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Post Info TOPIC: 6th Corneal Collagen Crosslinking Conference Milan 2011


Ophthalmologist

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Posts: 8
Date: Wed Apr 13 5:00 PM, 2011
6th Corneal Collagen Crosslinking Conference Milan 2011
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Update on keratoconus treatments

 

 

 

 

Introduction

 

Keratoconus and post-LASIK ectasia treatment has become interesting to ophthalmologists at last.

 

The recent 6

th Corneal Collagen Crosslinking meeting in Milan was the best attended ever with over300 surgeons present. Special interest sessions on post-LASIK ectasia at international refractive surgery meetings such as the ASCRS and ESCRS now have hundreds of people in the audience when they used to have fewer than fifty. The reasons for the change have been from patients and doctors. Patients are looking at websites such as KCGlobal for information and surgeons are learning that there are things that can be done rather than just trying a new contact lens until the patient is happy.

 

No longer are people satisfied with progressive changes in spectacles, contact lenses while they wait for a graft.

Current options

 

1) Continue in contact lenses: manufacturers are more interested in aspheric and toric lenses such as the Kerasoft which provide much better comfort and allow longer wearing times compared to gas permeable lenses, but they are not yet as good as optically as the older style. On the other hand gas permeable lenses are being blamed for corneal scarring and possible acceleration of the condition.

2) The only treatment with long term evidence for effect treatment of progression is still corneal collagen crosslinking. There is now almost 15 years of data from the first animal studies, and human follow up has been going on for over 7 years of the first series of treated patients. Some are still showing slight improvements. Professor Doyle Stulting at the CXL conference in Milan says he expects FDA approval for epithelium off treatment in the US for both keratoconus and post-LASIK ectasia in the next few months. He is hopeful that there will be an epi-on treatment available available soon as well. This is a marked changei n view in the last few months.

 

He also thinks that crosslinking could reduce the need for

 

corneal transplants in the US by almost 50%

.

 

 

Professor Ebehard Spoerl showed very clearly that new riboflavin mixtures still don't penetrate enough to make a significant difference. However, by reducing the sodium chloride (salt) concentration there was better evidence of penetration. Studies are now in progress to see if this truly works. If successful it will bring about a great change in patient care as recovery times will be much quicker and side effects will be reduced (eg discomfort,blur and glare). It may also be possible to increase the uv power to get the same effect.

Professor Seiler suggested modifying treatments both in power and distribution as a way of applying the uv power more efficiently. Opacities may develop early on after damage to the corneal nerves.

The corneal nerves regrow after several weeks and this may be an explanation of the temporary nature corneal spots that can be seen sometimes after treatment. Opacities were more common if patients used bandage contact lenses after treatment rather than just drops or if the cornea was under 400 microns thick before treatment or the cornea was especially steep.

Older patients apparently do better according to Professor Vinciguerra. This may be because the condition is more aggressive in children.

Professor Hafezi showed the importance of early treatment in children as 88% of 67 eyes progressed if not treated.

Dr. Kanallopoulos is having success with combined laser surgery and crosslinking, but there have been quite a few reports of corneal opacities (cloudy areas) and others found they were getting unintended long sight.

3) The advice of most people was to stick to epi-off treatment for now if there is progression and not wait in the hope that there will be an effective epi-on treatment in the very near future.

4) Keraflex has had mixed reviews. The idea is really good: a non-invasive treatment for the irregularly shaped cornea, with crosslinking to keep it in the new shape, but it does regress like other corneal , is unpredictable and can leave a doughnut-shaped steep ring on the cornea, onto which it can be impossible to fit a contact lens. As a result the person may be worse off. On the other hand I have heard of cases where the person has been very happy after treatment. Vision was not perfect, but patients were much happier and could see much better. It will take time to get enough results and long term data to tell what will be the decision and how long the effects will last. I would still wait on this.

5) Intacs and Ferrera corneal ring implants. These have been around a long time so are well known for safety and are even accepted by the U.S. Army for front line soldiers. Because of the increased interest in this more research has been done on the size and positioning of implants to improve the results. They still have the merit of reversibility, and the material (Perspex) has been shown to be safe for at least 70 years in the eye. Intacs rings are becoming more sophisticated with a variety of lengths now rather than a single one,experience has shown that adjustments to this behave in a predictable way and improve results.

Implantation can either be manual or using a laser. Each method has advantages and disadvantages. The laser method is easier, but there can be problems with the formation of the tunnels (incomplete or too deep in thin areas). The manual method is better when the corneal thickness is variable, but takes a little longer.

6) Phakic lens implants. These have been steadily increasing in numbers as LASIK has declined, especially for the higher levels of myopia. Now that crosslinking is available to

stabilise the cornea it is safe use these to correct higher levels of astigmatism (above 4.0D),but it is important to wait for stability which may be up to a year after crosslinking. Again these are reversible and can be removed like Intacs. Artisan and Artiflex are the best known,but there is a lot of research going on in this area and new lenses are being developed.

7) For information on incisional procedures such as mini-ARK see Professor Lombardi's article

 

David Jory MBBS FRCOphth

 

 

www.davidjorysurgery.co.uk and

dwj@davidjory.co.uk

tel 02070 990 970

All enquiries are welcome.

 



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London Centre for Refractive Surgery, 15 Harley St
London W1G 9QQ www.LCRS.co.uk


Member

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Posts: 5
Date: Fri Apr 15 12:44 PM, 2011
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Thank you very much for your post Dr. Jory!

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