FocalPoints

Clinical Modules for Ophthalmologists

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Advances in the
Surgical Treatment of
Keratoconus
Aylin Kılıç, MD
Joseph Colin, MD

Reviewers and Contributing Editor Consultants

George A. Stern, MD, Editor for Cornea and External Disease James J. Reidy, MD, FACS
Elmer Y. Tu, MD, Basic and Clinical Science Course Faculty, Section 8 David J. Schanzlin, MD
Edward K. Isbey III, MD, Practicing Ophthalmologists Advisory Committee for Education

FPv30n02_0312.indd 1 1/25/12 4:21 PM

 Claiming CME Credit Focal Points Editorial Review Board
The American Medical Association requires that all learners George A. Stern, MD, Missoula, MT
participating in activities involving enduring medical materi- Editor in Chief; Cornea and External Disease
als complete a formal assessment before claiming continuing
D. Michael Colvard, MD, FACS, Encino, CA
medical education (CME) credit. To assess your achievement in
this activity and ensure that a specified level of knowledge has Cataract Surgery
been reached, a post test for this module is provided. A mini- Bradley S. Foster, MD, Springfield, MA
mum score of 80% must be obtained to pass the test and claim Retina and Vitreous
CME credit.
Syndee J. Givre, MD, PhD, Raleigh, NC
To claim Focal Points CME credits, visit the Academy
Neuro-Ophthalmology
web site and access CME Central (www.aao.org/CME) to
report CME credit you have earned. You can claim up to Ramana S. Moorthy, MD, FACS, Indianapolis, IN
2 AMA PRA Category 1 Credits™ per module. CME credit may Ocular Inflammation and Tumors
be claimed for up to three (3) years from date of issue.
Eric P. Purdy, MD, Fort Wayne, IN
Oculoplastic, Lacrimal, and Orbital Surgery

Focal Points (ISSN 0891-­8260) is published quarterly by the American Acad- Steven I. Rosenfeld, MD, FACS, Delray Beach, FL
emy of Ophthalmology at 655 Beach St., San Francisco, CA 94109-­1336. For Refractive Surgery; Optics and Refraction
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The American Academy of Ophthalmology designates this enduring mate-
Kim Torgerson, Publications Editor
rial for a maximum of 2 AMA PRA Category 1 Credits™. Physicians should claim
only the credit commensurate with the extent of their participation in the activity.
The Academy provides this material for educational purposes only. It is not
intended to represent the only or best method or procedure in every case, nor
Clinical Education Secretaries and Staff
to replace a physician’s own judgment or give specific advice for case manage-
Gregory L. Skuta, MD, Senior Secretary for Clinical Education,
ment. Including all indications, contraindications, side effects, and alternative
agents for each drug or treatment is beyond the scope of this material. All Oklahoma City, OK
information and recommendations should be verified, prior to use, with current Louis B. Cantor, MD, Secretary for Ophthalmic Knowledge,
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ii Focal Points : Module 2, 2012

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 Learning Objectives
At the completion of this module,
the reader should be able to:
• Discuss the indications, surgical techniques, results,
and complications of the use of intracorneal ring
segments in the treatment of keratoconus
• Discuss the indications, techniques, results, and
complications of collagen crosslinking, with and
without photorefractive keratectomy, in the
treatment of keratoconus
• Describe the use of long-­acting intracameral gases
to treat corneal hydrops
• Compare the relative merits of deep anterior
lamellar keratoplasty and penetrating keratoplasty
in the treatment of keratoconus
Financial Disclosures
The authors, reviewers, and consultants disclose the follow-
ing financial relationships. Joseph Colin, MD: (C) Abbott Medical
Optics, Addition Technology, Alcon Laboratories. D. Michael
Colvard, MD, FACS: (C) Abbott Medical Optics, Bausch & Lomb;
(P) OASIS Medical. Steven I. Rosenfeld, MD, FACS: (C) Inspire
Pharmaceuticals; (L) Allergan. David J. Schanzlin, MD: (C) Aaren
Scientific, OASIS Medical. C. Gail Summers, MD: (L) BioMarin
Pharmaceutical, (S) NOAH (The National Organization for Albinism
and Hypopigmentation). Elmer Y. Tu, MD: (L) Alcon Laboratories.
The following contributors state that they have no significant financial
interest or other relationship with the manufacturer of any commer-
cial product discussed in their contributions to this module or with
the manufacturer of any competing commercial product: Bradley S.
Foster, MD; Syndee J. Givre, MD; Daniel Mummert; Edward K.
Isbey III, MD; Susan R. Keller; Aylin Kılıç, MD; Ramana S. Moorthy,
MD; Eric P. Purdy, MD; James J. Reidy, MD, FACS; George A. Stern,
MD; Kim Torgerson.
C = Consultant fee, paid advisory boards or fees for attending a
meeting
L = Lecture fees (honoraria), travel fees or reimbursements when
speaking at the invitation of a commercial sponsor
P = Patents and/or royalties that might be viewed as creating a
potential conflict of interest
S = Grant support for the past year (all sources) and all sources used
for this project if this form is an update for a specific talk or manu-
script with no time limitation
FPv30n02_0312.indd 1
Contents
Introduction 1
Intracorneal Ring Segments 3
• Surgical Technique 5
• Results 6
• Complications 6
Collagen Crosslinking 6
• Surgical Technique 7
• Results 8
• Complications 8
Combined Collagen Crosslinking
and Intrastromal Rings 8
Combined Collagen Crosslinking
and Photorefractive Keratectomy 9
Treatment of Corneal Hydrops 9
Lamellar Keratoplasty 9
Conclusion 10
Clinicians’ Corner 12
Introduction
Keratoconus is a progressive ectatic disorder of the cor-
nea that generally affects younger individuals. As the
disease progresses, the central cornea thins and the
cornea assumes a conical, rather than spherical, cross-­
sectional shape. Physical findings include a steep cor-
neal curvature, apical thinning, and striae at the level of
Descemet’s membrane (Figure 1, Figure 2). A V‑shaped
curvature of the lower lid margin on downgaze is termed
Munson’s sign (Figure 3). The apex of the cone is usually
decentered inferiorly (Figure  4). This leads to progres-
sive myopia and astigmatism, usually irregular, leading
to a loss of best spectacle-­corrected visual acuity (BSCVA).
Later in the disease, scarring at the level of Bowman’s
membrane often occurs. Tears in Descement’s mem-
brane cause edema (hydrops), with subsequent scarring,
that further decreases visual acuity (Figure 5). Corneal
topographic analysis, using either a Placido-­based or
Scheimpf lug camera system, is often helpful in making
the diagnosis and following progression of the disease
Focal Points : Module 2, 2012 1
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 Figure 3 ​A V‑shaped curvature of the lower lid margin on
Figure 1 ​Slit-lamp photograph of a patient with keratoconus,
downgaze is termed Munson’s sign. (Reprinted, with permis-
demonstrating increased corneal curvature, apical thinning,
sion from Colin J, Ertan (Kılıç) A, Intracorneal Ring Segments
and striae at the level of Descemet’s membrane. (Reprinted,
and Alternative Treatments for Corneal Ectatic Diseases.
with permission from Colin J, Ertan (Kılıç) A, Intracorneal
Ankara: Kudret Eye Hospital, 2007:14.)
Ring Segments and Alternative Treatments for Corneal Ec-
tatic Diseases. Ankara: Kudret Eye Hospital, 2007:13.)

Figure 4 ​Oblique slit-beam view of a patient with keratoco-

nus shows inferiorly decentered protrusion of the cornea.

Figure 2 ​Optical distortion created by the cone is easily vis-

ible in the red reflex.

(Figure 6). Keratoconus diagnostic software is available

with most topographic systems and generally utilizes a
significant difference between superior and inferior cur-
vatures to suggest the diagnosis.
Treatment of early keratoconus includes the use of
glasses or soft contact lenses to improve visual acuity.
When irregular astigmatism precludes adequate cor-
rection with glasses or soft lenses, rigid gas-­permeable
Figure 5 ​Slit-lamp photograph of a patient with hydrops, a
contact lenses, which mask the surface irregularities,
central opacity due to edema created by a tear in Des-
often restore vision. Some patients, however, cannot cemet’s membrane. (Reprinted, with permission from
be comfortably fit with a rigid lens, and as the disease Colin J, Ertan (Kılıç) A, Intracorneal Ring Segments and
progresses, the cornea may become too steep to main- Alternative Treatments for Corneal Ectatic Diseases. Ankara:
tain a contact lens on the eye. In some cases, this can be Kudret Eye Hospital, 2007:14.)

2 Focal Points : Module 2, 2012

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Figure 6 ​Typical topographic picture of keratoconus,
demonstrating greater than normal central curvature, with
steeper curvature inferiorly.
managed with the use of newer, ultra-large scleral, rigid
gas-­permeable contact lenses, but cost and need to travel
to be fit with these lenses can be prohibitive. In addition,
central corneal scarring can limit vision despite the use
of any optical device. Traditionally, when patients could
not get adequate vision with either glasses or contact
lenses, the only surgical option has been penetrating ker-
atoplasty (PKP).
Recent advances have added to the surgical options
for keratoconus. They also can be applied to two closely
related diseases, pellucid marginal degeneration and
post-­L ASIK ectasia. Intracorneal ring segments can
improve uncorrected (UCVA) and best-­corrected visual
acuity (BCVA), or allow for successful contact lens fit-
ting in a previously unfittable patient, avoiding the need
for keratoplasty. A new technique called collagen crosslink-
ing (CXL) can increase the biomechanical rigidity of the
cornea, f latten the cornea, and prevent progression of
the disease. While laser remodeling of the cornea would
threaten to worsen the disease in an untreated cornea,
it might be successfully and safely performed in a cross-
linked cornea.
Corneal hydrops, traditionally treated medically, can
cause a prolonged period of disability while waiting for
the edema to resolve. This period can be shortened by
the intracameral injection of a long-­acting gas bubble.
PKP has generally been a very successful technique for
restoring vision in patients with advanced disease. Graft
FPv30n02_0312.indd 3
rejections, however, are common, and threaten graft sur-
vival. Recent advances in lamellar surgery techniques
that enable near-­equivalent visual outcomes to PKP have
made deep anterior lamellar keratoplasty (DALK) a viable
option to PKP, sparing the risk of endothelial graft rejec-
tion. In this module, these new surgical techniques for
the treatment of keratoconus are discussed.
Intracorneal Ring
Segments
Intracorneal rings affect the keratoconic cornea in two
ways. First, the ring effectively adds tissue and elevates
the anterior surface of the cornea overlying the ring. Since
the central cornea f lattens in the direction of an elevated
area, the 360° placement of the rings causes a generalized
f lattening of the central cornea, reducing the amount
of myopia. The f lattening effect of the ring segments is
proportional to the thickness of the ring and inversely
proportional to the diameter of the ring segments. Asym-
metric placement of rings of different thicknesses can
reduce astigmatism and centralize an eccentric cone.
Secondly, in keratoconus, the corneal elastic modulus
is reduced due to pathology in the corneal stroma. This
causes the cornea to be more deformable in response
to stress, leading to thinning and protrusion (increased
curvature), which are the hallmarks of keratoconus
(Figure 7). By shortening the path length of the collagen
lamellae central to the segments, there is a redistribu-
tion of corneal stress, interrupting the biomechanical
cycle of keratoconus disease progression (Figure 8).
The goal of ring segment surgery is to reduce the
degree of myopia and astigmatism, improving UCVA and
BCVA. Shifting the position of the cone more centrally
within the cornea may also improve higher-­order aberra-
tions, such as coma. Unlike purely refractive procedures,
however, the goal is not emmetropia; rather, a success-
ful procedure is one that improves vision enough that
the patient can be comfortably corrected to an adequate
level of vision with spectacles or contact lenses, avoid-
ing riskier procedures such as keratoplasty. This goal is
achieved approximately 70% of the time.
There are a variety of intracorneal ring segments
used worldwide, including the Bisantis Intrastromal
Segmented Perioptic Implant (Opticon 2000 SpA and
Soleko SpA, Rome, Italy), the Keraring Intrastromal
Corneal Ring Segment (Mediphakos, Inc, Belo Hori-
zonte, Brazil), the Ferrara Ring Segment (Mediphakos),
and the ­MyoRing intracorneal continuous ring (Dioptex
GmbH, Linz, Austria). The Intacs Ring Segment (Addition
Focal Points : Module 2, 2012 3
1/25/12 4:21 PM
 Technology Inc, Sunnyvale, California) is the most widely
used corneal ring segment and the only one used in the
Uniform thickness =
Uniform stress United States. In this module, discussion is limited to
the Intacs segments, which are approved by the Food &
Drug Administration (FDA) for use in the United States as
a Humanitarian Device Exemption. The Intacs segments
IOP
consist of a pair of polymethylmethacrylate (PMMA)
semicircular pieces, each having an arc length of 150°
Thinnest point = and a hexagonal cross-­sectional shape. When implanted
Maximum stress surgically, the Intacs rings have an external diameter of
8.10 mm and an internal diameter of 6.77 mm. The thick-
ness of the ring determines the refractive effect. In the
U.S., the FDA-­approved rings are available in thicknesses
IOP
ranging from 0.21 mm to 0.45 mm. Current designs have
a predicted myopic range of correction from –1.00 D to
Figure 7 ​A uniform corneal thickness (top) produces a –4.10 D. A newer Intacs design, Intacs SK, has an inner
uniform stress distribution. A nonuniform corneal thickness
diameter of 6 mm and an oval cross-­sectional shape.
(bottom) produces a stress concentration in the thinnest
region. (Reprinted, with permission from Colin J, Ertan Intacs can be used in patients with keratoconus, pel-
(Kılıç) A, Intracorneal Ring Segments and Alternative Treat- lucid marginal degeneration, and post-­LASIK ectasia who
ments for Corneal Ectatic Diseases. Ankara: Kudret Eye are not adequately and comfortably corrected with rigid
Hospital, 2007:160.) gas-­permeable contact lenses. They should not be used
in patients with significant central corneal scarring or

Intacs Placement

Flattening Central to Segments

Peripheral Steepening Cornea Thickens
Over Segments

Cornea Thins

Redistribution of
Stress

Increased Strain Increased Stress

(Increased Curvature) Concentration

Keratoconus:
Modulation of Biomechanical Properties

Figure 8 ​The red biomechanical cycle reflects disease progression in keratoconus. The blue biomechanical cycle reflects the impact
of Intacs placement. Once the segments are inserted, the curvature is decreased centrally, including the region of the cone. As cur-
vature is decreased in this region, the stress is redistributed, and the decompensatory biomechanical cycle of keratoconus is broken.
(Reprinted, with permission from Colin J, Ertan (Kılıç) A, Intracorneal Ring Segments and Alternative Treatments for Corneal Ectatic
Diseases. Ankara: Kudret Eye Hospital, 2007:164.)

4 Focal Points : Module 2, 2012

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 in patients with untreated atopic disease or evidence ONLINE VIDEO:

of local or systemic infection. While there are no abso- Intacs Insertion: Mechanical Technique, 2 min 00 sec
lute guidelines for the maximum corneal steepness to
be treated with Intacs, some surgeons in the U.S. have The incision and stromal tracks can also be created
suggested 58 D as an upper limit, determined by corneal with the femtosecond laser. Femtosecond laser channel
topography analysis. creation provides a precise tunnel and keratotomy depth,
width, and location; a uniform 360° channel; rare need
Surgical Technique for suture placement; minimal channel haze and edema;
minimal risk of epithelial defect or stromal edema; lower
Intacs procedures are generally performed using topi- risk of infectious keratitis; easier surgical access in deep-
cal anesthesia, as ballooning of the conjunctiva from a set eyes; and completion of the track within seconds
peribulbar block would interfere with the attachment without manipulating the cornea.
of the suction ring used in the creation of the stromal
tracks. Surgery is performed around the geometric cen-
ter of the cornea, which is marked with ink. The incision
axis is determined, and the incision site and location of
the rings is delineated using a specially designed marker.
In the U.S., the “steep axis technique” (placing the inci-
sion at the topographic steep axis of the cornea) seems
to be most popular, but a standard temporal incision can
also be used. After measurement of the corneal thickness
at the incision site, a guarded diamond knife is used to
make the incision depth approximately 70% of the cor-
neal thickness. While there is no requirement pertain-
ing to central corneal thickness, the cornea must have
a thickness of at least 480 µm at the incision site. After
initiation of a stromal channel at the base of the incision,
a complete circular stromal channel is created with a
stromal spreader. The Intacs segments are then inserted a
(Figure 9). The choice of Intacs segments, and whether
done symmetrically or with different-­sized segments, is
based on mean refractive error, amount of astigmatism,
and location of the cone. After correct placement of the
Intacs segments, the incision is closed with tight 10‑0
nylon sutures with the knots buried. Patients are treated
with antibiotic and steroid eyedrops and oral analgesics.
Figure  10 shows examples of pre- and postoperative
topography.

Figure 10 ​Corneal topography examples. a. Preopera-

tive topography prior to Intacs insertion. b. Postoperative
topography, demonstrating flattening of the central corneal
curvature and reduction of topographic astigmatism.

Figure 9 ​Slit-lamp photograph showing perfect placement

of Intacs inserts in a keratonic cornea.

Focal Points : Module 2, 2012 5

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 ONLINE VIDEO: where the cone crossed the 180° meridian. Both groups

Intacs Insertion: Femtosecond Laser Technique, 1 min 35 sec showed similar improvements in UCVA and BCVA.

Results
Table 1 summarizes visual and refractive outcomes after
the use of intracorneal ring segments. While reported
series have varied according to incision placement, size
of rings, and whether rings were placed symmetrically
or asymmetrically, results have been extremely consis-
tent. There is generally a 2 to 4 Snellen line improvement
in UCVA, a 1 to 2 Snellen line improvement in BSCVA,
a 3 to 4 D improvement in spherical equivalent refrac-
tion, a 4 to 5 D reduction in mean and maximal kera-
tometry readings, and a mild reduction in astigmatism.
Comparisons between the manual and femtosecond laser
methods of Intacs surgery have not shown a consistent
difference in results between the two methods.
There have also been comparisons between the use of
a single ring segment vs paired segments. It stands to
reason that in patients with markedly decentered cones
or extreme astigmatism, the best surgical results would
be obtained by maximizing the asymmetry of ring place-
ment (ie, using a single ring). In one report, the surgeon
chose to use a single 0.45‑mm inferior ring in patients
whose cones were entirely within the inferior half of the
cornea, whereas a 0.25‑mm segment was placed superi-
orly and a 0.45‑mm segment placed inferiorly in patients
Complications
Implantation of intracorneal ring segments is generally a
very safe surgical procedure. Most significant intraopera-
tive complications occur while dissecting the channel for
the rings. These include creating too shallow a channel
or uneven channel depth, anterior or posterior perfora-
tions, and decentration of the channels. These complica-
tions should be avoided with the use of the femtosecond
laser. Postoperatively, infections are rare but do occur.
In addition, sutures can loosen and lead to secondary
infection. Segments can migrate, especially if patients
rub their eyes, leading to unwanted optical effects (Fig-
ure 11). Overlapping segments can cause pressure necro-
sis of the cornea and corneal ulceration. If the ring
segments cause significant unwanted effects, they are
easily removed, with the cornea reverting to very near
the preoperative topography. One advantage of ring seg-
ment surgery is that the central cornea is not violated.
Later keratoplasty can be performed, either after ring
segment removal, or around the ring segments.
Collagen Crosslinking
While early keratoconus is readily managed with glasses
or rigid gas-­permeable contact lenses, the disease is often

Table 1. Visual and Refractive Outcomes After Placement of Intracorneal Ring Segments in
Keratoconic Eyes
AUT H O R F OLLO W - U P EYES I M P R O V E M E NT

Colin, et al (2001) 12 months 10 Mean K: 4.10 D

Mean SE: 2.12 D
Siganos, et al (2003) 11 months 33 Mean K: 3.23 D
Mean SE: 1.39 D
Ertan (Kılıç), et al (2006) 12 months 118 Mean K: 3.9 D
Mean SE: 3.85 D
Alio, et al (2006) 36 months 13 Mean K: 2.56 D
Mean SE: 1.45 D
Kymionis, et al (2007) 60 months 17 Mean K: 1.57 D
Mean SE: 2.52 D
Kanellopoulos, et al 6 months 20 Mean K: 3.10 D
(2006) Mean SE: 3.69 D
Colin, et al (2006) 6 months 57 Mean K: 4.3 D
Mean SE: 3.1 D
Ertan (Kılıç), et al (2008) 10.39 months 306 Mean K: 2.79 D
5.04 (SD)
Kubaloglu, et al (2011) 18 months 96 Mean K: 3.63 D
Mean SE: 5.88 D
SE: spherical equivalent; K: keratometry

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Figure 11 ​Rotation of inferior Intacs segment and migration
across incision into upper channel. (Reprinted, with permis-
sion from Colin J, Ertan (Kılıç) A, Intracorneal Ring Segments
and Alternative Treatments for Corneal Ecstatic Diseases.
Ankara: Kudret Eye Hospital, 2007:139.)
progressive, and advanced disease leads to the need for
keratoplasty in as many as 21% of affected patients. A
procedure that could prevent progression would limit
the morbidity associated with the disease. That is the
primary goal of corneal collagen crosslinking (CXL). Cur-
rently, CXL is an investigational procedure in the United
States, with several multicenter studies in progress
aimed at gaining FDA approval of the procedure.
Optimal corneal optics require a regular arrange-
ment of stromal cells and macromolecules. The lattice
arrangement of collagen fibrils embedded in the extra-
cellular matrix acts to reduce light scattering by means
of destructive interference. In keratoconus, a decrease
in the number of collagen lamellae, increased separa-
tion of the collagen bundles, and a loss of the orderly
arrangement of stromal fibrils compromises the optics
of the cornea. CXL alters the biomechanical properties
of corneal collagen to arrest these pathologic changes.
This treatment creates additional chemical bonds within
the corneal stroma, increasing its rigidity by 4.5×, and
increases the diameter of collagen fibrils by means of
a photopolymerization limited to the anterior corneal
stroma.
Surgical Technique
Ribof lavin is a key component of the photochemical
crosslinking treatment as it increases corneal absorption
of ultraviolet A (UVA) to approximately 95% and thereby
protects the deeper ocular structures, especially the
endothelium, from UVA damage. The damage from UV
FPv30n02_0312.indd 7
light depends on its wavelength, its irradiance, and the
irradiation time. Photokeratitis has been shown to occur
in the cornea at wavelengths of 270 to 315 nm (UVB),
with dose densities ranging from 0.12 to 0.56 J/cm2. Cat-
aract has been caused by wavelengths between 290 and
365 nm. Thermal or blue light–induced photochemical
retinal damage is caused by a wavelength range of 400
to 1400 nm. To minimize potential UV toxicity, a precise
370‑nm UVA wavelength is used in CXL. The UVA irradi-
ance must be checked with a meter. In addition, suffi-
cient concentrations of ribof lavin will limit penetration
of the UV light to a depth of 400 µm. To avoid poten-
tial risk for the endothelium, lens, and retina, preopera-
tive pachymetry must be performed in each patient to
exclude patients with extended areas less than 400‑µm
stromal thickness.
In the traditional technique, the central 9 mm of the
corneal epithelium is removed by one of various meth-
ods. This facilitates the penetration of 0.1% ribof lavin in
20% dextran, which is administered as an eyedrop every
3 minutes for 30 minutes until the stroma is completely
saturated and ribof lavin reaches the aqueous. Then the
cornea is irradiated using a 370‑nm wavelength ultravio-
let (UV) lamp at a radiance of 3 mW/cm2 for 30 minutes
(5.4 J/cm2 surface dosage after 30 minutes), continuing
to instill the ribof lavin drops every 5 minutes during the
UV irradiation. The ribof lavin absorbs the UV light to a
depth of 400  µm, protecting deeper structures within
the eye and activating the photopolymerization process.
Therefore, a minimum of 400 µm stromal thickness is
required for CXL to prevent damaging effects of UV light
on deeper structures. After the treatment is completed,
a bandage soft contact lens is placed on the eye, and the
patient is treated with antibiotic and steroid eyedrops
for 10 days. The contact lens is removed when the epi-
thelium heals.
ONLINE VIDEO:
Collagen Crosslinking for Keratoconus, 8 min 55 sec
There is active research looking at variations of the
technique, with the aims of shortening the duration of
the procedure and avoiding the need to remove the epi-
thelium. Modifications of the vehicle of the ribof lavin
solution, including altering the tonicity, components
of the vehicle, and inclusion of substances intended
to increase epithelial permeability, are being tested to
determine whether adequate transepithelial penetration
of ribof lavin can be achieved. Also, higher-­intensity UV
irradiation for shorter periods of time has been tested.
An alternative approach has been to directly inject ribo-
f lavin solution into an intrastromal pocket created with
a femtosecond laser.
Focal Points : Module 2, 2012 7
1/25/12 4:22 PM
 Results
The results of major trials of collagen are described in
Table 2. After an initial stage in the first postoperative
month where the cornea may steepen and develop some
haze, 6 months after CXL most corneas show some f lat-
tening compared to the preoperative curvature, with
an average reduction of approximately 2  diopters. As
a result, there is usually improvement of maximal and
average keratometry readings, UCVA, and BCVA. After
the first 6 months, there is stabilization of the corneal
topography, without progression of the disease. Stud-
ies of patients with progressive keratoconus comparing
treated eyes to controls demonstrate statistically signifi-
cant improvements between the treated and untreated
groups in UCVA, BCVA, maximal and average K readings,
corneal topographic indices, and higher-­order aberra-
tions after 1 year of follow-­up. In patients examined with
confocal microscopy, observations 3 to 6 months after
surgery include decreased edema, increased stromal den-
sity, and repopulation of the stroma with activated kera-
tocytes in the anterior stroma, with the deep stroma and
endothelium appearing unaffected.
Complications
CXL is a simple, easy procedure, but it can cause some
adverse outcomes. Inappropriate UV delivery, either
because of incorrect wavelength or excessive dosage, or
insufficient stromal ribof lavin concentration, can lead
to endothelial damage. The lens and retina are also at
risk from UV irradiation.
Stromal haze is common in any procedure where
the epithelium is removed and generally responds to
Table 2. Outcomes of Clinical Studies of Collagen Crosslinking
AUT H O R NU M B E R O F PATI E NTS
Wollensak, et al (2003) 22
Raiskup-Wolf, et al (2008) 241
Witting Silva, et al (2008) 24/23
Grewal, et al (2009) 102
Vinciguerra, et al (2009) 28/28
Agrawal, et al (2009) 37
Capparossi, et al (2010) 44
Kmax = keratometry value in the steepest meridian, BCVA = best-­corrected visual acuity, BSCVA = best spectacle-­corrected visual acuity,
SE = spherical equivalent refraction
8 Focal Points : Module 2, 2012
FPv30n02_0312.indd 8
treatment with topical steroids. Herpetic keratitis with
iritis, sterile keratitis, persistent epithelial defects,
microbial keratitis, and permanent corneal haze have
been reported as complications after CXL treatment in
keratoconic eyes. All of these complications are related
to the need to remove the epithelium; there is hope
that if transepithelial penetration of ribof lavin can be
achieved, eliminating the need for epithelial removal,
these complications can be markedly decreased. Kera-
tocyte damage is not considered a major issue, as many
other corneal procedures, including excimer laser refrac-
tive surgery, cause keratocyte damage at similar depths
with repopulation by migrating keratocytes occuring by
6 months, with no long-term consequences observed.
Combined Collagen
Crosslinking and
Intrastromal Rings
CXL and intracorneal rings have complementary effects
on the corneal biomechanics and refractive parameters.
CXL has its effect mainly on the anterior cornea, and
intracorneal ring segments provide f lattening effects
and redistribution of stress on deeper layers. Sequential
or simultaneous treatment with both intracorneal rings
and CXL appears to have an additive effect over either
procedure alone. Combined treatment results in greater
improvement of UCVA and BCVA, more reduction of
myopia and astigmatism, and a greater than two-fold
reduction of mean and steepest keratometry readings
F OLLO W - U P ( M OS ) I M P R O V E M E NT
3–47 Kmax 2.01 D,
BCVA 1.26 lines, SE 1.14 D
6–72 Kmax 2.57 D
BCVA improved in 58%
3–12 Kmax 1.45 D, BSCVA 0.12 logMAR
12 Stable BSCVA, sph equivalent, curvature
12–24 Kmax 6.16 D
BSCVA 0.14 lines
12 Kmax 2.73 D in 66%,
BCVA improved ≥1 line in 54%
48 Kmax 2.0 D
BCVA 1.9 lines
1/25/12 4:22 PM
 compared to either procedure alone. Postulated expla-
nations for the greater effects include a simple addi-
tion of the effect of the two procedures, coupling from
crosslinking of collagen around the ring segments, and
greater effect of crosslinking due to pooling and concen-
tration of ribof lavin in the channel around the ring seg-
ments. Simultaneous implantation of corneal rings and
CXL provides the advantage of delivering ribof lavin to
the cornea by direct injection into the stromal channel,
avoiding the need for epithelial removal.
Combined Collagen
Crosslinking and
Photorefractive
Keratectomy
Laser refractive surgery has generally been contraindi-
cated for keratoconus, based on the premise that abla-
tive procedures would further weaken an already weak
cornea, worsening the underlying condition. With the
advent of collagen crosslinking, however, it is possible
that the increased corneal rigidity created by that pro-
cedure would enable simultaneous or subsequent laser
ablation to be successfully performed.
Since an initial report of his first case in 2007, Kanel-
lopoulos has described the “Athens Protocol” in which
a limited, topographically guided photorefractive kera-
tectomy (PRK), removing no more than 50 µm of corneal
stroma to regularize the abnormal keratoconic topog-
raphy, is simultaneously combined with CXL. He found
significant improvements in UCVA, BSCVA, mean and
maximal keratometry, and spherical equivalent refrac-
tion, with stable results for up to 4 years. He also found
that more improvement is achieved with simultaneous
treatment compared to sequential treatment of CXL fol-
lowed 6 months later by PRK.
Treatment of
Corneal Hydrops
With progression of corneal ectasia, Descemet’s mem-
brane is stretched to a point where it can tear sponta-
neously, leading to a rapid inf lux of aqueous f luid into
the corneal stroma, creating significant corneal edema.
This condition, called corneal hydrops (Figure  5), has
FPv30n02_0312.indd 9
traditionally been treated conservatively with topical
medications including cycloplegics, hypertonic saline
drops and ointments, and aqueous suppressants. Cor-
neal hydrops occurs in approximately 3% of patients
with keratoconus.
With conservative management, resolution of the
edema generally takes 2 to 6  months. In 2002, it was
found that a series of 1 to 4 air injections into the ante-
rior chamber, combined with supine positioning, led
to a shortening of the duration of edema from an aver-
age of 64 to 20 days. Because of the need for repeated
injections, the use of longer-­acting gases was proposed.
Intracameral injections of isoexpansile concentrations
of both sulfur hexaf luoride (20% SF6) and perf luoro-
propane (14% C3F8) gases have been used with similar
results, with fewer injections needed. SF6 was injected
in a volume of 0.1 ml, whereas C3F8 was injected to fill
two-thirds of the anterior chamber. Injection of a long-­
acting gas into the anterior chamber carries a risk of
pupillary block glaucoma, and one group did routine sur-
gical iridotomies to eliminate this complication. Malig-
nant glaucoma has also been reported. In addition, a rare
complication has been migration of gas into the corneal
stroma, actually prolonging the period of edema. While
gas injection shortens the duration of edema by more
than 50%, it does not change the ultimate visual acuity,
once the edema subsides, when compared to eyes that
receive conservative management.
Lamellar Keratoplasty
Until the advent of intracorneal rings and CXL, patients
who could not achieve adequate vision with optical
devices, such as rigid gas-­ permeable contact lenses,
had no option other than keratoplasty to improve their
vision. Because of historically superior visual results
when compared to lamellar procedures, PKP has been
the preferred procedure. PKP, however, is an intraocu-
lar procedure with significant risks, the most impor-
tant being endothelial graft rejection that, in the young
keratoconus population, occurs in as many as 40% of
patients. Lamellar corneal transplantation, which spares
the healthy recipient endothelium and therefore avoids
this complication, might be a better choice of proce-
dure if visual results similar to PKP could be achieved.
Advances in lamellar surgical techniques, using mecha-
nized microkeratome technology to achieve smoother
dissection planes or manual techniques that remove all
recipient tissue down to Descemet’s membrane, collec-
tively described as deep anterior lamellar keratoplasty
(DALK), have the potential to achieve these results.
Focal Points : Module 2, 2012 9
1/25/12 4:22 PM
 Residual posterior stromal thickness is an important
determinant of visual acuity after DALK. Therefore, for
manual techniques, baring of Descemet’s membrane is
important. The most popular techniques for achieving
a dissection to Descemet’s membrane are variations of
Anwar’s “big bubble” technique. In this technique, a
half-­thickness trephination is performed, followed by a
lamellar dissection and removal of the anterior half of
the corneal stroma. A large air bubble is then injected
into the residual posterior stroma using a cannula or
30‑gauge needle. If this is successfully performed, the
air creates a dissection plane at the level of Descemet’s
membrane and separates Descemet’s membrane from
the overlying stroma. Once this separation is achieved,
the remaining posterior stroma is removed, leaving only
Descemet’s membrane and endothelium. The donor cor-
nea, from which Descemet’s membrane and endothe-
lium have been removed, is then sutured into place.
ONLINE VIDEO:
DALK With Modified Big Bubble, 4 min 20 sec
Several recent studies comparing standard PKP to
Descemet’s-­baring DALK for the treatment of kerato-
conus have shown equivalent visual results, comparing
UCVA and BCVA, refractive spherical equivalent, kerato-
metric astigmatism, contrast sensitivity, and wavefront
aberrometry. The risk of endothelial rejection in these
studies was absent following DALK, compared to 15%
following PKP, although epithelial and anterior stro-
mal rejections did occur, none leading to failure of the
graft. In addition, there is better long-term retention of
endothelial density following lamellar procedures. DALK
patients require less postoperative steroids, leading to
faster wound healing, and earlier suture removal means
faster visual rehabilitation.
DALK techniques have a steep learning curve, and suc-
cessful baring of Descemet’s membrane is not achieved
in all cases, even in the hands of highly experienced sur-
geons. Surgical time is increased. Poor stromal dissec-
tion or significant perforation of Descemet’s membrane
requires conversion to PKP. In addition, DALK is not
advisable for patients who have suffered from hydrops,
in which a break in Descemet’s membrane has previously
occurred. Given potentially equivalent visual results
with lower complications rates, it seems worthwhile for
10 Focal Points : Module 2, 2012
FPv30n02_0312.indd 10
corneal surgeons to consider converting to DALK as their
preferred keratoplasty technique for keratoconus.
Conclusion
Keratoconus is a progressive disorder, usually worsening
through the fourth decade of life. The traditional treat-
ment of keratoconus has primarily focused on methods
of visual rehabilitation. In the future, controlling the pro-
gression of the disease will be another important treat-
ment goal. That would allow more patients to go through
life without significant visual impairment. Although long-
term results with controlled studies are not yet available,
early results indicate that intracorneal ring segments
not only provide better visual quality but also may help
control the progression of keratoconus. With the advent
of collagen crosslinking, and perhaps with the combina-
tion of these modalities, the need for keratoplasty should
decrease. Combined crosslinking and topographically
guided PRK holds promise for even greater recovery of
vision. Moreover, it will be possible to help patients with
advanced disease with state of the art lamellar corneal
surgery. Ultimately, keratoconus will be treated by under-
standing and controlling the genetic basis of the disease.
These newer procedures are complementary in man-
aging patients through the progression of keratoconus.
When approved, CXL will be used early in the course of
the disease, once progression has been identified. Intra-
corneal ring segments are most effective in the mid-
course of the disease, when contact lenses may no longer
be effective, but before keratoplasty is the only option.
DALK will be reserved for patients with advanced dis-
ease, with a decreased risk of endothelial rejection when
compared to PKP.
Aylin Kılıç, MD, is a practicing ophthalmologist at Dunya
Eye Hospital, Ankara, Turkey.
Joseph Colin, MD, is a practicing ophthalmologist at
Hôpital Pellegrin and Chairman of the Department of
Ophthalmology at Bordeaux University Medical School,
Bordeaux, France.
1/25/12 4:22 PM
 Clinicians’Corner
Clinicians’ Corner provides additional viewpoints on
the subject covered in this issue of Focal Points. Con-
sultants have been invited by the Editorial Review
Board to respond to questions posed by the Acade-
my’s Practicing Ophthalmologists Advisory Committee
for Education. While the advisory committee reviews
the modules, consultants respond without reading the
module or one another’s responses. –Ed.
FPv30n02_0312.indd 11
1. What clinical exam signs and testing do you use to
identify early keratoconus?
Dr. Reidy: The first sign of early keratoconus is decreased
vision from progressive astigmatism. In the early stages
of keratoconus the slit-lamp biomicroscopic findings are
usually minimal. Alterations of the red ref lex as viewed
with either a retinoscope or a direct ophthalmoscope are
often present before frank ectasia can be detected with
the slit lamp. The mainstay of the early diagnosis is com-
puterized topographic imaging of the cornea. Traditional
Placido-­based imaging demonstrating focal steepening of
the inferior cornea with an inferior-­superior difference
of 3 diopters or more is suggestive of keratoconus. More
sophisticated Scheimpf lug imaging demonstrates focal
elevation of the anterior surface of the cornea with a
corresponding posterior surface elevation and localized
thinning over the apex of the elevation.
Dr. Schanzlin: The popularity of refractive surgery has
made the diagnosis of early keratoconus very impor-
tant, and over recent years several clinical parameters
have been developed to assist in this task. Classically,
the diagnosis of keratoconus is based on the clinical find-
ings of increasing myopia and astigmatism accompanied
by asymmetric corneal steepening and corneal thinning.
With the advent of Placido disc corneal topography in
the 1980s, Rabinowitz and Klyce taught the importance
of the inferior-­superior difference and radial-­axis skew in
the diagnosis of keratoconus. For the diagnosis of early
keratoconus, however, I rely heavily on the Pentacam
topographic analysis and higher-­order aberration analy-
sis from a Hartmann-­Shack aberrometer.
The Pentacam (Oculus, Lynwood, Washington) is a
rotating Scheimflug camera corneal imaging system that
allows for accurate measurement of the anterior and
posterior corneal surface topography. The Pentacam soft-
ware analyzes the elevation topography of these surfaces
in reference to a best-fit sphere, calculates an axial cur-
vature map based on the elevation data, and determines
Focal Points : Module 2, 2012 11
1/25/12 4:22 PM
 Clinicians’Corner
the thickness of the cornea over the analyzed area. Using
the reports from the Pentacam, we can pick up the earli-
est signs of keratoconus, which include elevation of the
posterior f loat above the best-fit sphere, and the inferior
displacement of the thinnest point of the cornea. The
recent addition of the Belin/Ambrosio Enhanced Ectasia
analysis software (Oculus) takes the early identification
of keratoconus to a new level.
I also find that patients with early or subtle kerato-
conus have abnormal coma that is easily observed on
Hartmann-­Shack aberrometry devices such as the Wave­
Scan WaveFront System (Abbott Medical Optics, Santa
Ana, California) or with similar Zernicke analysis avail-
able on some corneal topography devices.
2. Briefly describe your surgical techniques for intra-
corneal ring segments. Do you prefer same-size
or asymmetric-­sized segments, including single
segments?
Dr. Reidy: I make my incision temporally with a microm-
eter diamond blade and perform the lamellar dissection
manually with the special lamellar dissector from the
Intacs system. The segments are usually centered along
the vertical meridian. If the cone is inferiorly displaced,
I insert a thinner segment above and a thicker segment
below in order to displace the cone more centrally. If the
cone is more centrally located, I use segments of equal
thickness that will result in greater overall f lattening.
Dr. Schanzlin: For years, I used the manual instruments
developed by KeraVision (Fremont, California) to implant
intracorneal ring segments. Although occasionally I have
a case where I prefer the manual technique, most of my
cases now are done using the Intralase iFS Femtosecond
Laser (Abbott Medical Optics) to create the channels and
the entry incision. I perform the surgeries under the
VISX laser using the ring illuminator.
I begin each case with a povidone-­iodine (Betadine)
prep to the lids and lashes, and instill Betadine into
the conjunctival cul-de-sac. The patient is then situated
under the microscope and the geometric center of the
cornea is marked using the inked tip of a Sinskey hook.
I find it important to mark the geometric center of the
cornea because the apex of the cornea will shift due to
the applanation device of the femtosecond laser. The
12 Focal Points : Module 2, 2012
FPv30n02_0312.indd 12
patient is then moved to the Intralase unit and docking is
achieved in the usual manner. Prior to running the laser
pattern, the laser’s software is used to center the treat-
ment pattern over the geometric center of the cornea.
Most femtosecond lasers have software for the intracor-
neal ring segment surgery. I generally set the software to
produce a channel at 70% of the corneal thickness in the
area of the incision. I set the inner diameter of the chan-
nel at 6.8 mm, and the outer diameter of the channel at
7.8 mm. I set the axis of the incision to match the steep
meridian of the manifest refraction, specifically the axis
of the “plus” cylinder.
After the channels have been made, and I position
the patient again under the VISX microscope with the
ring illumination, I apply a Tegaderm drape to isolate
the eyelashes. I make a mental note of the corneal mire
from the ring illuminator. I then use a blunt “corkscrew”
device of my own design to open the channel 360°. Fol-
lowing this maneuver, the intracorneal ring segments
can easily be placed within the channels. I then place a
single 10‑0 nylon suture to reapproximate the wound,
and I bury the knot. At the end of the case, it is gratify-
ing to see the round mire from the ring illuminator of
the VISX microscope ref lecting from the corneal surface.
I almost always use the same size of intracorneal ring
segments, and similarly I almost always implant two seg-
ments. I select the size of the intracorneal ring segments
based on the spherical equivalent of the refractive error
as recommended by the manufacturer. While I do find
that approximately 15% of the time I need to remove
the superior intracorneal ring segment, I rationalize my
approach by saying is easier to take the superior intra-
corneal ring segment out than it is to put the segment
in if I decide I need it later. Unfortunately, in my hands,
I have not been able to predict which cases will do well
with only one segment.
3. How often do significant complications with intra-
corneal ring segments, such as worsening of
vision, occur and how often do the segments need
to be removed due to complications?
Dr. Reidy: Complications associated with intracorneal
rings segments are unusual; however, erosion of seg-
ments into the anterior chamber and extrusion or melt-
ing of segments through the overlying cornea stroma
1/25/12 4:22 PM
 have been reported. Infectious keratitis along the lamel-
lar tracts has also been reported. These complications
can be sight-­threatening. These types of complications
may be less likely when lamellar dissections are created
with solid-­state lasers that are able to produce incisions
more precisely than with the manual systems. Combined
analysis of 3  different studies reported that approxi-
mately 65% to 75% of patients gained 2 or more lines of
uncorrected visual acuity (UCVA), while 20% to 30% of
patients had no change in UCVA (defined as + or –1 line
of vision). One of the studies reported 9% of patients lost
2 or more lines of UCVA.
Dr. Schanzlin: Intracorneal ring segments have helped
many patients achieve improvement in best-­spectacle
acuity as well as improvement in correctable vision with
contact lenses. In our practice, patients are not consid-
ered for intracorneal ring segments until they are proven
failures with modern keratoconus contact lenses. In a
recent review of my cases, I found that over 95% of
patients achieved 20/40 visual acuity with contact lens
fitting; 60% of these patients were successfully fit with
a toric soft contact lens, while the rest needed a rigid gas-­
permeable contact lens or hybrid contact lens.
Nonetheless, there are patients in my experience who
do not achieve improvement with intracorneal ring seg-
ments. I believe the lack of effect in these cases is most
likely secondary to the extreme elasticity of the cornea.
In cases where there is no effect, I generally leave the
intracorneal ring segments in place for up to 3 months
to allow for adequate time for a favorable topographic
response, but if the corneal topography is not altered
to the point of allowing for a successful contact lens fit,
then I will remove the intracorneal ring segments.
Complications of intracorneal ring segments have
been documented in the literature and include corneal
melt, cornea infection, anterior corneal protrusion, pos-
terior corneal protrusion into the anterior chamber, crys-
talline deposits in the channel, and epithelial ingrowth
into the channel. My experience with complications has
been limited to one case of intrachannel infection, which
was treated with intracorneal ring segment removal and
topical fortified antibiotics, and ultimately resolved with
no loss in best-corrected visual acuity (BCVA).
The safety profile for intracorneal ring segments
for the treatment of keratoconus has been good. Many
FPv30n02_0312.indd 13
patients have avoided penetrating keratoplasty. Nonethe-
less, in cases where intracorneal ring segments have not
produced the desired effect, I have been able to success-
fully perform penetrating keratoplasty using a standard
technique. Specifically, some surgeons have questioned
whether the Intacs channels make penetrating kerato-
plasty more difficult. In my experience, the intracorneal
ring segments channels do not interfere with either pen-
etrating or lamellar keratoplasty techniques.
4. What is your understanding of the longest-­term
results with collagen crosslinking (CXL)?
Dr. Reidy: The Siena Study has reported results of
44  eyes with a minimum of 4  years of follow-up. The
mean K value was reduced by a mean of 2 diopters, and
UCVA improved by 2.7 Snellen lines. The Dresden group
has reported on 241 eyes with 6 to 60 months of follow-
­up. The mean K value decreased 2.68 D in the first year
(142 eyes), 2.21 D in the second year (66 eyes), and 4.84 D
in the third year (33 eyes). The BCVA improved by greater
than or equal to 1 line in approximately 55% of patients
over 3 years. They reported on 23 eyes with follow-­up of
between 4 to 6 years, during which time the cornea f lat-
tening remained stable at approximately 2.5 D.
Dr. Schanzlin: Crosslinking of the cornea has been per-
formed in Europe for more than 10 years, and reports
of long-term follow-up of keratoconus patients treated
with this new technique are increasing. These reports
show significant topographic f lattening, often accompa-
nied by improvement in best-­spectacle corrected visual
acuity as well as contact lens corrected visual acuity. Per-
haps what is most heartening is that stabilization of the
attack process seems to be achieved in most cases, and
this effect seems to last over the reported follow-­up peri-
ods of 4 or more years. Although a few patients have
needed re-­treatment, this does not seem to add a signifi-
cant risk given the potential benefit of stabilization of
the disease.
5. What complications should clinicians watch for in
CXL?
Dr. Reidy: Clinicians who perform CXL need to be vigi-
lant for the occurrence of sterile infiltrates occurring in
the first several days after treatment. These respond to
Focal Points : ModulE 2, 2012 13
1/25/12 4:22 PM
 Clinicians’Corner
topical steroid treatment and usually result in a nebular
stromal scar. Some patients will progress despite treat-
ment. Not all patients will respond to treatment. The
Dresden Group reported on complication and failure
rates seen in 117 eyes of 99 patients that were followed
for 1  year. They concluded that if treatment was con-
fined to patients 35 years of age or younger, who had
BCVA less than or equal to 20/25, and maximal K read-
ings of 58 diopters or less, complication and failure rates
could be significantly reduced.
Dr. Schanzlin: Corneal crosslinking is not without com-
plications, although the incidence of these appears to
be small. In the first several days after the procedure,
ophthalmologists should watch for slow epithelial heal-
ing, bacterial infection, and iritis. Additionally there
have been reports of herpes simplex keratitis and Acan-
thamoeba keratitis following the crosslinking procedure.
Late onset of stromal haze may rarely limit visual acu-
ity. Additionally, there have been case reports of diffuse
lamellar keratitis following crosslinking of post-­L ASIK
ectasia cases.
6. What are the main advantages and disadvantages
of deep anterior lamellar keratoplasty (DALK) vs
penetrating keratoplasty (PKP)?
Dr. Reidy: The main advantage of DALK vs PKP is reten-
tion of the patient’s own endothelium, and therefore
the patient cannot experience endothelial rejection. The
long-term rate of endothelial loss after DALK may be less
than PKP. In addition, the structural integrity of an eye
that has undergone DALK is greater than an eye that has
undergone PKP. The main disadvantages of DALK are an
increased level of technical difficulty and, for most sur-
geons, longer surgical times.
Dr. Schanzlin: The advantages of the procedure include
the following: immune rejection of the corneal endothe-
lium does not occur; the procedure is extraocular; long-
term use of topical corticosteroids is obviated; sutures
may be removed earlier; and the eye is more resistant to
traumatic rupture. The disadvantages of DALK include
the following: the surgery is difficult to perform and
the learning curve is prolonged; if stromal tissue is
left behind, BCVA may be limited due to stromal haze;
and posterior corneal ectasia may result in loss of best
14 Focal Points : Module 2, 2012
FPv30n02_0312.indd 14
corrected visual acuity. Other complications seen with
DALK include ruptures of Descemet’s membrane, dou-
ble anterior chamber, endothelial cell loss secondary to
the air injection, interface debris, interface hemorrhage,
interface vascularization, interface infection, interface
epithelial ingrowth, folds in Descemet’s membrane,
sequestered viscoelastic in the interface, and occasional
corneal epithelial resurfacing problems.
7. Which keratoplasty procedure do you perform (or
favor) for keratoconus? Is that likely to change in
the future?
Dr. Reidy: Until recently, the majority of my surgeries for
keratoconus have been PKP, however I have been transi-
tioning to DALK over the past year. In the future, I believe
DALK could overtake PKP, not only for keratoconus, but
for corneal scars and stromal dystrophies as well.
Dr. Schanzlin: I find that I am doing fewer keratoplasty
procedures for keratoconus now that intracorneal rings
are available. When keratoplasty is necessary, however, I
still find the visual results with penetrating keratoplasty
gratifying. With PKP for keratoconus, I perform an 8‑mm
host trephination and I use an 8.25‑mm donor button.
In most cases I use a double-­running suture technique.
Since most patients with keratoconus are familiar with
rigid gas-­permeable contact lens wear, I usually fit the
patient with this type of lens at 4 weeks after surgery.
Patients tolerate the contact lens fitting very well after
the surgery, and they achieve excellent visual acuity
quickly with this approach.
8. Once intracorneal ring segments, CXL, and DALK
are fully FDA-­approved and available, what do you
foresee as the surgical management of keratoco-
nus in the future?
Dr. Reidy: In the future, early detection of keratoconus
combined with CXL has the potential for eliminating
most invasive procedures (lamellar and penetrating ker-
atoplasty) for keratoconus. CXL alone, or in combination
with either ICRS or PRK, may be able to return these
patients to emmetropia.
Dr. Schanzlin: Of course, intracorneal ring segments
are approved for use for the treatment of the myopia
1/25/12 4:22 PM
 and astigmatism associated with keratoconus under
a Humanitarian Device Exemption for cases that are
proven contact lens failures and where the only remain-
ing option is keratoplasty. So the real question here is
what will our approach be once CXL is approved. In my
opinion, this is going to drastically alter our approach to
keratoconus. I believe that in the future, patients who
show the earliest signs of progression of keratoconus
will undergo the CXL procedure. For many patients, this
means that they may receive a crosslinking treatment
in their early 20s. For cases with more advanced disease,
I believe our first line of treatment will be CXL alone or
combined with intracorneal ring segments. The desire
of this approach will be to halt the progression of the
FPv30n02_0312.indd 15
disease early so as to eliminate or drastically reduce the
number of patients who ultimately will need corneal
transplantation.
James J. Reidy, MD, FACS, is an Associate Professor of
Ophthalmology and the Director of the Cornea Service
at the State University of New York, School of Medicine
& Biomedical Science, Buffalo, New York.
David J. Schanzlin, MD, is a Professor of Ophthalmol-
ogy, University of California, San Diego and Director,
Cornea & Refractive Surgery, Shiley Eye Center, San
Diego, California.
Focal Points : ModulE 2, 2012 15
1/25/12 4:22 PM
 Suggested Reading
Agrawal VB. Corneal collagen crosslinking with ribof lavin
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Related Academy Materials
Gorovoy MS, Rosenwasser GOD. Advances in Lamellar Corneal
Surgery. Focal Points: Clinical Modules for Ophthalmologists.
Module 4, 2008.
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