1. Management of Keratoconus using KeraSoft IC

2. 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.

3. 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

4. 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

5. 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

6. 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

7. Example of corneal rehabilitation

8. 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.

9. 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

10. 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

11. 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

12. 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

13. Management Plan Spectacle refraction was:
OD: -8.00/-1.50 x VA 6/19
OS: /-4.50 x VA 3/36
He was fitted in spherical power KeraSoft IC:
OD: 8.40:14.50:STD DS VA 6/15
OS: 8.20:14.50:STD 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 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.

14. 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

15. 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:FLT /2.50 x 170 VA 6/9-2
OS: 8.20:14.50:STD /-5.00 x 140 VA 6/12-2
He was now able to resume driving

16. 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

17. For all irregular corneas
KeraSoft IC
For all irregular corneas