Download CASE ONE CASE ONE CASE ONE

1/31/2017
REFRACTIVE CANDIDATE?
Case Studies
…and other cornea cases
……and some updates 
CAROL J. HOFFMAN, MD
MEDICAL DIRECTOR
KREMER EYE CENTER
CASE ONE
• 26 Yr old female for refractive screening
– Last used contact lenses one year ago
– No past eye problems
– No family history of eye problems
– MRX -6.25 -.75 x 090 20/20
-4.50 – 1.25 x 060 20/30
 SLE & FUNDUS Exam WNL
CASE ONE
CASE ONE
• Refractive surgery candidate?
– Posterior elevation OS
– Inferior front surface steepening
– Diagnosis: Keratoconus OS
– Would not recommend Laser refractive surgery
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What Topography Makes a Patient a Non Candidate
For Laser Refractive Surgery?
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KERATOCONUS
Obvious keratoconus
Forme Fruste Keratoconus
Irregular Astigmatism
Bad BAD Display
Keratoconus
• A bilateral progressive disease of the cornea characterized by
ectasia, a thinning and forward protrusion of the cornea.
– Partially genetic
– Increased risk with
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Eye rubbing
Contact lens wear
Connective tissue disorders
Ocular allergy
Down’s Syndrome
FORME FRUSTE KERATOCONUS
Forme Fruste Keratoconus
• Subclinical Keratoconus defined by topographic changes which
are some what loosely defined, but in general include
– Posterior elevation
– Inferior steepening
– Asymmetric bow ties
• Best corrected vision is still good
Belin Ambrosio Enhanced Ectasia Display (BAD)
– Combines elevation and pachymetric data comparing normal and ectatic
corneas
– The CTSP measures the distance between the thinnest point of the cornea
and the geometric center..this distance is greater in ectatic disease.
– PTI measures the percentage of increase from the thinnest point out to
the periphery, ectatic corneas have a more abrupt progression of
thickening from the thinnest point to the periphery
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BAD DISPLAY
ABNORMAL BAD
• RED FLAG-HIGH SENSITIVITY FOR ECTATIC DISEASE
• YELLOW FLAG IS SUSPICIOUS:
– Repeat to get better quality images
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Head position
Lids and lashes out of the way
Treat any surface abnormalities
Out of contact lenses 2-4 weeks-or longer
– Either no surgery or PRK
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ABNORMAL BAD
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ABNORMAL BAD
49 YEAR OLD
CORRECTS TO 20/20
STABLE REFRACION
NORMAL PENTACAM 6 MAP DISPLAY
• PLAN: PRK
ABNORMAL BAD
ABNORMAL BAD
• 21 YEAR OLD
• UNKNOWN STABILITY OF REFRACTION
• ABNORMAL PENTACAM 6 MAP DISPLAY
PLAN: NO REFRACTIVE SURGERY NOW, WAIT ONE YEAR,
RECHECK PENTACAM
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CASE TWO
• 30 yr old male for refractive screening
– Wears soft daily contact lenses
– Mrx +6.00 – .50 x 160 20/20
+6.00 – .50 x 040 20/20
 Normal
 Topography
 SLE
 Fundus Exam
CASE TWO
• Candidate For Laser Refractive Surgery?
– No, Rx too high for hyperopic wave front correction
– Conventional treatment of hyperopia not good enough
Parameters For Laser Vision Correction
 iDesign
 Myopia -5D- 11D, with up to -5D astigmatism
 Hyperopia not approved yet
 Mixed Astigmatism-Just approved, software installation soon
 Wave Front
 Hyperopia-up to +3.00 MRSE with between 0- 2 D of Astigmatism
 Mixed Astigmatism- Up to + 6.00 with 1- 5 D Astigmatism
CASE THREE
• 55 Yr old male for a refractive surgery screening
– No contact lens wear
– Mrx -3.75 -1.00 x 015 20/20
-4.25 -0.75 x 165 20/20
 SLE
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CASE THREE
CASE THREE
CASE THREE
CASE THREE
• Diagnosis:
– Posterior Crocodile Shagreen
• A benign degenerative condition of the cornea that is usually asymptomatic
• Bilateral symmetrical polygonal opacities with intervening clear spaces within
the central posterior cornea
• LASIK/PRK not contraindicated
What Cornea Cornea Conditions Are a
Contraindication for LASIK?
• Absolute
– Cornea thickness <500
• PRK/Visian and option
– Cornea scar affecting vision
– Keratoconus
– Cornea Dystrophies
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CASE 4
• 47 yo male presents for an enhancement evaluation.
– LASIK OU for high myopia 2000
– LASIK Enh OU 2004
– Vision decreased over the last year, fit for contact lens, but vision
fluctuates
CASE 4
• VA sc OD 20/80, OS 20/100
• Mrx OD plano: – 3.25 x 160 20/25
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OS -1.25 – 1.50 x 180 20/20
– SLE 2.4 mm x .5mm plaque of epithelial ingrowth at 7 oclock
– Treatment? Enh or Cell removal
CASE 4
• Cell removal OD
– 4months post op
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VA sc OD 20/80
Mrx OD -1.00 -1.75 x 165 20/20Few nests of cells at flap edge, not progressing.
Plan?
• PRK OD
CASE 4
• 4 months post PRK OD
– VA sc 20/30
– Mrx OD +.75 -1.25 x 015 20/20-2
– But..autorefraction +2.00-3.75 x 013
– Progression of nest of cells
– Treatment?
• ND:YAG laser
• 1 month post op plano 20/20-
ND:YAG FOR EPI INGROWTH
• ND:YAG laser
– Commonly used to treat posterior capsule
opacification post CEIOL
– First described for epithelial ingrowth 2008
– Set low .1-1.0mj
– Post op-steroid taper
– Result in most-marked reduction, halt progression,
complete resolution
• Can be repeated
• Rare complication-surface breakthrough leading to new
cells.
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ND:YAG FOR EPI INGROWTH
ND:YAG FOR EPI INGROWTH
• Main advantage
– Avoid flap re lift
• No reintroduction of new cells
• Reduces risk of infection
– Quicker recovery
– Done in the office setting
ND:YAG FOR EPI INGROWTH
COLLAGEN CROSSLINKING UPDATE
CXL is the therapeutic technique of using UV light and Riboflavin
to strengthen chemical bonds in the cornea
• FDA approval status
– 4/2016 Avedro received FDA approval for it’s specific riboflavin
formulation and UVA irradiation delivery system
CXL
• Indications
– Progressive ectatic disease of the cornea based on
vision, astigmatism, and topography
• Contraindications
– Cornea thickness <400 microns
– History of herpetic eye disease
– Cornea scarring or opacification
– Severe ocular surface disease.
– Advanced disease-may not be improving their life
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CXL
• Kremer Hybrid Technique
– Disrupt but do not remove epithelium
– Instill riboflavin drops for 20-30 minutes
– UV light 18mw x 5 minutes
– FDA approved unit 3mw x 30minutes
• Post op
– Bandage contact lens
– Antibiotic drops and Ketorolac for 2-3 days
– Prednisolone taper over 1 month
CASE 5
CASE 5
• 19 year old male with decreased vison OS for one year. Positive
for Asthma, allergies, and aggressive eye rubbing.
• Vacc 20/20 OD, 20/60 OS
• Mrx OD -1.00 -.75 x 085 20/20
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OS +1.25 -3.00 x 090 20/25
• SLE: Clear corneas, no voigts, Fe Line or thinning OU
CASE 5
• Keratoconus OS
• Forme Fruste Keratoconus OD
• Treatment options
– Crosslink OU vs. OS
CASE 5
• Collagen Cross Linking performed OU
– Hybrid technique
– Will need RGP cl fit for best vision.
• 6 months post CXL
– VA with RGP OD 20/20, OS 20/25
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CASE 5
CASE 5
CASE 5A
CASE 5A
• Patient #5’s twin sister presents for rule out KC-no visual
complaints, non eye rubber
• Vasc 20/20 OD, 20/25 OS
• MRX: plano 20/20 OD, -.25 -.50 x 180 20/20-2
• SLE: WNL
CASE 5A
CASE 5A
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CASE 5A
COLLAGEN CROSS LINKING
• Forme Fruste Keratoconus OU
• Take Home Points:
– Plan ?
• Crosslink ou
• Observe
Decided to recheck Pentacam 6 months if any progression would cross link at
that time. If no change re check pentacam 6 months, then yearly.
– Variety of ways to get crosslinking
– Siblings should be screened
– Aggressively treat atopy/allergies to stop eye rubbing
– The earlier we catch the keratoconus the better
REFRACTIVE UPDATE
iDESIGN
Methods of assessing visual system
US Refractive Market overview
• US patient pool largely untapped
• More than half of U.S. population require some
form of vision correction9
• Millennial group is the largest generational
group with 86 million people, 7% larger than
Baby Boomer group10
– ~5 million millennials have had LASIK11
Phoropter (Manifest) Method
of Refractive Error Measurement
WaveFront Method of
Refractive Error Measurement
One single data point
Over 120 data points
– ~25 million more (5x) are considering LASIK11
• LASIK is the most commonly performed refractive
procedure9
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Wavefront-guided
lasik
creating the wavefront map
• Highly precise 3D maps
are generated, detailing
higher and lower order
aberrations
• This accurate assessment
allows the surgeon to
tailor the treatment that’s
100% personalized
Patient wavefront
measurement
Each spot is analyzed as to how
the light is traveling in that part
of the eye
Wavefront software
calculates the
wavefront map and
generates a laser
treatment plan
Actual eye capture Images
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What is the
idesign system
The new brain for
lasik
• An innovative approach to
measuring and treating
refractive errors - working
like a computer “brain”, it
captures over 1,200 points of
data to create a complete
picture of the eye’s unique
imperfections and generate
a 100% personalized
treatment plan.
• 5x the Resolution*
• Ease of Use12
• Treat Broad Range of
Patients
• Quality Outcomes1,13
*Compared to the WaveScan System
5 measurements
within a single
capture
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sequence
• Wavefront refraction
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Pupillometry
• Measures pupil diameter under variable lighting
conditions—mesopic and photopic
Wavefront aberrometry
Corneal topography
Keratometry
Pupillometry
Scotopic image
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Photopic image
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The idesign system
helps you treat more
patients
The idesign system results in clearer, sharper vision
your patients will enjoy
• 99% of people were not limited in active sports or outdoor activities after surgery 13
– Correct a broad range
of astigmatism (up to -5
D) in people with
nearsightedness
• 99% of people had little to no difficulty with the clarity of their vision after surgery 13
• 97% of people were satisfied with their vision after surgery13
• 93% of people had little to no difficulty driving at night after surgery 13
– Potential to capture
complex, challenging
eyes
• Majority of people achieved 20/16 or better vision after surgery1
– Pupil capture range:
4mm – 9.5mm
– 18 years of age or older
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Star S4 IR® laser
Iris registration technology
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Advanced customvue treatment
• Replaces manual, ink-based methods of treatment alignment
• Aligns treatment on the cornea and provides greater
alignment accuracy
• Centers the treatment correctly
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Star s4 ir® excimer laser features
How the star s4 ir® laser works
• Utilizes ultraviolet light to precisely reshape the cornea
• Iris Registration (IR): Provides alignment accuracy and precise
ablation placement
• This reshaping is designed to correct vision problems
• Variable Spot Scanning (VSS): Ensures that intricate shapes are
precisely ablated
• Sub micron amounts of tissue are removed with each laser
pulse with the total treatment on the eye amounting to less
than the width of a human hair
• Variable Repetition Rate (VRR): Varies the laser’s pulse rate to
minimize thermal effects
• ActiveTrak 3-D Active Eye Tracking: Captures all 3 dimensions of
intra-operative eye movements - no dilation required
• ActiveTrak Automatic Centering: Locates, and then automatically
sets the treatment center to the -center of the pupil
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Discover the components of the iLASIK® technology
suite
THANK YOU!
• iDESIGN system: Precise diagnosis gained through highly
accurate wavefront measurement and truly personalized
treatment planning to help doctors deliver improved quality
of vision1
• iFS® femtosecond laser: Built from a legacy of innovative
IntraLase® technology, greater precision and predictability for
custom-designed LASIK flaps to enhance patient
outcomes2,3,4,5
• STAR S4 IR® excimer laser: Industry trusted to deliver what you
aim for with precise levels of ablation accuracy6,7,8
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