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Instructional course IC 1 Corneal cross linking therapy: Operative technique. Auhor: Kristina Mikek, Slovenia Co. Authors :    Carina Koppen, Belgium    Zoltan Nagy, Hungary   David O Brart, UK. Preoperative assessment Patient counseling

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instructional course ic 1 corneal cross linking therapy operative technique

Instructional course IC 1Corneal cross linking therapy: Operative technique

Auhor: Kristina Mikek, Slovenia

Co. Authors :    Carina Koppen, Belgium

   Zoltan Nagy, Hungary  

David O Brart, UK

slide2
Preoperative assessment

Patient counseling

The role of epithelial removal

Riboflavin dosage regimens

UVA exposure regimens

UV lamps and calibration

Postoperative care and follow up

Complications

K. Mikek

process of corneal cross linking
Process of corneal cross linking
  • Patient is referred to your service
  • Preoperative diagnosis
  • Decision on therapeutic intervention
  • Treatment procedure
  • Corneal cross linking therapy
  • Post operative follow up visits

K. Mikek

preoperative diagnosis
Preoperative diagnosis
  • Measurements performed outside of your ophthalmology department and/or refractive changes given from the patient can not serve as a basis for a treatment decision
  • Before final decision for cross linking treatment some check up examinations – depends on progression of the disease
  • Family history of keratoconus or progression of keratoconus

K. Mikek

preoperative examination
Preoperative examination
  • Rigid contact lenses must be removed for at least 2 weeks to achieve reasonable measurements of the cornea
  • Most patients with keratoconus who came for the treatment don’t wear contact lenses because they have problems with them

K. Mikek

preoperative examination6
Preoperative examination
  • Refraction
  • Visual acuity
  • Slit lamp examination (cornea, lens and retina)
  • Specular microscopy – morphology of endothelial cells and density
  • Corneal topography and Sheimpflug images
    • Corneal thickness map

K. Mikek

is the patient for cross linking treatment
Is the patient for cross linking treatment?
  • Progression of ectasia verified by corneal topography – change of max K by > 1 Dpt
  • Age of the patient – corneal changes?
  • Can the patient expect any benefit from corneal cross linking treatment – CL tolerance, visual performance?

K. Mikek

is the patient for cross linking treatment8
Is the patient for cross linking treatment?
  • Are there any risk factors that might lead to unpleasant healing responses and complications after treatment – rheumatism, keloid formation, pregnancy, dry eyes…?
  • Is the corneal thickness suitable for treatment, do I have to swell the cornea?

K. Mikek

what we have to explain to the patient before treatment
What we have to explain to the patient before treatment?
  • Postoperative follow up time and hazy vision in the first 1 to 2 weeks after the cross linking treatment
  • Some pain and photophobia on the day of surgery
  • Results of stability statistically proven on the long term

Based on the preoperative examination:

  • Real expectation regarding the visual acuity (do not promise to the patient!)

K. Mikek

treatment procedure
Treatment procedure

K. Mikek

Calibration of the UV cross linker:

  • To get the right energy to the cornea
  • To avoid “hot spots” on the cornea and possible complications
            • Wollensak G, Spoerl E, Seiler T. Am J Ophthalmol 2003
treatment procedure11
Treatment procedure
  • Topical anesthetic eye drops and pilocarpin at the time of surgery
  • Partial epithelium removal – abrasio (diameter 8 to 9mm)
    • Brush, 20% of ethanol, lines or punctures in the epithelium
  • Applying riboflavin 1 drop every 2 min for 30 min
  • Slit lamp inspection – blue light: staining of the anterior chamber
  • Start UV- illumination with UV cross linking device: 1 drop of Ribo every 2 min for 30 min

K. Mikek

treatment procedure12
Treatment procedure
  • At the end of surgery therapeutic contact lens is placed on the surface of the cornea
  • Eye drops at the end of surgery:
    • 0,1 % prednisolon
    • Ciprofloxacin

K. Mikek

postoperative treatment
Postoperative treatment:
  • 0,1% prednisolon 3 times/day
  • Ciprofloxacin 4 times/day
  • Artificial tears hourly

Besides this:

  • Pain killers - among these Lyrica, which helps the most

Removing of the contact lens:

  • 3rd postoperative day

K. Mikek

treatment procedure14
Treatment procedure
  • Based on animal experimental studies and clinical studies the following parameters are the most appropriate for maximal safety of cross linking treatment:
    • Corneal deepithelization (diameter 8 to 9 mm)
    • 0,1% riboflavin in 20% dextrane – swelling the cornea if the corneal thickness after abrasio is less than 400 microns with riboflavin hypotonic solution!
    • 3mW/cm2 at 365 nm for 30 min

K. Mikek

cross linking cause of action
Cross linking – cause of action

Riboflavin diffusion

UV –light illumination and absorption

Formation of oxygen radicals

Chemical reactions and cross link formation

Changes of the biomechanical properties of the cornea

K. Mikek

M.Mrochen, IV.international congress of corneal cross-linking, 2008

background of corneal cross linking
Background of corneal cross linking
  • Molecular level – collagen molecules
  • Microscopic level – collagen fibrillae of linked collagen molecules
  • Tissue level – collagen lamellae – parallel arrangement of the fibrillae
  • Organ level – cornea –arrangement of interlaced collagen lamellae

K. Mikek

M.Mrochen, IV.International Congress of Corneal Cross-linking, 2008

complications
Complications
  • Delayed corneal reepithelization
  • Drop of the therapeutic CL out of the treated eye and infection
  • Corneal endothelium cell damage – in thin corneas
  • Keratouveitis
  • Very seldom severe corneal haze

K. Mikek

conclusions
Conclusions
  • Corneal collagen cross-linking is now the only treatment which could stop the progression of keratoconus or iatrogenic ectasia of the cornea
  • Complications rate of the treatment is low and mostly treatable or not affecting the visual acuity:
    • With careful counseling of the patients before treatment and following the guidelines for cross linking treatment !

K. Mikek

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