1. 1 Keratoconus (KC) : Improvement of KC’s Visual Rehabilitation after Intra Corneal-Rings (ICR's) with Corneo-Scleral lenses (CSL) ( SPOT ® LAO Laboratories) without Cross-Linking Solange Leroux Les Jardins, MD 1 Guillaume Leroux Les Jardins, MD 1,3,4 1 : Private Practice, Paris, France 3 : Ancien Chef de Clinique-Assistant, Université Paris V Groupe Hospitalier Cochin - Hôtel Dieu, Paris, France 4 : Praticien Attaché Cochin-Hôtel Dieu, Paris, France NO FINANCIAL INTEREST www.lerouxlesjardins.com RSSD Chicago 2014

2. 2 Retrospective Study Patients with progressive and severe Keratoconus (grade 3,4) 14 eyes, 14 patients (11 men, 3 females) Pre operative spherical equivalent (SEQ): - 4.8 D (-12 to - 0.5) Pre operative astigmatism : - 4.6 D. (-7 to-1.75) BCVA LogMar : 0.39 (1 to 0.1) All Corneal Contact lenses intolerant Cross-linking not possible as all these KC eyes had too thin corneas Mean age : 32 years (18 à 60) Operated on with ICR's Femtolaser IntraLase iFis (AMO ®) used to perform intrastromal channel Using Ferrara Nomogram, Ferrara Rings (5 mm Optical Zone), 3 months at least after surgery, adapted with Corneo Scleral SPOT® lenses to get a better VA Mean Follow up 21 months (6 à 52) after ICR’s surgery Visual Acuity (VA) exprimed in LogMar t-test (Graphpad Prism 5 Software ©), p <0.05 : significative * Résults expressed in Mean +/- Standard Error Mean (SEM) et (Min-Max) Material & Method STATISTIC ANALYSIS Purpose To study the tolerance and BCVA improvement with the use of CSL (SPOT-LAO®) (1,2 ) after ICR’s surgery for KC www.lerouxlesjardins.com

3. 3 CORNEO SCLERAL LENSES (CS LENSES) SPOT ® (LAO) : Large diameter Corneo-scleral Contact lenses No contact with the corneas nor with ICR’s www.lerouxlesjardins.com ADAPTATION WAS SUCCESSFULL FOR ALL THE PATIENTS TOLERANCE WAS VERY GOOD FOR ALL THE PATIENTS NONE HAD DIFFICULTIES WITH THE MANIPULATION NO COMPLICATION Corneo scleral Lenses don’t touch the cornea Don’t moove on the cornea, And dust can’t go under it.

4. ICR’s RESULTS : SPHERICAL EQUIVALENT (SEQ) ( Before CS SPOTS ® LENSES) 14 EYES PRE-OP SEQ : -4,8 D. (-0.5 à -12) POST-OP SEQ : -1.77 D. (0.5 à -5) SIGNIFICANT DEACREASE PRE / POST-OP SEQ P**<0,01 www.lerouxlesjardins.com 4

5. MEAN PRE-OP BCVA : 0.39 (1.3 à 0.1) LogMAR MEAN BCVA AFTER ICR’s 0.29 (1.3 à 0.1) LogMAR : ns No significative Gain of UDVA before and after ICR’s (Our most difficult cases)° MEAN BCVA AFTER ICR’s AND CSL SPOTS ADAPTATION 0,07 (0. 5 à 0.1) LogMAR p < 0.0005 IMPRESSIVE GAIN OF BCVA AFTER ICR’S AND SPOT CSL BEST CORRECTED VISUAL ACUITY (BCVA) RESULTS AFTER ICR’s and AFTER ICR’s + CORNEO SCLERAL LENSES ( LogMAR) www.lerouxlesjardins.com 5

6. 6 RESULTS All 14 patients were equipped with CS SPOT ® All 14 patients tolerated well CS SPOT ® and learned easily the manipulation All 14 patients had an impressive gain of BCVA None out of the 14 patients needed glasses with CS SPOT ® www.lerouxlesjardins.com DISCUSSION ICR’s improve visual acuity and stabilize KC (3,4,5,6) Nevertheless, Refractive result is better when KC isn’t too severe and emmetropia is rarely obtained. In this series : ICR’s have stabilized KC at the follow-up ICR’s have improved spherical equivallent, But in these 14 eyes, refractive results had to be improved. It has been possible to improve refractive results with Corneo scleral lenses with a good tolerance. No patient with ICR’s and Coreo-scleral lenses had to ware glasses. If we want to avoid corneal transplant to patients having severe KC, ICR’s are usefull tools to stabilize KC and to improve VA. If necessary to perfect the refractive result, Corneo scleral lenses are also a very usefull tool and should be proposed after ICR’s if necessary.

7. 7 www.lerouxlesjardins.com CONCLUSION In case of severe KC with too thin corneas to perform CXL, ICR’s improve KC’s CDVA and stabilizes KC but UDVA rarely returns to emmetropia. To improve the refractive results, CS SPOT ® is a very usefull tool and has to be known and proposed.

8. 8 BIBLIOGRAPHY 1 :Vers une réhabilitation des verres scléraux? J-M Laroche, F. Baechele, A.Delcampe, M.Drouin, M.Ortega, T. Huang-Xuan. J Fr Ophtalmol 2004 ; 27 : 877-882 2 : Vision-Related Function After Scleral Lens Fitting in Ocular Complications of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Tougeron-Brousseau B, Delcampe A, Gueudry J, Vera L, Doan S, Hoang-Xuan T, Muraine M. Am J Ophthalmol. 2009 Dec ;148(6):852-9 3 : Correction of irregular astigmatism with intracorneal ring segments. Touboul D, Pinsard L, Mesplier N, Smadja D, Colin J. J.Fr.Ophtalmo 2012 Mars 35(3):212-9 4 : Outcomes of intrastromal corneal ring segments for treatment of keratoconus: Five-year follow-up analysis. Vega-Estrada A, Alio JL, Brenner LF, Burquera N. J Ctaract Refract Surg 2013, 39(8): 1234-40 5 : S. Leroux Les Jardins et al, ACR 2012. 6 : S. Leroux Les Jardins et al, SAFIR 2013. www.lerouxlesjardins.com