[Alternative methods of surgical treatment of keratoconus]

The introduction of early diagnostic methods for keratoconus into clinical practice has become the basis for the development of surgical treatment techniques for this pathology, such as corneal collagen crosslinking and interlamellar keratoplasty with implantation of intrastromal segments. The article analyzes the results of research by Russian and foreign specialists in these areas and presents the data on the combination of SMILE surgery and corneal crosslinking, the Rome protocol of corneal crosslinking, modifications of interlamellar keratoplasty, the use of femtosecond laser technologies, and some pilot studies. Modern requirements for ophthalmological care require a personalized approach to each patient, and therefore the surgeon should have a wide range of surgical methods of treatment applicable to different patient cohorts. The described methods of treatment, according to the authors, are the most promising.

Refractive approaches to visual rehabilitation in patients with keratoconus

PURPOSE OF REVIEW

As keratoconus is a chronic disease affecting young people, vision-related quality of life is often significantly impaired in patients with this disease. However, successful management of keratoconus, including visual rehabilitation strategies, can improve quality of life in these patients. This review will describe clinical approaches that improve vision-related quality of life in patients with stable keratoconus.

RECENT FINDINGS

Several types of contact lenses including scleral lenses have been used successfully to manage keratoconus. Eyes with severe keratoconus, even those in which fitting with other types of lenses is challenging, can be successfully fitted with scleral lenses. Although laser ablative procedures, such as photorefractive keratectomy (PRK) have been traditionally contraindicated in patients diagnosed with or suspected of having keratoconus, PRK has been attempted to partially correct refractive errors in keratoconus. Although phototherapeutic keratectomy and radial keratotomy have been reported to be used in eyes with keratoconus, effectiveness and safety results have varied. Implantation of phakic intraocular lenses and intraocular lenses, including toric intraocular lenses, which primarily correct regular astigmatism, with cataract extraction or refractive lens exchange can improve vision-related quality of life in patients with keratoconus by significantly reducing cylinder while improving uncorrected visual acuity.

SUMMARY

Appropriate selection and application of treatment options based on consideration of multiple factors will help patients with keratoconus, improving their vision-related quality of life and delaying or avoiding keratoplasty.

Long-term Results of Mini Asymmetric Radial Keratotomy and Corneal Cross-linking for the Treatment of Keratoconus

Purpose

To investigate the long-term results (at least 5 years of follow-up) of the mini asymmetric radial keratotomy (MARK) and corneal cross-linking (CXL) combined intervention, also known as the ‘Rome protocol,’ for patients with progressive stage I and II keratoconus and contact lens intolerance.

Methods

This was a retrospective observational case series. Fifteen eyes of 12 patients were evaluated, with a mean follow-up of 6.9 years. To assess the efficacy and stability of the MARK + CXL combined protocol, best spectacle-corrected visual acuity, mean pachymetry, and mean keratometry were recorded preoperatively and at least 1, 3, and 5 years postoperatively. Statistical analysis was performed using the R platform and involved the Wilcoxon signed-rank and Kruskal-Wallis non-parametric tests.

Results

Best spectacle-corrected visual acuity improved for all patients, from 0.46 ± 0.69 logarithm of the minimum angle of resolution (20 / 60) to 0.15 ± 0.69 logarithm of the minimum angle of resolution (20 / 30, p = 0.0006), while mean pachymetry increased in 93% of patients, from 442.80 ± 61.02 to 464.50 ± 62.72 µm (p = 0.003). Lastly, mean keratometry improved in 87% of patients after 6.9 years of observation from 48.82 ± 5.00 to 43.25 ± 3.58 diopters (p = 0.008). No intraoperative or postoperative complications were observed.

Conclusions

The MARK + CXL combined protocol was effective in treating keratoconus by halting corneal thinning and bulging. In addition, this procedure significantly improved visual acuity based on long-term follow-up data. Analysis of data from a larger cohort of patients would be useful to support these findings.

Case Report: Acute Hydrops with Descemet Membrane Schisis in Corneal Ectasia after Radial Keratotomy

SIGNIFICANCE

As patients with previous radial keratotomy (RK) are still occasionally encountered, recognition of the anatomy of post-RK corneas and management of their complications remain relevant. High-definition anterior segment optical coherence tomography (AS-OCT) is a very useful tool to assess these postsurgical corneas.

PURPOSE

To describe a case of acute corneal hydrops with Descemet membrane schisis after RK with observation by AS-OCT.

CASE REPORT

A 43-year-old woman presented with a 9-day history of sudden vision loss, foreign body sensation, and photophobia in her left eye. She had undergone bilateral RK 25 years ago at her local hospital. Slit-lamp examination revealed marked corneal edema and stromal clefts in the central cornea along with radial surgical scars in her left eye. Pentacam imaging showed the typical pattern of a post-RK cornea with ectasia in her right eye. Multiple dilacerations of collagen lamellae and fluid-filled intrastromal cysts together with epithelial edema were observed in her left eye using AS-OCT. A Descemet membrane detachment with schisis was also shown by AS-OCT. After 5 months of medication with topical 0.1% fluorometholone eye drops four times daily together with 3% ofloxacin eye ointment once daily, the corneal edema, Descemet membrane detachment, and Descemet membrane schisis had completely resolved resulting in pan-stromal scarring.

CONCLUSIONS

This report describes acute corneal hydrops with Descemet membrane schisis after RK imaged using high-definition AS-OCT. The acute hydrops was possibly caused by corneal ectasia or underlying keratoconus, which was aggravated by RK. High-definition AS-OCT is a useful tool to demonstrate the details of different corneal layers and to observe the resolving process of acute hydrops. Topical medications consisting of antibiotic, lubrication, and corticosteroid can be used to treat the acute event effectively.