1. Elias F. Jarade, MD, FICS. Corneal and Refractive Surgery Service, The Dubai Mall Medical Center, Dubai- U.A.E. Tel: +971 4 4495111; Mob +971 50 8565919 ejarade@yahoo.comejarade@yahoo.com and/or ejarade@emaarhealthcare.com ejarade@emaarhealthcare.com ejarade@yahoo.comejarade@emaarhealthcare.com Poster Number: P287 New nomogram for combining treatment modalities for keratoconus ASCRS, 2010 Boston USA

2. Keratoconus Management Keratoconus (KC) and corneal ectasia treatment comprises different modalities: Non interventional (optical): Eye glasses Soft contact lenses (SCL) Toric SCL Hard contact lenses Interventional (surgical): Corneal collagen cross-linking by riboflavin and ultraviolet-A Intra Corneal Ring Segment (ICRS) Surgery Corneal graft Phakic Intraoculas Lens (optical- surgical; stable KC with good BCVA)

3. New nomogram for combining different treatment modalities for keratoconus Purpose: To describe our nomogram for the combination of different treatment modalities for the treatment of keratoconus (KC) and corneal ectasia after refractive surgery Purpose: To describe our nomogram for the combination of different treatment modalities for the treatment of keratoconus (KC) and corneal ectasia after refractive surgery

4. New nomogram for combining different treatment modalities for keratoconus Results: Early case of KC (form frust keratoconus) or corneal ectasia with mild drop of visual acuity are treated with corneal collagen crosslinking (UV-X) as treatment of choice Early case of KC (form frust keratoconus) or corneal ectasia with mild drop of visual acuity are treated with corneal collagen crosslinking (UV-X) as treatment of choice Goal of UV-X is to stabilise the cornea and holt further progression of corneal ectasia Goal of UV-X is to stabilise the cornea and holt further progression of corneal ectasia Also, UV-X is indicated in: Also, UV-X is indicated in: young age young age Progressive ectasia Progressive ectasia Moderate to advanced ectasia Moderate to advanced ectasia Before phakic IOL (young age, progressive ecatsia and advanced cases) Before phakic IOL (young age, progressive ecatsia and advanced cases) Visual acuity (VA) is reserved in most cases after UV-X with no remarkable changes in VA or k-reading Visual acuity (VA) is reserved in most cases after UV-X with no remarkable changes in VA or k-reading

5. New nomogram for combining different treatment modalities for keratoconus Results: Combination of simultaneous UV-X and eximer laser surface ablation is performed in: Combination of simultaneous UV-X and eximer laser surface ablation is performed in: Early case of ectasia with drop of vision (mild refractive errors) and corneal thickness of more than 500 μm. Early case of ectasia with drop of vision (mild refractive errors) and corneal thickness of more than 500 μm. Ectasia after LASIK: tissue ablation must be limited to the corneal flap only (which does not contribute to the corneal biostability) and stromal bed (biomechanically active) should remain intact Ectasia after LASIK: tissue ablation must be limited to the corneal flap only (which does not contribute to the corneal biostability) and stromal bed (biomechanically active) should remain intact

6. New nomogram for combining different treatment modalities for keratoconus Results: Golden rule: ICRS is an additive-reversible procedure, therefore, it is becoming as our treatment of choice for visual rehabilitation for mild and moderate cases of KC and ectasia after refractive surgery with a spherical equivalence (SE) refraction of more than -8 to -10 D) with or without good best spectacle correct visual acuity (BSCVA) Golden rule: ICRS is an additive-reversible procedure, therefore, it is becoming as our treatment of choice for visual rehabilitation for mild and moderate cases of KC and ectasia after refractive surgery with a spherical equivalence (SE) refraction of more than -8 to -10 D) with or without good best spectacle correct visual acuity (BSCVA) If SE is beyond the capacity of ICRS: Phakic IOL, bioptic, tri- optic, and “ quadroptics ” If SE is beyond the capacity of ICRS: Phakic IOL, bioptic, tri- optic, and “ quadroptics ” Phakic IOL and corneal ecatsia: be careful about the anteriora chamber (AC) depth: usually it is over estimated in KC and ectasia Phakic IOL and corneal ecatsia: be careful about the anteriora chamber (AC) depth: usually it is over estimated in KC and ectasia Follow the manifest refraction axis of astigmatism regardless of the axis generated by automated machines (e.g. autorefraction and topography) Follow the manifest refraction axis of astigmatism regardless of the axis generated by automated machines (e.g. autorefraction and topography)

7. New nomogram for combining different treatment modalities for keratoconus Results: In case of high SE and poor BSCVA, ICRS surgery (mainly one ring) is implanted to enhance the BSCVA before phakic IOL implantation In case of high SE and poor BSCVA, ICRS surgery (mainly one ring) is implanted to enhance the BSCVA before phakic IOL implantation Corneal collagen cross linking is indicated before phakic IOL in most cases of: Corneal collagen cross linking is indicated before phakic IOL in most cases of: moderate to advanced KC moderate to advanced KC Young age Young age Progressive ectasia Progressive ectasia

8. To decrease irregularitie s& enhance BSCVA New nomogram for combining different treatment modalities for keratoconus Nomogram for the treatment of keratoconus and corneal ectasia after refractive surgery: Mild to moderate ectasia Early ectasia Poor UCVA Thin cornea or significant SE ICRS ±UV-X Corneal thickness more than 500 μm or after LASIK Combined UV-X and surface exciters ablation Good UCVA UV-X only Mild to moderate ectasia with or without good BSCVA ICRS ±UV-X Stable and relatively old age: Watch Unstable or young age: UV-X

9. Mild to moderate ectasia Early ectasia Poor UCVA Thin cornea or significant SE ICRS ±UV-X Corneal thickness more than 500 μm or after LASIK Combined UV-X and surface exciters ablation Good UCVA UV-X only Mild to moderate ectasia with or without good BSCVA ICRS ±UV-X Stable and relatively old: watch Unstable or young age: UV-X New nomogram for combining different treatment modalities for keratoconus Nomogram for ectasia with low to moderate SE:

10. To decrease irregularities& enhance BSCVA New nomogram for combining different treatment modalities for keratoconus Nomogram for ectasia with high SE: Advance ectasia

11. Case presentation: Stable, mild KC: 27 y.o. patient 26 y.o. lady with stable keratoconus Ref: -2.50 D -1.00 D axis 21 degrees: 20/22 -2.75 D -0.75 D axis 150 degrees: 20/25 Pachy: 530 µ m OU Tow months post phakic IOL: Tow months post phakic IOL: UCVA: 20/22 OU Phakic IOL

12. Case presentation: Stable, advanced KC: 36 y.o. patient Refraction: -4 D -3.5 axis 70 BSCVA 20/25 -4 D -3.5 axis 70 BSCVA 20/25 -8 D -5 axis 85 BSCVA 20/30 -8 D -5 axis 85 BSCVA 20/30 UCVA: 20/20 OD and 20/25 OS UV-X Phakic IOL (Toric ICL)

13. Case presentation: Progressive, advanced KC: 26 y.o. patient Refraction: -6.75 D -4.5 axis 97 BSCVA 20/40 -6.75 D -4.5 axis 97 BSCVA 20/40 -8 D -5 axis 133 BSCVA 20/40 -8 D -5 axis 133 BSCVA 20/40 UV-X Toric ICL: 20/25 OU

14. Case presentation: Stable, mild KC OD and stable advanced KC OS with drop of BSCVA OU; 27 y.o. Refraction: -1.5 D BSCVA 20/50 -1.5 D BSCVA 20/50 -8 D -2.25 axis 120 BSCVA 20/50 -8 D -2.25 axis 120 BSCVA 20/50 Management ICRS OD: 20/20 ICRS OD: 20/20 Only 1 ring OS: Ref: -8:00 D sphere with BSCVA 20/30 Only 1 ring OS: Ref: -8:00 D sphere with BSCVA 20/30 ICL OS: 20/22 N.B. No UV-X

15. Case presentation: Keratoectasia after LASIK: Stable mild ectasia OD and progressive advanced ectasia OS with severe drop of BSCVA OS; 35 y.o. Refraction: +1 -1.75 axis 53 BSCVA 20/40 +1 -1.75 axis 53 BSCVA 20/40 -7 D -2 axis 135 BSCVA 20/200 -7 D -2 axis 135 BSCVA 20/200 Management ICRS OD: 20/25 ICRS OD: 20/25 One ring OS: Ref -1.5 D -3.5 axis 128; BSCVA: 20/30 One ring OS: Ref -1.5 D -3.5 axis 128; BSCVA: 20/30 TICL OS: 20/22 UV-X

16. Case presentation: Keratoectasia after LASIK: Stable mild ectasia OD and progressive advanced ectasia OS with severe drop of BSCVA OS; 23 y.o. Refraction: -13 D -6 axis 45 BSCVA 20/80 -13 D -6 axis 45 BSCVA 20/80 Plano: 20/20- Plano: 20/20- Management Intacs SK (2 different segment): Ref +0.5 D -3.5 axis 10; BSCVA: 20/40 Intacs SK (2 different segment): Ref +0.5 D -3.5 axis 10; BSCVA: 20/40 TICL OD: 20/30 OD: UV-X N.B. No touch OS

17. New nomogram for combining different treatment modalities for keratoconus Conclusion: This nomogram was found very useful for the plan of treatment strategy of different stages of keratoconus and corneal ectasia after LASIK. Conclusion: This nomogram was found very useful for the plan of treatment strategy of different stages of keratoconus and corneal ectasia after LASIK.

18. Thank you