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Innovative intra-corneal ring-supported graft surgery for treatment of keratoconus and cornea regeneration: Surgical technique and case report.

ABSTRACT: Therapeutic options for corneal ectasia are evolving, with emphasis on the intra-stromal corneal ring for delaying or eliminating the need for penetrating keratoplasty. A 33-year-old man with grade 4 keratoconus and rising intolerance of the hard contact lens underwent a combination of a new innovative ring and graft with suture in the left eye. Excellent structural support and stability of the cornea were observed immediately post-operatively and 12 months after surgery. It appears as a feasible and safe therapy option for keratoconus eyes with reference to the instability and asymmetry of the cornea. Hence, as a safe and effective technique, it can be performed easily.

SUBMITTER: Jadidi K

PROVIDER: S-EPMC9675543 | biostudies-literature | 2022 Sep

REPOSITORIES: biostudies-literature

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Innovative intra-corneal ring-supported graft surgery for treatment of keratoconus and cornea regeneration: Surgical technique and case report.

Jadidi Khosrow K Mosavi Seyed Aliasghar SA Nejat Farhad F Aghamolaei Hosein H Pirhadi Shiva S

Indian journal of ophthalmology 20220901 9

Therapeutic options for corneal ectasia are evolving, with emphasis on the intra-stromal corneal ring for delaying or eliminating the need for penetrating keratoplasty. A 33-year-old man with grade 4 keratoconus and rising intolerance of the hard contact lens underwent a combination of a new innovative ring and graft with suture in the left eye. Excellent structural support and stability of the cornea were observed immediately post-operatively and 12 months after surgery. It appears as a feasibl ...[more]

PMID: 36018132

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Project description:ImportanceThe Cornea Donor Study (CDS) showed that donor age is not a factor in survival of most penetrating keratoplasties for endothelial disease. Secondary analyses confirm the importance of surgical indication and presence of glaucoma in outcomes at 10 years.ObjectiveTo assess the relationship between donor and recipient factors and corneal graft survival in the CDS.Design, setting, and participantsMulticenter prospective, double-masked, controlled clinical trial conducted at 80 clinical sites. One hundred five surgeons enrolled 1090 participants undergoing corneal transplant for a moderate-risk condition, principally Fuchs dystrophy or pseudophakic or aphakic corneal edema (PACE). Forty-three eye banks provided corneas.InterventionsCorneas from donors younger than 66 years and donors 66 years or older were assigned, masked to donor age. Surgery and postoperative care were performed according to the surgeons' usual routines. Participants were followed up for as long as 12 years.Main outcomes and measuresGraft failure, defined as a regrafting procedure or a cloudy cornea for 3 consecutive months.ResultsThe 10-year cumulative probability of graft failure was higher in participants with PACE than in those with Fuchs dystrophy (37% vs 20%; hazard ratio [HR], 2.1 [99% CI, 1.4-3.0]; P < .001) and in participants with a history of glaucoma before penetrating keratoplasty, particularly with prior glaucoma surgery (58% with prior glaucoma surgery and use of medications to lower intraocular pressure at the time of surgery vs 22% with no history of glaucoma surgery or medication use; HR, 4.1 [99% CI, 2.2-7.5]; P < .001). We found trends toward increased graft failure in recipients who were 70 years or older compared with those younger than 60 years (29% vs 19%; HR, 1.2 [99% CI, 0.7-2.1]; P = .04) or were African American (HR, 1.5; P = .11) or who had a history of smoking (35% vs 24%; HR, 1.6 [99% CI, 0.9-2.8]; P = .02). Lower endothelial cell density (ECD) and higher corneal thickness (CT) at 6 months (6% vs 41% for ECD ≥2700 vs <1700 cells/mm2 [P < .001]; 14% vs 36% for CT <500 vs ≥600 μm [P = .001]), 1 year (4% vs 39% for ECD ≥2700 vs <1700 cells/mm2 [P < .001]; 18% vs 28% for CT <500 vs ≥600 μm [P = .04]), and 5 years (2% vs 29% for ECD ≥1500 vs <500 cells/mm2 [P < .001]; 7% vs 34% for CT <550 vs ≥650 μm [P < .001]) were associated with subsequent graft failure.Conclusions and relevanceMost penetrating corneal grafts for Fuchs dystrophy or PACE remain clear at 10 years. The risk for failure is greater for graft recipients with PACE and those with a history of glaucoma. Measurements of ECD and CT during the course of postkeratoplasty follow-up are associated with a risk for failure. However, even with very low ECD and high CT at 5 years, most corneas remain clear at 10 years.

Project description:Custom high-resolution high-speed anterior segment spectral domain Optical Coherence Tomography (OCT) was used to characterize three-dimensionally (3-D) corneal topography in keratoconus before and after implantation of intracorneal ring segments (ICRS). Previously described acquisition protocols were followed to minimize the impact of the motions of the eye. The collected set of images was corrected from distortions: fan (scanning) and optical (refraction). Custom algorithms were developed for automatic detection and classification of volumes in the anterior segment of the eye, in particular for the detection and classification of the implanted ICRS. Surfaces were automatically detected for quantitative analysis of the corneal elevation maps (fitted by biconicoids and Zernike polynomials) and pachymetry. Automatic tools were developed for the estimation of the 3-D positioning of the ICRS. The pupil center reference was estimated from the segmented iris volume. The developed algorithms are illustrated in a keratoconic eye (grade III) pre- and 30 days post-operatively after implantation of two triangular-section, 0.3-mm thick Ferrara ring segments. Quantitative corneal topographies reveal that the ICRS produced a flattening of the anterior surface, a steepening of the posterior surface, meridional differences in the changes in curvature and asphericity, and increased symmetry of the anterior topography. Optical distortion correction through the ICRS (of a different refractive index from the cornea) allowed accurate pachymetric estimates, which showed increased thickness in the ectatic area as well as in peripheral corneal areas. Automatic tools allowed estimation of the depth of the implanted ICRS ring, as well as its rotation with respect to the pupil plane. Anterior segment sOCT provided with fan and optical distortion correction and analysis tools is an excellent instrument for evaluating and monitoring keratoconic eyes and for the quantification of the changes produced by ICRS treatment.

Project description:Corneal allogenic intrastromal ring segments (CAIRS) refer to the intracorneal placement of fresh, unprocessed, processed, preserved, or packaged allogenic rings/segments of any type/length. We described uniform-thickness CAIRS previously. We now describe a new technique of customized CAIRS to personalize the flattening effect as per individual topography. A prospective interventional case series of patients with pericentral/ paracentral decentered cones and gradation of keratometry with one side steeper than the other was conducted. Individually customized tapered CAIRS with variable volume, arc length, taper length, and gradient of taper were implanted. In total, 32 eyes of 29 patients with at least 1-year follow-up were included. Special double-bladed trephines and a CAIRS customizer template allowed the creation of individually customized CAIRS. Mean uncorrected distance visual acuity (UDVA) and spectacle-corrected distance visual acuity improved from 0.22 to 0.47 (P = 0.000) and from 0.76 to 0.89 (P = 0.001), respectively. Significant improvement was seen in K1, K2, Km, Kmax, topographic astigmatism, Q-value, sphere, cylinder, spherical equivalent, Root Mean Square (RMS), Higher Order Aberrations (HOA), and vertical coma (P < 0.01, 0.05). There was no significant change in the width or height of CAIRS between 1 month and last visit on anterior-segment optical coherence tomography. Five eyes continued to remain at the same UDVA, 27 eyes had at least 2 lines, and 13 eyes had at least 3 or more lines improvement in UDVA. The maximum improvement in UDVA was 7 lines. A significant difference in flattening was obtained at different zones across the tapered CAIRS. Thus, differential flattening was achieved across the cone based on the customization plan. Personalized customization was possible for each cornea, unlike limited models of progressive-thickness synthetic segments. Allogenic nature, greater customizability, efficacy, and absent need for large inventories are advantages compared to synthetic segments.

Dataset Information

Innovative intra-corneal ring-supported graft surgery for treatment of keratoconus and cornea regeneration: Surgical technique and case report.

Publications

Innovative intra-corneal ring-supported graft surgery for treatment of keratoconus and cornea regeneration: Surgical technique and case report.

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