic zone 7.8 mm optic zone 2-4skirt radii choices for each base 2-4skirt radii choices for each base

curve radiuscurve radius Skirt thickness consistent across Skirt thickness consistent across

full power rangefull power range Engineered edgeEngineered edge HyperBond™ junction technologyHyperBond™ junction technology

14.5mm

8.4 mm

Non-Ionic27% water Hydrogel Skirt

Non-Ionic27% water Hydrogel Skirt

Paragon HDS 100® Rigid Center

Paragon HDS 100® Rigid Center

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SynergEyes KCSynergEyes KC

3 skirt curve optionsfor fitting flexibility

Spherical Skirt begins at 9.0 mm diameter

Prolate ellipsoid base curve

FDA Clearance December 2005

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SynergEyes KC Diagnostic Set ParametersSynergEyes KC Diagnostic Set Parameters

AsphericAspheric

Base CurveBase CurvePowerPower

FlatFlat

SkirtSkirt

MediumMedium

SkirtSkirt

SteepSteep

SkirtSkirt5.7mm (59.00)5.7mm (59.00) -14.00-14.00 8.58.5 8.28.2 7.97.9

5.9mm (57.00)5.9mm (57.00) -14.00-14.00 8.58.5 8.28.2 7.97.9

6.1mm (55.50)6.1mm (55.50) -12.00-12.00 8.58.5 8.28.2 7.97.9

6.3mm (53.50)6.3mm (53.50) -10.00-10.00 8.88.8 8.58.5 8.28.2

6.5mm (52.00)6.5mm (52.00) -8.00-8.00 8.88.8 8.58.5 8.28.2

6.7mm (50.50)6.7mm (50.50) -6.00-6.00 8.88.8 8.58.5 8.28.2

6.9mm (49.00)6.9mm (49.00) -5.00-5.00 8.88.8 8.58.5 8.28.2

7.1mm (47.50)7.1mm (47.50) -4.00-4.00 9.19.1 8.88.8 8.58.5

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SynergEyes FittingSynergEyes Fitting

Lens MovementLens Movement .2mm to .3mm .2mm to .3mm

movement with blinkmovement with blink Slight lag in upward Slight lag in upward

gazegaze Free of scleral Free of scleral

impingementimpingement Free to move on “push Free to move on “push

up”up” Free of “edge fluting”Free of “edge fluting”

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The Fitting TipsThe Fitting Tips

• Never prescribe Flatter than Flat KNever prescribe Flatter than Flat K

• Counter-intuitive:Counter-intuitive:Corneas Corneas flatter flatter than 44.25D and than 44.25D and larger larger than than

12.0 mm: Steeper Skirt12.0 mm: Steeper Skirt

Corneas Corneas SteeperSteeper 44.25D and 44.25D and smallersmaller than 11.5 than 11.5 mm:mm: Flatter skirt Flatter skirt

Identical Apical Radius with Identical Apical Radius with Different HVID = Different HVID = different sagittal different sagittal

depthdepth

11.0 mm

12.0 mm3.60 2.96

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UPDATES FOR SYNERGEYESUPDATES FOR SYNERGEYES

Proprietary materials that has a SiHy skirt Proprietary materials that has a SiHy skirt and higher Dk GPand higher Dk GPThe GP will have less flexure, will likely The GP will have less flexure, will likely discontinue the enhanced profilediscontinue the enhanced profileTo reduce peripheral crimping, the skirt To reduce peripheral crimping, the skirt curves will be multicurve: bi or asphericcurves will be multicurve: bi or asphericCLEAR KONE : Additional KC lens for CLEAR KONE : Additional KC lens for more ectopic or decentered peaks with more ectopic or decentered peaks with reverse geometry to eliminate steep BCreverse geometry to eliminate steep BC

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Vault the cornea yet Vault the cornea yet aligns closer to cornea aligns closer to cornea allowing lower powersallowing lower powers

Reverse geometry at Reverse geometry at skirt to allow more tear skirt to allow more tear flow, easier removalflow, easier removal

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TIPS ON PIGGYBACKSTIPS ON PIGGYBACKS

SCL protects from RGP or environmentSCL protects from RGP or environmentReduces epithelial damage due to touchReduces epithelial damage due to touchProtects from apical nodulesProtects from apical nodulesConcurrent EBMDConcurrent EBMDHigh DK, easily replaced= SiHiHigh DK, easily replaced= SiHiSoft Modulus molds to highly toric/steep KSoft Modulus molds to highly toric/steep K+SCL to flatten the RGP+SCL to flatten the RGP- SCL to steepen the RGP fit- SCL to steepen the RGP fit

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Intra-Stromal RingsIntra-Stromal Rings

Ring segments are placed into peripheral corneal Ring segments are placed into peripheral corneal channels outside the visual axis to correct low to channels outside the visual axis to correct low to moderate myopia by flattening the cornea without moderate myopia by flattening the cornea without cutting or removing tissue form the central optical cutting or removing tissue form the central optical zonezoneFDA approval of Intacs in 1999 for low/mod FDA approval of Intacs in 1999 for low/mod myopia. myopia. Recently approved for keratoconus in US July Recently approved for keratoconus in US July 2004 Principle benefit: delay or eliminate corneal 2004 Principle benefit: delay or eliminate corneal graftgraftReversible/RemovableReversible/Removable

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Intacs StudiesIntacs Studies

By Wachler and et al.By Wachler and et al. 74 keratoconus eyes has insertion of intacs 74 keratoconus eyes has insertion of intacs

with F/U of 9 monthswith F/U of 9 months45% gain 45% gain ≥ 2 lines BCVA (worst pre-opt)≥ 2 lines BCVA (worst pre-opt)

51% had no effective changes51% had no effective changes

4% loss ≥ 2 lines of BCVA4% loss ≥ 2 lines of BCVA

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Single intrastromal corneal Single intrastromal corneal implant favored for paracentral implant favored for paracentral

conesconesColin Chan, MD and Boxer Wachler,MDColin Chan, MD and Boxer Wachler,MDCompared 20 eyes (double) vs. 17 Compared 20 eyes (double) vs. 17 (single)(single)Single used .25mm segment/ Single used .25mm segment/ Double .25&.35Double .25&.35All had paracentral/peripheral conesAll had paracentral/peripheral conesSignificantly better outcomes in change Significantly better outcomes in change in cylinder, K values, UBVA, BCVAin cylinder, K values, UBVA, BCVASingle 2-3 line gain, Double 1 line gainSingle 2-3 line gain, Double 1 line gain

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Complications of Intacs for KCNComplications of Intacs for KCN

UndercorrectionUndercorrectionOvercorrectionOvercorrectionNeovascularization toward the IncisionNeovascularization toward the IncisionMigration of One segment toward the WoundMigration of One segment toward the WoundExtrusionExtrusionStromal depositStromal depositFlap wrinkling (intracorneal inlays)Flap wrinkling (intracorneal inlays)Epithelial ingrowthEpithelial ingrowthResidual refractive errorResidual refractive errorComplication rate ranges from 5-30%Complication rate ranges from 5-30%

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Biomechanical Effect of Biomechanical Effect of Combined Riboflavin-UVACombined Riboflavin-UVA

The cross-linking in The cross-linking in KCN is abnormalKCN is abnormal

Too elastic and the Too elastic and the biomechanical biomechanical resistance is 50%resistance is 50%

Loss of Bowman’sLoss of Bowman’s

Kristen Fry, ODKristen Fry, OD

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Biomechanical Effect of Biomechanical Effect of Combined Riboflavin-UVACombined Riboflavin-UVA

GOAL:GOAL:

Increase cross-linking Increase cross-linking

Increase diameterIncrease diameter 12% Anterior12% Anterior 5% Posterior5% Posterior

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C3-R MechanismC3-R Mechanism

Riboflavin .1%

UVA 370nm

Corneal CollagenCrosslinking

BiomechanicalStiffness

Stability

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Theo Seiler, MDTheo Seiler, MD

Initial workInitial work AJO, 2003AJO, 200370% reduction in max K by 2D (N=23)70% reduction in max K by 2D (N=23)Increase in rigidity by 329% Increase in rigidity by 329% Increase in spacing (1nm) between the Increase in spacing (1nm) between the collagen molecules leads to increase collagen molecules leads to increase diameter with no effect on transparency diameter with no effect on transparency (150nm)(150nm)Increased resistance to enzymatic digestionIncreased resistance to enzymatic digestionHas been shown to be effective for Has been shown to be effective for iatrogenic ectasia in animals.iatrogenic ectasia in animals.Bed < 400 um, severe endothelial damageBed < 400 um, severe endothelial damage

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PROCESS OF C3R-TXPROCESS OF C3R-TX

Topical Anesthetic Epithelium is scrapedTopical Anesthetic Epithelium is scraped Acts as diffusion barrier, potential damageActs as diffusion barrier, potential damage

.1% Riboflavin drops q 5 min throughout.1% Riboflavin drops q 5 min throughout Protects the endothelium, lens, retinaProtects the endothelium, lens, retina Increases absorption into stromaIncreases absorption into stroma

30 min. radiation 370 nm UVA –3mW/cm30 min. radiation 370 nm UVA –3mW/cm33

Post-op FQ and pain reliefPost-op FQ and pain relief

Depth goes to 300 um therefore must have 400 Depth goes to 300 um therefore must have 400 um pachymetry to protect endotheliumum pachymetry to protect endothelium

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Studies by Eberhard Spoerl, Studies by Eberhard Spoerl, PhDPhD

Immediate Evidence of increased x linking:Immediate Evidence of increased x linking:Resistance to swelling and stretching utilizing Resistance to swelling and stretching utilizing Reicherts air pulse deforms cornea and Reicherts air pulse deforms cornea and measures area of deformation. measures area of deformation. Increases anchoring and reduces bulgeIncreases anchoring and reduces bulgeCellular Process 24h-12 weeksCellular Process 24h-12 weeksLeads to apoptosis of keratocytes with late Leads to apoptosis of keratocytes with late migration of keratoblasts that result in flattening migration of keratoblasts that result in flattening 5 yrs, N = 60, BCVA >1.4 lines K flat 2.87 D5 yrs, N = 60, BCVA >1.4 lines K flat 2.87 D

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Studies by Aldo Caporossi, MD Studies by Aldo Caporossi, MD University of Sienna, ItalyUniversity of Sienna, Italy

Suggests using it early in the disease Suggests using it early in the disease to freeze tissue and prevent further to freeze tissue and prevent further ectasia ectasia Scrapes the epithelium prior to Scrapes the epithelium prior to procedure.procedure.12 eyes followed for 3months in 2004.12 eyes followed for 3months in 2004.All showed improved UCVA, BCVA, and All showed improved UCVA, BCVA, and reduced steepness- reduced steepness- One side effect was transient stromal One side effect was transient stromal edemaedema

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POTENTIAL USES OF C3RPOTENTIAL USES OF C3R

Post-Lasik ectasiaPost-Lasik ectasia

Prevent KCN regression/scarsPrevent KCN regression/scars

Post CK-to enforce resultPost CK-to enforce result

Post-CRT- to enforce result? epithelialPost-CRT- to enforce result? epithelial

Boxer Wachler, MD has shown this to Boxer Wachler, MD has shown this to be an effective treatment when be an effective treatment when combined with Intacts for KCNcombined with Intacts for KCN

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ReferencesReferences

1.1. Colin J, Simonpoli-Velou S. Colin J, Simonpoli-Velou S. The Management of Keratoconus with The Management of Keratoconus with

Intrastomal Corneal RingsIntrastomal Corneal Rings. International Ophthalmology Clinics. . International Ophthalmology Clinics. 43(3):65-80, Summer 2003.43(3):65-80, Summer 2003.

2.2. Kaiser P, Friedman N, et. al. Kaiser P, Friedman N, et. al. The Massachusetts Eye and Ear The Massachusetts Eye and Ear Infirmary Illustrated Manual of OphthalmologyInfirmary Illustrated Manual of Ophthalmology. Ed. 2. 2004.. Ed. 2. 2004.

3.3. Kunimoto D, Kanitkar K, et al. Kunimoto D, Kanitkar K, et al. The Wills Eye ManualThe Wills Eye Manual. Fourth . Fourth Edition. Lippincott Williams & Wilkins 2004.Edition. Lippincott Williams & Wilkins 2004.

4.4. Roque M, Limbonsiong R, et. al. Roque M, Limbonsiong R, et. al. Myopia, Intracorneal RingsMyopia, Intracorneal Rings. . August 14, 2002. August 14, 2002. www.emedicine.com/oph/topic665.htmwww.emedicine.com/oph/topic665.htm

5.5. Wachler B, Chandra N, et. al. Wachler B, Chandra N, et. al. Intacs for KeratoconusIntacs for Keratoconus. American . American Academy of Ophthalmology. 2003. 1031-1039.Academy of Ophthalmology. 2003. 1031-1039.

6.6. Weissman B, Yeung K, et al. Weissman B, Yeung K, et al. KeratoconusKeratoconus. Jan 29, 2005 . Jan 29, 2005 www.emedicine.com/oph/topic104.htmwww.emedicine.com/oph/topic104.htm

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Thank youThank you