Intracorneal Ring Segments Followed by Simultaneous Topography-Guided Removal of Epithelium and Stroma With Accelerated Collagen Cross-Linking For Keratoconus (I-TRESK/CXL)

Abstract

Purpose: The aim of this study was to assess the visual, topographic, and aberrometric outcomes of a novel tissue sparing technique, topography-guided removal of epithelium, and stroma in keratoconus (TRESK) along with accelerated collagen cross-linking (CXL), 1 month after Intacs insertion. Design: Prospective interventional study. Methods: Fourty-eight eyes (45 patients) with keratoconus underwent femto-assisted Intacs insertion. After 1 month, TRESK and CXL (9 mW/cm2 for 10 minutes) was done. TRESK is a decentered trans-PTK (phototherapeutic keratectomy) with center and area of ablation at the location of the steepest tangential anterior curvature and area of the cone respectively. Total ablation (epithelium plus stroma) was limited to 75 μm. Postoperative measurements were performed 1 month after Intacs, 6 weeks after Intacs followed by TRESK/CXL, and at the final visit 12 months after Intacs followed by TRESK/CXL. Results: For all eyes studied, uncorrected distance visual acuity and corrected distance visual acuity (CDVA) (logMAR) improved from preoperative means of 1.05 ± 0.05 and 0.31 ± 0.03 logMAR to postoperative means of 0.52 ± 0.05 (P < 0.001) and 0.20 ± 0.02 logMAR (P = 0.009), respectively. The mean preoperative sphere, cylinder and mean refractive spherical equivalent decreased from −4.52 ± 0.98 D, −4.81 ± 0.25 D, −6.93 ± 0.99 D to −0.77 ± 0.53 D (P = 0.029), −3.13 ± 0.24 D (P = 0.002), and −2.34 ± 0.53 D (P = 0.021), respectively with a mean keratometric flattening of 5.06D (P < .0001) at the final visit. In total, 2.08% of the eyes lost 1 Snellen line of CDVA. Sixty eight percent and 27% of the eyes gained 2 Snellen lines or more of uncorrected distance visual acuity and CDVA, respectively. Conclusions: Simultaneous TRESK with CXL done 1 month after Intacs insertion (I-TRESK) in keratoconus eyes provided significant visual gain with refractive and topographic improvement. This novel procedure involving customized PTK before CXL is safe, easy to plan and perform, and provides good outcomes.

Management of keratoconus: an updated review

“…Combined with varying CXL protocols and intra- and inter-person variability (as part of the nature of the disease), it is understandable why optimum parameters are difficult to determine. However, there is cumulative evidence in the literature demonstrating the long-term effectiveness and safety of various CXL plus procedures, including CXL + ICRS ( 189 , 202 – 204 ), CXL + PRK/PTK ( 205 – 212 ), and CXL + PRK/PTK ± phakic IOL implantation ( Table 4 ) ( 213 – 217 ).…”

Biochemical and molecular alterations and potential clinical applications of biomarkers in keratoconus

“…[ 27 ] The epithelium is shown to have a typical pattern of thinning over the cone region,[ 28 ] and this has been utilized in newer customized laser treatments to improve visual outcomes in patients. [ 29 30 ] In the epithelial basement membrane, the expression of extracellular matrix (ECM) materials such as laminin, fibrin, and collagen is altered. [ 27 ] Breaks in the Bowman layer along with fibrotic changes have been documented using ultra high-resolution anterior segment optical coherence tomography (OCT) imaging and immunohistochemistry.…”

Resultados visuais, topográficos e refrativos do implante de segmentos assimétricos de anel corneano intraestromal em ceratocone

“…Muitas vezes, os pacientes podem já ter sido submetidos ao CXL, outras vezes ao implante de ICRS, mas o ceratocone está progredindo. Existe uma lógica de que o implante de segmentos de ICRS deve preceder o CXL, pois pode ser mais fácil inserir os segmentos de anéis do ponto de vista biomecânico156 .No mesmo dia, ICRS e CXL simultâneos também ganharam apoio157 . Hersh et al…”