Keratoconus and Other Corneal Ectasia Repair with Topographic Guided Ablation and Corneal Cross Linking
The treatment of Keratoconus and other forms of corneal ectasia (corneal weakening causing bowing forward of the cornea) have traditionally been treated with different types of rigid contact and scleral lenses to help the vision, and if the ectasia continued to progress, with corneal transplant. The idea of directly strengthening the weakened cornea came from Theo Siler, M.D. one of the most brilliant minds in the ophthalmology world. In 2003 he created the Dresden Protocol, which saturated the cornea with Riboflavin, and then shone an ultraviolet light on it for a set amount of time and energy to create new bonds in between the corneal cells increasing the structural strength of the cornea. A. John Kanellopoulos, another brilliant mind in the field of ophthalmology, then combined Corneal Cross Linking with topographic guided ablation and called it the Athens Protocol. Topographic guided ablation would reduce the irregularity of the cornea, creating a more “normal” shape, and the corneal cross linking would help to strengthen the cornea after this was done. This normalization is used to create more uniform optical surface, allowing for the possibility of better optics, the ability to see more without glasses or contacts, and the use of a soft contact lens instead of a rigid one. This revolutionized the treatment of corneal ectasia, and now this treatment is the gold standard in the rest of the world for the treatment of keratoconus and other forms of corneal ectasia.
It is important to understand that the primary goal of this procedure is to PREVENT corneal transplant, and the secondary goal is to normalize the cornea in a way that soft contact lenses can be used, or in some cases even allow for vision without glasses or contacts. How much the eye(s) can be corrected depends on the amount of corneal tissue present, since the cornea gets thinner as the ectasia progresses.
Dr. Motwani expressly follows the Athens Protocol, and has learned his procedures directly from Dr. Kanellopoulos, who is considered the world expert on this procedure and has the most experience. Therefore, Dr. Motwani relies on Dr. Kanellopoulos’ experience to provide the most advanced, most stable possible procedures.
Topographic guided ablation and corneal cross linking are performed consecutively, on the same day one after the other. Since it is necessary to remove the surface epithelium to perform both, initial healing time is similar to a PRK, with the epithelium taking from 3-7 days to heal. It is common for patients to find themselves initially more nearsighted after the procedure, and contact lenses can be worn after the second week if necessary. The initial nearsightedness fades quickly over several weeks, and healing and improvement from the procedure occurs across 6-12 months.
This procedure works not only for keratoconus, but post-LASIK ectasia, pellucid marginal degeneration, or any other source of corneal ectasia. If corneal irregularity has occurred without corneal weakening or thinning, corneal cross linking may not be necessary, and only topographic guided laser correction may be necessary.
CASE 1 – OD
44 year old female, OD PRK, OD CORNEAL CROSSLINK
Preop Manifest: OD: -0.75-4.25×80 BCVA 20/20
T- Cat Treatment; OD: -0.00-1.50X088
6 month post op: OD: -0.25 D/S and 20/20
CASE 1 – OS
44 year old female, OS PRK, OS CORNEAL CROSSLINK
Preop Manifest: OS: -1.00-2.00X080 BCVA 20/20
T- Cat Treatment; OS: -1.50-0.75X094
6 month post op: OS: -0.75 D/S and 20/25 OU: 20/25
CASE 2 – OD
22 year old male, OD PRK, OD CORNEAL CROSSLINK
Preop: OD: -0.50-1.25X172 BCVA 20/20
T- Cat Treatment; OD: -0.00-1.50X008
Post OP 9 months refraction OD: plano 20/25
CASE 2 – OS
22 year old male, OS PRK, OS CORNEAL CROSSLINK
Preop Manifest: OS: -8.75-7.75X165 BCVA 20/60
T- Cat Treatment; OS: -0.00-2.00X158
Post OP 9 months; OS: -3.25-0.50 X106 20/70
OU vision: 20/25
- 22 year old male with keratoconus OS>OD.
- Right eye had aberration treatment via PRK and Contoura Measured Astigmatism treatment.
- Left eye had aberration treatment via PRK and enough tissue to treat 2D of Contoura Measured Astigmatism (full measured astigmatism was -5.57D)
- This was followed immediately by corneal cross linking in both eyes.
CASE 3 – OD
20 year old male, OD CORNEAL CROSSLINK
Preop: OD: -10.00-4.75X029 20/80
Post OP 5 months refraction OD: -7.50-0.50X180 20/50
CASE 3 – OS
20 year old male, OS PRK, OS CORNEAL CROSSLINK
Preop: OS: -1.50-5.00X135 BCVA 20/40
T- Cat Treatment; OS: -0.00-2.00X160
Post OP 5 month OS Refraction: -4.50-1.25X016 20/50 OU: 20/50
- 20 y.o. male with severe keratoconus OD>OS
- OD keratoconus severe and unable to perform any laser treatment. Corneal cross linking only, which resulted in an improvement of refraction and best corrected vision.
- OS treated via PRK with Contoura aberration repair as well as 2.0D of astigmatism treatment.
- Patient had corneal cross linking both eyes.
- Patient now abele to wear soft contact lenses and achieve 20/50 vision. Patient now able to attend school and training for career.
CASE 4 – OD
24 year old male, OD PRK T-CAT REPAIR, OD CORNEAL CROSSLINK
Preop Manifest: OD: -7.50-3.25X015 BCVA 20/50
T- Cat Treatment; OD: -0.00-0.00X015
Post OP 2 months: -8.50, -1.00 x 180 20/40
CASE 4 – OS
24 year old male, OS PRK T-CAT REPAIR, OS CORNEAL CROSSLINK
Preop Manifest; OS: -3.50-2.75X160 BCVA 20/30
T- Cat Treatment; OS: -0.00-0.00X160
Post OP 2 months: plano and 20/30
- 24 year old male with keratoconus OD>OS
- Only enough tissue available to perform Contoura aberration repair via PRK on both eyes, no astigmatism or sphere treated.
- Corneal cross-linking performed both eyes.
- Pt now able to wear soft contact lenses in both eyes with best corrected vision of 20/50 at one month post-op.
CASE 5 – OD
31 year old female, OD PRK T-CAT, OD Corneal Crosslink
Pre-Op Manifest; OD: -3.50-1.25X030 BCVA 20/20
T-CAT Treatment; OD: -2.00-1.50X023
Post OP 10 month; OD: -1.50-1.00X035 and 20/20
OU vision without correction: 20/40
CASE 5 – OS
31 year old female, OS PRK T-CAT, OS Corneal Crosslink
Pre-Op Manifest; OS: -1.75-4.75X120 BCVA 20/30
T-CAT Treatment; OS: +0.00+0.00X102
Post OP 10 month; OS: -2.50-2.75X140 and 20/30
OU vision without correction: 20/40
- 31 y.o. female with progressive keratoconus OS>OD
- Refractive correction utilizing Contoura Measured astigmatism minus approximately 30% and aberration repair performed on right eye. Not enough tissue for refractive repair left eye, so only aberration repair performed. Both were performed via PRK.
- Corneal cross linking performed both eyes immediately after Contoura PRK.
- Patient has 20/40 vision without correction one year out, and best corrected vision OD is 20/20 and OS is 20/30.