1. Femtosecond laser assisted penetrating keratoplasty
Pf. 주천기/St. 노창래/R4 김재윤

2. C/C Dec VA(OD) for 4yrs M/35 No known systemic dz
2006년 에어건에 의해 우안 수상후 지속된 시력감소로 내원
5년전까지는 우안 시력 0.8정도 였음.
No known systemic dz
Ocular trauma/op (+/-)
Gls(-), Eye drops(-)
2006년 우안 수상후 지속된 시력감소로 각막이식 위해 내원

3. VA OD FC/30cm (n-c) OS 1.0 IOP OD 9 OS 15 mmHg at 4:30(PM) Exo No exophthalmos /(OU) EOM Straight at 1' position by H-test, no LOM /(OU) Lid No swelling, No mass /(OU) Conj. OD Mildly injected OS Not injected Cornea OD Mod edematous c microbullae, and linear, oblique, 7mm sized detachment of Descmet's memb(5 o/c-> 10 o/c), diffuse stromal opacity at central area OS Clear AC Deep & cell (-) /(OU) Pupil Round & nl sized, LR(+) /(OU) Lens Clear / (OU) B-scan(OD) : flat OD

4. AxL
OD : mm
OS : mm
1061μm
852μm
897μm
940 μm
943 μm

5. Visante OCT - Preop

6. Design of Graft

7. 2010.09.20 IEK(OD) # 각막정보 사인 : Driver's TA로 인한 brain death
사시 : :43
적출시 : :20
담금시 : :45
CD 2645, clear zone 10 m

8. 2010.09.20 IEK(OD) # 각막정보 사인 : Driver's TA로 인한 brain death
사시 : :43
적출시 : :20
담금시 : :45
CD 2645, clear zone 10 m

9. < POD #4 >
VA OD 0.2 (n-c) IOP OD 10 mmHg at 7: 00 am by tonopen Cornea OD Well grafted D’s cornea, mod edematous c DM folding AC OD Deep at center, 1/2CT at pph and cell(+) Pupil OD Round & nl sized, LR(+/+) Lens OD Clear

10. Visante OCT – Post op

11. Femtosecond laser assisted Keratoplasty

12. Laser Spectrum INTRALASE ® FS Ultraviolet Visible Infrared Argonnm
Diode nm
Er:Yag
2940 nm
Nd:Glass
1053 nm
CO2
10,600 nm
Excimer
193 nm
100 nm
400 nm
700 nm
100,000 nm
INTRALASE ® FS
Ultraviolet
Visible
Infrared

13. Principle of FS laser Femtosecond laser
(Nd:Glass) 1053 nm (near infrared)
Each pulse of focused laser light lasts approximately seconds ( femtoseconds)
In one second, light travels 7.5 times around the globe
In 100 femtoseconds, light travels across a human hair
Power = Energy/Time, extremely high power attained at relatively low energy

14. Principle of FS laser
Surgical effect is achieved through “Photodisruption” at a molecular level
No thermal or shock wave transmission to surrounding tissues
Laser pulses focused to precise intrastromal locations (± 5 microns)
Computer controlled optical delivery system places thousands of pulses next to each other creating flaps, incisions, lamellar resections, keratectomy

15. Photodisruption A pulse of laser energy is focused to
a precise location inside the cornea
A microplasma is created, vaporizing
approximately 1 micron of corneal tissue
1 Micron

16. Photodisruption
5 to 12 Microns
An expanding bubble of gas & water is created separating the corneal lamellae

17. Photodisruption
The bi-products of photodisruption (CO2 & water) are absorbed by the mechanism of the endothelial pump, leaving a resection plane in the cornea

18. Photodisruption
Thousands of laser pulses are connected together in a raster pattern to define a resection plane

19. Photodisruption Gas & water are absorbed or liberated
when corneal flap is lifted
A resection plane is created

20. Photodisruption
Laser pulses can be stacked on each other to create a vertical cleavage plane

21. Photodisruption
Laser pulses can be stacked on each other to create an angled cleavage plane

22. Keratoplasty
Traditional PPKP : Refractive errors, suture-related problem, torsional astigmatism d/t decenteration and wound dehiscence
Mannual Top hat : transplant more endothelial cells, keeping anterior edge at a safe distance from the limbus
But difficult to master, is time consuming, and may damage donor tissue.
Femtosecond laser : creating full-thickness corneal trephination with customized locking edges at the graft-host junction

23. New approach to keratoplasty
Lamellar keratoplasty
Horizontal surface to surface wound
Minimize the risk of an immune reaction in the graft
Decreased quality of VA due to fibrosis in the wound
Shaped manual
keratoplasty
The ability to vary the donor graft sized depending on the amount of endothelium needing to be transplanted
Difficult to master
Time comsuming
Damage to donor tissue
Earlier suture removal
Stronger wound healing
Shaped PPKP: stepped nature
Earlier suture removal
Valve sealing edge design

24. Femtosecond laser(Intralase®)
Cornea is transparent for laser beam of Intralase
(in contrast to Excimer laser)
→ Allows laser treatment of deep corneal layers such
as endothelium or posterior stroma
The IntraLase® Enabled Keratoplasty software can be
programmed to produce different configurations with
computer precision.

25. IEK (IntraLase Enabled Keratoplasty)
The IntraLase Enabled Keratoplasty application allows the user to perform three cut segments:
a posterior side cut, lamellar cut, and anterior side cut.
Ring Lamellar Cut
Posterior Side Cut
Full Lamellar Cut
Full Thickness Cut
Anterior Side Cut

26. IEK (IntraLase Enabled Keratoplasty)

27. Example Pattern Combinations for Penetrating Keratoplasty
Vertical Sidecut
Tophat
Tongue & Groove
Mushroom
ZigZag
X’Mas Tree

28. IEK(Vertical)
538(μm)
IEK(Z-squre)

29. 580(μm) IEK(Top-hat) IEK(Mushroom) 542(μm)
Mushroom-POD#5 이후에 f/u 이 잘 되지 못함
월초에 찍었을 것 같음 다시 Visante OCT 자료 찾아보기
IEK(Mushroom)
542(μm)

30. Example Pattern Combinations for Lamellar Keratoplasty
DALK
DSEK
DLEK
PSC ONLY

31. IEK (IntraLase Enabled Keratoplasty)

32. TopHat Shape Provides large endothelial surface transplantation
Endothelial dystrophy 등에서 유리
Fuch’s 등

33. Mushroom Shape Preserves more host endothelium
Keratoconus등의 자기 내피는 건강한 경우 유용

34. ZigZag Shape Hermetic wound seal
Angled edge provides smooth transition between host and donor
©1997 – 2006 IntraLase Corp. All rights reserved. Confidential – Revision A

35. Femtosecond Laser–assisted Penetrating Keratoplasty Stability Evaluation of Different Wound Configurations Bahar et al. ; Cornea, Vol 27(2), 2008

36. Femtosecond laser versus manual dissection for tophat penetrating keratoplasty Bahar et al. ; Br J Ophthalmol, Vol 93, 2009

37. IntraLase Enabled Keratoplasty
Patient Selection
Contraindications
any corneal opacity adequately dense to obscure visualization of the iris
descemetocoele with impending corneal rupture
previous corneal incisions that might provide a potential space into which the gas produced by the procedure can escape
corneal thickness requirements that are beyond the range of the system

38. IntraLase Enabled Keratoplasty
Patient Selection
Other Considerations
severe corneal thinning
subjects with pre-existing glaucoma
a history of steroid responsive rise in intraocular pressure
preoperative IOP > 21 mm Hg in the operative eye
subjects with more than 1200 um corneal thickness at the 9mm peripheral zone
active intraocular inflammation
active ocular infection