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ICRS combined with accelerated CXL Dr. Lovisolo

 
ICRS combined with accelerated CXL
Dr. Lovisolo

Dr. Carlo F. Lovisolo Quattroelle Custom Eye Centers, Milan Italy

ICRS combined with accelerated CXL.

This presentation, courtesy of Doctor Carlo Lovisolo from Milan (Italy), explains the last advances and the doctors experience in combining intrastromal segments and accelerated crosslinking for keratoconus treatment. The presentation also explains PRK corneal surface treatment and the use of phakic lenses. Note: this presentation is addressed to professionals.


   

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    ICRS combined with accelerated CXL.

    Close S.I.TRA.C. Meeting 21-23 February 2013

    PERCORSO FORMATIVO 1 ADVANCED INTERNATIONAL CXL COURSE

    ICRS combined with Accelerated CXL

    Dr. Lovisolo has no proprietary or financial interest in any device or product mentioned in this presentation

    Carlo F. Lovisolo, MD

    Quattroelle Custom Eye Centers Milan Italy

    Since 2006: Topo-guided Ablation (CIPTA) combined with CXL to improve coma& irregular astigmatism

    The Athen’s Protocol: Excimer laser (Allegretto) topo-linked ablation Kanellopoulos AJ Clin Ophthalmol 2012;6:87-90

    LIGI CIPTA topo-guided transepithelial ablation Stojanovic J Refract Surg 2010;26:145-52

    Simultaneous topo-guided PRK + CXL for KC Kymionis GD et al: Am J Ophthalmol 2011;152:748-55

    Issues

    Hyperopic shift (Dresden protocol) Gaussian shape: “hot center & cool edges Overall lack of predictability Epithelium compensation Cut rate of KC tissue (achieved vs. expected ablations) Lack of information on posterior corneal surface Inaccurate astigmatism correction Overoblate asphericity Aberropia (diplopia) from tilt compensation Safety Limit of 400 µm? Soaking time after Bowmann removal?

    Epithelium compensation revealed with VHF Echography (Artemis 2)

    Thins over cone apex Thickens at cone base Thins on segments’ top Thickens at segments’ edge

    OCT Corneal Epithelial Thickness Map

    First impression Less accurate than Artemis (pixel size around 3 microns) Useful for looking at gross changes

    Posterior Corneal Astigmatism & Asphericity

    The new PRECISIO software release includes a “total surface analysis” about astigmatism & asphericity

    It shows why when we correct the anterior Q value we achieve an overall postop overoblate shape

    Now we can plan adequate astigmatism and asphericity corrections

    Tissue sacrifice: Moderate ectasia, nipple cones excellent indications

    Safety limits:topo-guided ablations not feasible in the vast majority of cases

    Downward displacement of corneal apex To correct tilt: Max Ablation Depth: 274 μm Minimal residual pachymetry: 179 μm

    Since 1999: ICRS’s reproducible flattening & recentering effect

    Significant reduction of Coma after ICRS Corneal apex recentered

    Triple procedure: 1) ICR 2) after 3-6 months CXL + topoguided ablation

    Best case must become average outcome!

    24 yo PreOp UCVA 20/200 BSCVA: 20/30 with -5.0 sph -3.0 cyl

    PostOp UCVA 20/25++; BSCVA: 20/20 with -0.50 cyl

    Custom Phakic IOL’s

    Preop BSCVA 20/80 -13.0 -12.0 x 115° Kera Ring + CXL + Topo-link + T-ICL. Postop UCVA: 20/20

    Drawbacks of Dresden Protocol

    Pain Long, tedious downtime Transient (?) loss of BCVA Unpredictable hyperopic shift (centre vs. periphery effect) Healing changes of stroma Sterile infiltrates Long lasting Haze Scar (Burn?) Keratocyte apoptosis Risk of endothelial cell damage (safety pachymetry of 400 µm established) Some failure to stop progression Time-consuming, boring procedure :complications New data available :controversial basic science

    Preliminary results after a 15-month experience with Accelerated CXL

    Advantages of Accelerated CXL

    Less Pain Shorter downtime Faster more controlled procedure :less complications Reduced loss of BSCVA Faster stabilization :Earlier intraocular compensation (custom phakic IOL’s) More predictable refractive outcomes Similar healing changes of stroma Risk of endothelial cell damage: to be established Failure to stop progression: to be established New Scientific Evidence :new horizons Thin corneas Topo-guided CXL LASIK Xtra Greater patient / surgeon satisfaction

    Thank you for attention

    Carlo F. Lovisolo, MD Quattroelle Custom Eye Centers Milan Italy

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