Keratoconus Functional and Micromorphological Preoperative Evaluation

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Battistina Greco
7 anni fa
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Siena University Department of Ophthalmology

1 Siena University Department of Ophthalmology and Neurosurgery Head: Prof. Aldo Caporossi Keratoconus Functional and Micromorphological Preoperative Evaluation S. Baiocchi MD, PhD C. Tommasi MD A. Caporossi MD, FRCS First Italian Abilitating CCL Course Siena 2 February 2007

2 KC Functional Evaluation Parameters Age at diagnosis < 18 y, y,, > 25 y Subjective Progression Indexes: Objective Progression Indexes: UCVA BSCVA (attention!!! More than 50% of AXIS errors) GPCLVA CONTACT LENS TOLERANCE = No untolerance / low compliance = < 4 h/d untolerance = > 4 h/d low tolerance = > 6 h/d mid tolerance = > 8 h/d tolerance = > 12 h/d high tolerance Biomicroscopy Topography (Kc pattern, K max, K average, cylinder) Topo-Aberrometry (Coma Value and Axis to optimize refraction) Pachometryc Map (Thinnest Point evaluation) Micro-morphology (Confocal Microscopy) Staging Amsler, Krumeich, Rama, Sitrac Follow up 6 m (< 25 y) 12 m (> 25 y) - Specific Therapeutic decision based on: Age Stage Progression

3 Why CCL in KC? PRIMARY: TO STABILIZE KC Age: years Clinical and instrumental progression (Refractive, topographic, Pachimetric, Aberrometric) in the last 6-12 months Thinnest point > 400µ Clear Cornea Post-LASIK ectasia SECONDARY: TO IMPROVE CORNEAL SIMMETRY Age years K ave > 53-55D Vogt s striae Significant Spherical ametropy and anisometropy (> 4 D) Contact lenses low compliance Subjective worsening not instrumentally supported (low patient s compliance) Corneal Melting

4 Krumeich s s KC Staging KC Stage 1 Stage 2 Stage 3 Stage 4 Miopia and astigmatism < 5 D CCL >5D a <8D CCL >8 D <10D Not measure K readings < 48 D < 53 D > 53 D > 55 D Corneal Opacities Vogt s Strie No scar Vogt s Strie No scar Vogt s s Strie No scar scar Pachometry normal > 400 µm > 200 µm < 400 µm < 200µm

5 Documentazione distribuita da A.I.CHE. - Associazione Preclinico Italiana CHEratoconici 1 Stadio ONLUS ( 2 Stadio 3 Stadio 4 Stadio Età Visus Familiarità +\- NEGATIVA anni CCL anni CCL Es.: OD 10\10 naturale Es.: OD 10\ OS 8\10 nat 10\10 corr. sf. OS 8\ sf=-1 cil. Variabile OD 10\10 l.ac. OS 10\10 l.ac. Variabile OD 7\10 l.ac. OS 3\10 l.ac. Miopia\Astigmatismo < 5 D >5 / <8 D >8 / <10 D Non misurabile K Readings < 48 D < 51 D > 53 D > 55 D Pachimetria Normale > 400 µ 200 / 400 µ < 200 µ RMS Coma Zywave µ Coma Corneal Wavefront µ µ Coma Cornea/ Astig. Topogr. µ Coma Cornea/ µ Astig. Aberro. Microscopia Confocale >0.45/<0.81 >0.30/<0.70 >0.23//<0.42 >0.2/<0.6 >0.70 / <1.02 >0.55/<1.28 >0.41/<0.72 >0.54/<1.12 Cellule Epiteliali Allungate >0.94 * (eseguibile 50% casi) >0.89/<2.72 >0.65/<0.94 >1.00/<1.88 Aumento Spessore Epitelio Non eseguibile >1.94/<3.56 >0.79/<1.14 >1.75/<2.55 Fibre Collagene Alterate Non Eseguibile >3.12 >1.03 >2.28 Opacità iperriflettenti Cicatrici No Strie Vogt Strie Vogt Cicatrici Soluzioni Ottiche Soluzioni Chirurgiche Occhiali, Lenti Corneali anche usa e getta Occhiali, lenti semirigide Lenti corneali Lenti corneali? semirigide semirigide Intacs, Epi, Lamellare Lamellare, Perforante Perforante Informazione chirurgica Scelta chirurgica Controlli No No No No Generica 6 mesi se età < 25 aa, 12 6 mesi età < 25, 1 anno 6 mesi età < 25 aa, 12 mesi in età > 25 aa età > 25 mesi età > 25 aa No Orientamento chirurgico Si\No Esigenze Personali Possibilità chirurgiche Si

6 Keratoconus WHERE IS THE AXIS?

7 Documentazione distribuita da A.I.CHE. - Associazione Italiana CHEratoconici ONLUS ( Uncoherence between Refractive and Elevative (Aberrometric) Axis In approximatively 70% of first-second stage KC we have an uncoherence between refractive and elevative axis orientation. This condition can produce many errors worsening the BSCVA

8 KC: cyl axis WTR ATR WTR Ta nge nz i a l e J a v a l El e v a t i v o S ogge t t i v o

9 140, 00 TANGENTIAL VS ELEVATIVE AXIS Asse Topografico: Tangenziale Vs Elevativo WTR 120, , 00 ATR 80, 00 60, 00 40, 00 20, 00 WTR A sse T ang enziale A sse Elevat ivo 0,

10 140 BSCVA: ELEVATIVE VS SUBJECTIVE AXIS Asse Soggettivo (BSCVA) Vs Elevativo ATR A sse Elevat ivo A sse So gget t ivo

11 Determinazione dell asse topografico elevativo

12 1 Cheratoconi: KC Functional Visus Evaluation: (Media) Mean Visual Acuity 11, , 0 0 9, 0 0 9,27 9,37 8, 0 0 7, 0 0 6, 0 0 5, 0 0 4, 0 0 5,03 7,09 T angenziale Javal Elevativo B SC VA 3, 0 0 2, 0 0 1, 0 0 0, 0 0

13 Conclusions KC cyl axis depend from apex dislocation axis (Coma axis). Dioptric topographycal measurements (Tangential or Axial algorithms map) are wrongly influenced by the asimmetry of corneal surface KC apex dislocation axis is constantly localized at ATR - 20 (+/- 20 ) according with international system

14 Keratoconus dark microstriae anterior - mid stroma keratoconus banding pattern

15 Keratoconus dark microstriae deep stroma keratoconus banding pattern

16 Reticular pattern dark microstriae Potential risk of early or late haze developement!

Pre op Figure 4. Sub-clinical wound healing: haze is detectable by in vivo HRT II confocal microscopy in a case of advanced keratoconus with large dark micro-striae and deep stromal Vogt striae (A).

17 Pre op Figure 4. Sub-clinical wound healing: haze is detectable by in vivo HRT II confocal microscopy in a case of advanced keratoconus with large dark micro-striae and deep stromal Vogt striae (A). Corneal edema at 1 month (B). Initial keratocytes repopulation after 3 months (C) Activated keratocytes nuclei (D, green arrows) with increased stromal reflectance (D, red arrows) and microscopically detectable haze after 6 months. Pre operative keratoconus reticular banding pattern and marked Vogt s striae as predictive haze risk factor

18 Preoperative marked Vogt s striae Potential risk of post operative haze development, poor refractve result

19 Hyperdense hyperactivated Keratocytes in younger patients Potential risk of post operative early haze development

20 haze and related factors detected by HRT II pre operative confocal microscopy Haze Age and pre op keratocytes analysis Pre op marked Vogt Strie at slit lamp examination Pre op Reticular Pattern Dark Microstrie at confocal microscopy 5 15 % < 22 years 1 case 20 % pre op increased number of activated keratocytes 3 60 % 3 60 % > 22 years 4 cases 80 %

21 Conclusions Pre op Vogt strie at slit lamp examination or reticular pattern dark microstriae at confocal microscopy can be considered predictive risk factors for post operative haze development (relative exclusion criteria, steroid management) Presence of pre operative hyperactivated keratocytes nuclei in the anterior stroma seems to be related with predictive increased risk of early haze development, somentimes agerelated (steroid management) Topical steroids are recommended only in the post operative of patients with higher risk of haze development Pre operative Confocal analysis is recommended before CCL enabling us to assess pre operative sub clinical and clinical conditions allowing optimization of inclusion criteria and postoperative therapy reducing complications

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