The arrival of advanced therapeutic modalities for keratoconus has provided ophthalmologists with a growing menu of treatment options. The author discusses the challenge of determining which treatment is the best to use and highlights his experience with a triple procedure and a four-stage approach.
Which treatment, when?
Along with the availability of newer, more sophisticated options for the management of keratoconus comes the challenge of determining which treatment to use and when to use it to deliver the best possible outcomes for each patient.
While ICR implantation alone helps to reduce corneal steepening and reduce refractive errors, many ophthalmologists recognize that combining treatments may help to further improve vision and slow progression. Further, a combination procedure is necessary in patients with loss of visual acuity and evidence of progression.
The effect of a triple procedure on refractive outcomes: Our experience
At the World Eye Hospital in Istanbul, Turkey, we conducted a prospective, case-series study, on 16 eyes of 10 patients with progressive keratoconus (defined as an increase in the cone apex keratometry of 0.75 D or alteration of 0.75 D in the spherical equivalent [SE] refraction in a period of at least 6 months), to evaluate the effect of a triple procedure comprising Keraring ICR implantation followed by CXL and topo-guided transepithelial PRK on visual acuity.
The mean interval between Keraring ICR implantation and CXL was 7 months, and the mean interval between CXL and topo-guided transepithelial PRK was 8.2 months. Postoperative visual acuity and pachymetry/topography results were evaluated after each stage of treatment, with a mean follow-up time of 6.2 months.
Findings showed that the mean LogMAR uncorrected distance visual acuity (UDVA) and mean corrected distance visual acuity (CDVA) were significantly improved (p < 0.05) from 1.14 ± 0.36 and 0.75 ± 0.24 preoperatively to 0.25 ± 0.13 and 0.13 ± 0.06, respectively, after completion of the three-step procedure. Uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA) also improved, from 0.05 and 0.2, preoperatively, to 0.7 and 0.9, respectively, after the final procedure. Moreover, both UDVA and CDVA, as well as UCVA and BCVA also improved significantly after the ICR implantation, indicating that the Keraring is an effective method for improving visual acuity in patients with progressive keratoconus.