Hoe gaat het met de corneale refractie chirurgie? Annette Geerards, Oogziekenhuis Rotterdam

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1 Hoe gaat het met de corneale refractie chirurgie? Annette Geerards, Oogziekenhuis Rotterdam

2 Effect Central flattening Voorbijgaand/reversibel Definitief

3 Voorbijgaand/ reversibel Contactlenzen: RGP, SCL, hybride Orthokeratology: RGP, voorbijgaand, 1/3 stopt, 3/4 discomfort Intrastromal ringsegments

4 Definitief Incisional Laser Inlay

5 Radiaire keratotomie Geen weefselverlies Obsoleet

6 PERK study (Arch Ophthalmol 1994) Prospectieve evaluatie van RK, 10 jaar na behandeling Alleen variatie in OZ afhankelijk van myopie

7 Resultaten PERK Long term instability Hyperopic shift 43 %, multifocal cornea 3 % complications : loss BCVA, bacterial keratitis, scarring, irr astigm, glare, starburst

8 Photoablation( excimer ) Photorefractive keratectomy ( PRK ) Lasek ( laser assisted sub-epithelial keratomileusis) LASIK ( laser assisted keratomileusis) PTK

9 PRK/ surface ablation (a review: Clinical and experimental Ophthalmol 2010; ) (a review: Clinical and experimental Ophthalmol 2010; ) Patient selection : assesment Indications : < +4D, tot -8D, cyl 4 D Contra indications: dry eye, active infections ( HSV), unstable refraction, scar, ocular diseases, diabetes, atopy, pregnancy, connective tissue disease.

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11 Techniques Removal epithelium and BM mechanical Alcohol assisted Amoils brush Lasek Epi-Lasek

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13 LASEK Ethanol 20 %, sec

14 Separation plane in Epi -lasek

15 Definitions Safety = bcva post/bcva pre Efficacy= ucva post/ bcva pre Predictability= % tussen +/ D Stability

16 UDVA uncorrected distance visual acuity UIVA* uncorrected intermediate visual acuity UNVA* uncorrected near visual acuity Binocular UDVA binocular uncorrected distance visual acuity Binocular UIVA* binocular uncorrected intermediate visual acuity Binocular UNVA* binocular uncorrected near visual acuity CDVA corrected distance visual acuity CIVA* corrected intermediate visual acuity DCIVA* distance-corrected intermediate visual acuity CNVA* corrected near visual acuity DCNVA distance-corrected near visual acuity Binocular CDVA binocular corrected distance visual acuity Binocular CIVA* binocular corrected intermediate visual acuity Binocular DCIVA* binocular distance-corrected intermediate visual acuity Binocular CNVA* binocular corrected near visual acuity Binocular DCNVA binocular distance-corrected near visual acuity

17 JCRS, Kohnen 2011, 7-9

18 Indications Profession ( police) BM disease Thin Deep set eye < 41 D, > 48 D Suction risk: glaucoma ( bleb) Cheap

19 Results focus kliniek ( 5 years) vs Dirani et all ( 6-13 years) Myopia Safety Efficacy % >20/40 +/0,5 D Focus 0-4 1,09 0,97 97,6 89,5 Focus ,09 0,95 97,2 75,5 JCRS, 2010, 36 (10) ,2 45,9 JCRS, 2010, 36 (10) ,1 25, 1 Pred

20 Limitations PRK/LASEK/Lasik( Allan S : Cochrane collaboration, 2006, Ophthalmol, 2010) ( Allan S : Cochrane collaboration, 2006, Ophthalmol, 2010) postoperative pain, haze, slow result LASIK: flap related : free cap, incomplete pass, ingrowth, melt, DLK Meta analyse PRK vs LASEK: Only difference : more haze after 1 mth, no more after 3 month No difference in pain (63 % epith defect)

21 Long term stability PRK: comparative excimer laser (JCRS, 2010; ) Broad beam vs scanning slit Follow up 8 years PRK myopia -1-7 D Results : BB more central islands Stable 2 years SS, 5 yr BB +/-0,5 D : 48,1 % / 73,5 % +/- 1 D : 85,2 % / %

22 Bijwerkingen Decentered ablations, central islands Dry eye Haze ( use of mmc 0,02 %) Ectasia? ( 400 μ)

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24 Mitomycine 0,02 % Alkylating, cytotoxic, antiproliferative Reduces myofibroblasten ( haze) Keratocytes repopulation after 6 months

25 LASIK Eerste generatie microkeratoom: manueel langs dovetail ring Tweede generatie ACS ; automated lamellar keratoplasty, dikte flap afh van baseplate Derde generatie : modificatie, Hansatoom Vierde generatie : verbetering in voorspelbaarheid en std

26 Flapdikte Bepaald door : IOP, preoperatieve dikte, curvature, kwaliteit mes, translation speed Voorspelbaarheid

27 LASIK- complications Keratectasia/ std flap dikte Flap related complications: wrinkles, epithelial downgrowth Dry eye Infectious keratitis

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29 Keratectasia

30 Dry eye Mechanisme: beschadigen sensorische innervatie : tear en mucine minder(reflex ) n. trigeminus: na flap centraal verlies sensorische zenuwen in subepith plexus: na 5 maanden genormaliseerd blink rate = verminderd: cornea reflex na 6 maanden hersteld

31 Infectious keratitis ( Ophthalmol 2010; 117) Lage frequentie ( 0,035 % ) Risico: blefaritis, epitheel defect, droge ogen 90 %, 1 maand, dagen Symptoms: pijn ( 42 % ), visus ( 35 %), fotofobie ( 9 %), tranen ( 21 %) Verwekker : St epid ( 16 % ), Str pneum ( 14 %)

32 Infectious keratitis 2 Kweek! Gr +, 7 dagen, late : atypische mycobacteria Therapie : flap lift, irrigatie anti biotica, syst doxy ( collagenase remmer ) oorzaak: instrumentarium, handschoenen, perioculaire flora

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34 Femtosecond laser Ultrafast pulses ( photodisruption with minimal collateral damage) Overlap ablation diameters spot Intended thickness reproducibility Side cut : flap stability, less epithelial ingrowth Smooth interface 2001: 100 % mechanical microkeratomes 2009: 55 % femtosecond

35 Femtosecond laser

36 Complications f second Transient light sensitivity Vertical gas breakthrough (bm) DLK Rainbow glare Expensive

37 Femtosecond lasers Laser type Intralase i FS DaVinci LDV Femtec Visumax Zeiss Wavelight golflengte khz 200 khz 200 khz Laser engine 150kHz 20.8 mhz laser pulse energy 1μJ nj 4,6μJ nj 0,7 μj IOP increase mmhg >25 mmhg >26 mmhg >26 mmhg mmhg

38 Andere toepassingen Cornea chirurgie: DSEK, DMEK, DALK Biopsie Limbal stem cell transplantation Intrastromale procedures : ringsegment, lens...

39 Ik dank u voor de aandacht