THE CHALLENGES CORNEAL IRREGULARITIES POST-LASIK ECTASIA IS THIS A GOOD LASIK CANDIDATE? 3/5/2015. FITTING THE IRREGULAR CORNEA Challenges & Solutions

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1 DISCLOSURE STATEMENT No disclosure statement. CORNEAL IRREGULARITIES Course Title: Lecturer: FITTING THE IRREGULAR CORNEA Challenges & Solutions Phyllis Rakow, COMT, NCLM, FCLSA(H) Keratoconus Pseudokeratoconus Pellucid Marginal Degeneration Post-LASIK Ectasias Trauma Post-Corneal Transplant Please silence all mobile devices. THE CHALLENGES IS THIS A GOOD LASIK CANDIDATE? VA sc 20/70 OD; 20/70-1 OS OD X 75 = 20/20 OS X /20 Pachymetry 520 microns OU POST-LASIK ECTASIA POST-REFRACTIVE SURGERY Patient G.M. 48 y/o female RK OU + AK OS for post-op astigmatism 2005 LASIK OS for recurrence of high astigmatism Hx of strabismus - OD deeply amblyopic c/o severe ghosting OS; fluctuating VA during day Irregular astigmatism Unable to achieve functional VA with glasses Rose K2 rigid lenses now worn OD OS

2 POST-LASIK ECTASIA POST-REFRACTIVE SURGERY Easy Fit! 9/21/07 topography & diagnostic fitting Auto Ks Initial trial Rose K2 IC 8.44 (40.00) Aligns well VA 20/20-2 with overrefraction Lens ordered: Rose K2 IC 8.44 (40.00) Std. PCs BXO PSEUDOKERATOCONUS Patient wore LWC torics 12 years Referred for keratoconus Refit with GP lenses 1 year later: ectasia resolved SOFT LENS INDUCED CORNEAL WARPAGE ACT ENHANCEMENT KCN Patient W.M. 44 y/o male Advanced KCN OS CL Failure Transplant consult Piggyback fit suggested Soft lens: Oasys GP Trial: Rose K Well-aligned centrally Moderate inferior standoff FLAT/STEEP DESIGNS (ACT) ACT DESIGN Make 1 edge quadrant flatter or steeper than the others Can steepen inferior portion of lens over steepest area of cone EG: 1 PC at 90 ; another at 270 Keeps normal curvature superiorly Minimize or eliminate lower edge standoff Prism ballast maintains orientation of lens 2

3 Patient I.M. 89 y/o male Pseudophakic Post-PK for bullous keratopathy 1999 POST- PK Initial Trial Rose K 2 Post-Graft (7.60) Good centration Mid-peripheral seal-off BCVA 20/50± with plano Trial #2 Rose K2 Post-Graft (7.70) Good centration Feather touch in ectatic area Standoff inferiorly D overrefraction BCVA 20/50 POST- PK Final lens ordered: Rose K2 Post Graft Material: BXO Act Grade 1 Good centration Feather touch inferiorly in ectatic area Well aligned in mid-periphery No more inferior edge standoff POST- PK POST-TRAUMA & INFECTION Patient A.A. 50 y/o male Previous SL wearer CL-induced corneal abrasion OD mm X 7.0 mm central ulcer Pseudomonas cultured POST-TRAUMA & INFECTION Refraction -OD: X 55 - BCVA: 20/70± - RGP: Dyna Intralimbal OZ - VA: 20/25 - Wears multifocal RGP OS Can We Fit a GP Multifocal on an Atypical Cornea? Must use anterior surface design Must be able to achieve good centration Lid attachment Good alignment Lenses must translate 3

4 ANTERIOR SURFACE MULTIFOCALS Minimal asphericity on posterior lens surface Fit conventionally Approach true alignment fit similar to sphere Can be fabricated with: Toric posterior surfaces Reverse geometry curves Keratoconus designs PATIENT SELECTION Long-term rigid lens wearers Mature presbyopes Keratoconus PMD Post-Graft Post-LASIK High astigmatism PATIENT SELECTION Well-centered, large diameter current lenses Diameter 9.5 mm Average pupil size Lower lid able to assist in translation Ability to resolve simultaneous images EXPERIENCE WITH RECLAIM DESIGN High definition, aberration control optics Improved contrast Minimal optical confusion Optimal intermediate vision STARTING OFF SIMPLE PELLUCID MARGINAL DEGENERATION M.G. 66 y/o female Current Rose K CLs OD: OS: Standard/steep edge lift OU Add OU 4.0 mm Distance OZ Visual acuity OD 20/20-1 J3 OS 20/20-1 J3 E.S. 60 y/o female Fitting lenses: Rose K2 Post Graft Best Fit parameters: OD Standard edge lift Grade 1 ACT OS Standard edge lift No ACT enhancement Add OU 3.0 OZ VA: OD 20/25-1 J1 OS 20/25+2 J1 J1+ OU 4

5 POST-CORNEAL TRANSPLANT R.D. 51 Y/O female Corneal transplants OU 10+ years ago OD: 3.12 D cyl OS: 8.60 D cyl Current CLs: Rose K2 Post- Graft OD: OS: Standard edge lift Add: OZ OU VA: OD 20/20-2 J1 OS 20/20-2 J1 J.K. 60 y/o female 5 yrs. Post-LASIK Current refraction: OD: X 161 = 20/40 OS: X 114 = 20/30 Sim Ks OD: 38.75/38.87 OS: 38.75/39.87 OD: RSS 8.33/ OS: RSS 8.23/ Add OZ VA: 20/20-3 OU J2 OU POST- LASIK J.K. 60 y/o female 5 yrs. Post-LASIK Current refraction: OD: X 161 = 20/40 OS: X 114 = 20/30 Sim Ks OD: 38.75/38.87 OS: 38.75/39.87 OD: RSS 8.33/ OS: RSS 8.23/ Add OZ VA: 20/20-3 OU J2 OU POST- LASIK S.N. 49 y/o male chef Wearing GP monovision Eye rubber KCN mentioned in past Topography done Sim Ks: OD: 48.71/42.97 OS: 47.34/42.57 Stores CLs dry Inserts with saliva OD: No reliable refraction OS: X 170 = 20/20 Inquired re. GP multifocals Topography sent to lab (Art Optical) Renovations Bi-torics requested Lenses designed: Art Optical Renovations Bitorics OD: 7.96/ / OS: 7.96/ / Add OU VA: OD: 20/20 OS: 20/15-1 J 2 OU Perfect lid attachment & alignment OU 5

6 N.R. 60 y/o female Long-term GP wear Current back torics OD: 8.63/ OS: 8.95/ Add OZ OU VA: OD 20/25± J2 OS 20/25+1 J2 FLAT CORNEAS EVALUATING THE FIT Refine distance vision with loose lenses Place overrefraction in trial frame Evaluate transition from distance to near vision If overrefraction gives good distance but unacceptable near, reassess centration, add power, & OZ diameter TROUBLESHOOTING Poor Distance Vision Lens decentered Anterior OZ too small Patient looking through intermediate or near zone Residual astigmatism TROUBLESHOOTING Poor near vision Anterior OZ too large Not enough add Lens not translating Residual astigmatism TROUBLESHOOTING Flare Large pupil AOZ too small Decentration Inferior pooling Ghosting Inability to resolve simultaneous images Residual astigmatism Decentration CONCLUSION Front surface GP multifocals Simple to fit Employ conventional fitting techniques Can be fit on patients with atypical corneas if good centration can be achieved 6