Management of Keratoconus using KeraSoft IC

Keratoconus demographics DUSKS 1997-2000 Dundee University Scottish Keratoconus Study Age 24+/- 9 years 98% Employed 80% Driving Licence Dependents They NEED to see A recent study of keratoconus patients (post CLEK) shows that they are in general, young, economically active and often have dependents. They need to see ALL day and if they have limited wear time, then they are often left partially sighted if they cannot use glasses.

Traditional Management Detection Management End Point Often referred only when vision significantly impaired Rigid Lenses Monitor Hope it stabilises Grafts Spectacles RGPs Traditional management of keratoconus did not rely on early detection because there was no treatment or cure Rigid contact lenses dispensed when vision was impossible to correct properly in spectacles Once contact lenses no longer work, then grafting was the only option

Modern Management Detection Treatment End Point Early detection (topography) Soft lenses CXL Surgical reshaping Soft lenses Long term stability Soft lenses Spectacles Management of keratoconus has been transformed by the possibilities provided by corneal collagen cross linking – CXL This offers the possibility of halting progression and stabilising the condition. Thus in the future, if the condition is detected early enough, patients may never need to be fitted into complex rigid lenses

Review of KeraSoft IC in Keratoconus Proved successful in fitting all levels of keratoconus Patients achieve good vision and long wearing times Does not cause corneal moulding in the same way as rigid lens types Can rehabilitate damaged corneas

Role of KeraSoft IC in patients undergoing CXL Rehabilitation before CXL Cornea should be in best possible condition before CXL Scarred and damaged corneas increase the risk of permanent scarring after the procedure Some patients may be refused treatment if cornea is too scarred Post surgical Corneal shape fluctuates post CXL KeraSoft IC flexes with shape changes Can therefore be worn earlier than rigid contact lens types after the procedure

Example of corneal rehabilitation

KeraSoft IC hand in hand with CXL Case RA OD Initial Spectacle VA 6/12 CXL 2008 KeraSoft IC wear until 2012 Biofinity Toric VA 6/6+3 Spectacle VA 6/6 OS Initial Spectacle VA 6/9 KeraSoft IC wear until 2012 Progression - Spectacle VA 6/15 CXL 2012 KeraSoft IC VA 6/6pt This patient was originally -8.00DS in both eyes and underwent LASIK in 2002. She began to develop post LASIK ectasia in 2008 and had the CXL procedure in the right eye only as the left eye appeared to staibilise on its own. She wore KeraSoft IC successfully in both eyes until 2012, when she presented with rapid deterioration/progression in the left eye. She underwent CXL in that eye – meanwhile the right eye had improved so much that she was able to move into disposable lenses and could attain good vision with spectacles in that eye.

Timing of CXL procedures Initial assessment Identify the eye most in need of cross linking. This will most often have the worst VA Start CXL work up Begin planning for CXL on this eye. Px requires time to recover from the procedure. Plan CXL for other eye Move forward with CXL for the other eye once the first one has stabilised and has reliable vision

Managing CXL and Soft Contact Lens Wear Newly Diagnosed Reasonable VA with spectacle correction Go ahead at convenience of patient Newly diagnosed, requires a CL fitting in both eyes Identify the first eye to have CXL Fit the other eye with KeraSoft IC or soft lens and ensure fit and vision stable Go ahead with CXL on the other eye and fit with CL afterwards Already wearing soft lenses Can wear lenses up to day before surgery Can resume wear around 2 weeks post surgery

Managing CXL and Rigid Contact Lens Wear Issues presented by previous wear Corneas are moulded by rigid lens types This moulding effect can take at least 4-6 weeks to fully dissipate with normal corneas (Tsai et al 2004) Amount of moulding is directly related to number of years RGPs worn Wearing rigid lenses until just before the procedure can result in more corneal shape changes post op In some cases, RGP lenses can cause scarring May need to rehabilitate cornea to allow CXL to take place Not advisable to wear RGPs straight after surgery Most surgeons advise to wait a couple of months without RGP wear post CXL

Ashley B Case History Diagnosed at 19 and wore Hybrids contact lenses followed by Semi Sclerals Presented age 31 with poorly fitting lenses and VA of : OD: 6/19 OS:6/15 and had stopped driving due to poor vision He had a highly visible triangular scar in the right eye and resolved hydrops in the left eye Pachymetry showed both corneas were below the 400 microns recommended for CXL After consultation with David Jory, he decided to go ahead with Femto-pocket CXL

Management Plan Spectacle refraction was: OD: -8.00/-1.50 x 10 VA 6/19 OS: -11.00/-4.50 x 160 VA 3/36 He was fitted in spherical power KeraSoft IC: OD: 8.40:14.50:STD -6.00 DS VA 6/15 OS: 8.20:14.50:STD -10.00 VA 6/24 5 months after refit, his prescription had stabilised in KeraSoft IC lenses OD: 8.40:14.50:STD -6.00/-2.50 x 170 VA 6/12 pt OS: 8.20:14.50:STD -9.00/-6.00 x 180 VA 6/15 It was decided to perform Femto Pocket CXL on the worst left eye first Femto pocket CXL is a procedure whereby pockets are cut into the stroma using the Femto Second laser, leaving the epithelium intact. Riboflavin is injected into the pockets and UV exposure is carried out as normal. This procedure is used on thin or scarred corneas to reduce issues caused by removal of the epithelium.

OS CXL 31 OCT 2011 OD CXL 12 MAR 2012 Initial topography 5 months KeraSoft IC Scarring close up Scarring Initial placedo 9 months KeraSoft IC Initial topography Just before CXL

Management Plan He returned to KeraSoft IC wear 5 days after the procedure in the left eye After three months he went ahead with the same procedure in the right eye As the scarring had reduced he could technically have gone ahead with epi –off but he elected to do Femto-pocket to allow a fast return to work. He resumed wear of his KeraSoft IC lens after 4 days 1 month post op results: OD: 8.20:14.50:FLT2 -7.50/2.50 x 170 VA 6/9-2 OS: 8.20:14.50:STD -7.00/-5.00 x 140 VA 6/12-2 He was now able to resume driving

Ashley B Management Plan KeraSoft IC Both eyes At 4-5 months OD full RX CXL OS OCT 2011 RGP VA OD 6/19 OS 6/15 3/12 post op Optimise OS CXL OD 1/12 post op Modify Rx both eyes MAR 2012 VA OD 6/9-2 OS 6/12-2 BCVA 6/7.5

For all irregular corneas KeraSoft IC For all irregular corneas