Managing progressive keratoconus with the triple procedure

Take-home message: Findings from a study undertaken at Dr Lovisolo’s practice indicate that in carefully-selected patients, a triple procedure, comprising Keraring implantation followed by accelerated CXL and topo-guided ablation can provide significant functional improvement in cases of progressive keratoconus. 

 

By Dr Carlo F. Lovisolo

Keratoconus, a condition characterised by thinning and steepening of the central cornea, visual distortions and gradual loss of corrected distance visual acuity (CVDA), requires careful management in order to halt progression and improve the patient’s vision. Fortunately, in addition to spectacles and contact lenses, surgeons now have access to a plethora of treatments that can delay or even eliminate the need for a corneal transplant; dramatically improve both corrected and unaided vision; and boost patients’ quality of life. Such treatments include femtosecond laser surgery, corneal collagen cross-linking (CXL) using riboflavin and ultraviolet light, phakic intraocular lenses (IOL), intrastromal corneal ring segments (ICRs) and tomography-guided surface excimer laser ablations (phototherapeutic keratectomy – PTK).^1,2

Did you know these 7 men were ophthalmologists?

Customising keratoconus treament

Treatments such as implantation of an ICR may be offered as a sole treatment, for example, in patients with loss of CDVA and evidence of corneal surface irregularity. In this instance, use of an ICR helps to reduce corneal steepening by re-centring the corneal apex and correcting both lower and higher order secondary aberrations; ICR implantation may also delay or even eliminate the need for keratoplasty.^3,4 Corneal collagen cross-linking may also be used as a sole treatment in patients with initial keratoconus in whom there is no or limited evidence of corneal surface irregularity or loss of CDVA. However, in many cases, it is necessary to provide step-wise, synergistic treatments in order to provide maximum benefit. For example, in patients with evidence of disease progression, corneal surface irregularity and loss of CDVA, performing CXL post-ICR will also help to improve the biomechanical properties of the cornea.⁵ In selected cases, the surgeon may then decide to perform topography-guided surface photokeratectomy (PTK) and/or add a phakic IOL. Clearly then, the ability to combine different treatment modalities allows us to customise treatment according to each patient’s needs.

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