Lecture: Keratoconus Worldwide: Understanding the Diagnostic & Therapeutics Alternatives

Keratoconus is a corneal collagen disease characterized by progressive corneal ectasia. Over the years, the diagnosis and treatment of this condition have advanced significantly. Join this webinar and gain a comprehensive understanding of keratoconus, its diagnostic methods, and various treatment alternatives. We will discuss topics such as intracorneal rings (PMMA/CAIRS), corneal cross-linking, and corneal grafts. After this webinar, attendees will understand the concept of “personalized treatment of keratoconus” where each patient can be evaluated and treated according to their specific stage of the disease. (Level: All)

Lecturer: Dr. Carlos Gordillo, Ophthalmologist, Zaldivar, Argentina


>> Hello everyone. Welcome. I’m Dr. Carlos Gordillo from Argentina. It’s great to be here today. Thank you very much to Cybersight for the opportunity to share with you this presentation. I’ll start with the presentation now. The title says keratoconus worldwide. The idea of this presentation is to share with your my experience and be able to understand some concepts that I think is really important for every doctor to be aware regarding keratoconus. So I have all these slides here for you today. I will try to get to the beginning. Well, I see there are so many people from worldwide connected. Welcome to everyone. As I was told before, the webinar is to share the concepts about keratoconus and understand the diagnostic alternatives and therapeutics that we have. I’m from Argentina. I was born in the north. And now I have my practice in Argentina. It’s a huge country and we are able to see a lot of people from around the country and different countries near from Argentina. I was able to learn a lot about this disease in the last 12 years. And I’ve seen how it’s changing continuously. The main objectives of this presentation is to define and understand the keratoconus. The definition, the prevalence and the demographics. Also to identify the etiology and the risk factors. Also be talking about genetics and environmental influence. To learn about the diagnostic techniques because many of us, we can assess topography and tomography but we will be able to see what we do if we don’t have this technology. Also to know about the recent advances and to explore all the different alternatives we have. So regarding this presentation, my first slide is this one. It’s the definition of keratoconus. The definition comes from the Greek kera is cornea and Conus is the shape. It’s characterized by bilateral asymmetric, it’s one eye more than the other. It’s progressive and irregular. It leads to poor vision because of high astigmatism. That’s the main thing when the keratoconus already developed in the patient. So we have a lot of history regarding keratoconus because we have been like seeing the first description of the disease in many years back. As you can see in this slide, we have the first description in 1748 and through the years we had a lot of new information and when the new information comes, new technologies and new alternatives for the patients. Before we used to see the patients when they arrived to the consultation with a really high astigmatism and big keratoconus. Nowadays the history is different. So remember this at the very beginning, bilateral, asymmetrical and progressive. It’s not always like that. The keratoconus is always about taking care of each case. But if you see one patient with signs of keratoconus in the first eye, you need to look the other one. So what about the epidemiology. We used to see different numbers throughout the years. Nowadays we can talk about the prevalence of 1 in almost 400 patients, 375. That’s lot. 1 to every 2,000. It’s really big the difference. And it’s going to be changing depending on the place where the patient lives. We see the different papers that we have already. We can see there are some patients with a really low rate of keratoconus and others with a huge amount of people and population with the keratoconus. So it’s very important to be aware of this because in some countries, we almost don’t see the diagnosis. And others we have a huge amount of patients. So far we have been able to see these different papers with different information about the different doctors from around the world that came together and did this statistics. The last global consensus on keratoconus and ectatic diseases is telling us there are a lot of reasons or risk factors for developing keratoconus as down syndrome, relatives of patients like father, sister, mother with keratoconus already. Electrolytes ocular allergies, ethnic factors. We have seen Asian and Arabian people have much more keratoconus development. And also the eye rubbing and floppy eyelid and atopy and different syndromes with connective tissue disorders. If you have a patient with some of these disorders, you need to be aware and also if you have a population that is under, like, tropical environment and under, like, risk factors that I have told you before, you need to be aware of that. So in this slide we’re going to be able to see the population in this paper. You can see that a lot of Asian population has a huge amount in this sample of patients, yes. Because here for this paper, we don’t see much of Latin American population. I can tell you I live here, we have a huge amount of patients with keratoconus. But, well, anyway, you are going to be able to see here the relation between the different disease and the development of keratoconus and the most huge relationship is between allergy, eye disease, and the amount of patients that develop the keratoconus. And then also, some patients with atopic disease in the skin may have a huge relationship with the keratoconus. What about genetics? This has been studied for many years right now and there are some updates that we have an association between the genes that have been identified for several genetic — associated with keratoconus. Nowadays we need a bigger sample. But so far we have identified these seven loci that confirm the association with keratoconus. So it’s really a specific, we know there has been a lot of studies in different countries. But we need a bigger sample to understand which of them are really associated with keratoconus. We will have to wait for more time for this information. Anatomy. We know the cornea is like, the collagen in the cornea and the anterior stroma is 3, 5, and 6. And we have 1, 5, and 6. In the posterior stroma, we have 1 and 6. The first part, and 3, 5, 8, 9, and 12 in the last part. The posterior stroma. Here you see the different sizes of different slice of the cornea. The keratoconus is mostly in the anterior stroma. What do we see in the anatomy? We can see in the histopathology, there is an epithelial thinning. There is a degeneration and/or rupture in the Bowman’s layer and stromal thinning. This is only for you to understand what’s happening. You can see here in the picture that Bowman’s layer ruptures. This happens when we have a really high keratoconus. What about confocal microscopy. This is like invivo. So we can see a patient with keratoconus without taking out the cornea, of course. With this nerves reduction and increase in the reflectivity of the keratocytes. A reduction in the numbers of keratocytes and of course stromal loss. If you see a patient using the confocal microscopy, you’re going to be able to see the nerves that look bigger but a reduction in the number, in the final number of the nerves will be [inaudible] What about the physio pathology? We have this inhibitors, proteas inhibitors that can increase or reduce. When they reduce, there’s an apoptosis of the keratocytes as I was telling you before and that will develop a thinning on the stroma. With the thinning of the stroma, the cornea is going to begin to move and to change the shape. So this is a normal cornea. And this is a keratoconus. You see the bridge between the different collagen sizes are affected. What will be the patient’s symptoms? Most of them at the beginning are asymptomatic. But some of them will have blurred vision that does not improve with correction. Frequent changes of glasses. Maybe photophobia for some of them. And halos. Most of them have these night halos. At least in one of the eyes. And they have an irritant so they’re chronic eye rubbers. This is important for you to know. This is how they see. The patient with keratoconus, they are able to tell you the — region is not good. But in the afternoon when they have progressive keratoconus, they’re going to lose all the shapes and start seeing the light with these difficulties. Depending on the grade of keratoconus, you need to know — the patient. What about the bio microscopy? We have corneal thinning. It could be central or peripheral. Usually it’s peripheral in the inferior and temporal quadrant of the cornea. We’re going to see thickened nerves. Vogt lines or stria because of the collagen moving. Incomplete or complete ferrous ring and Fleischer sign. Here you see a patient with a really increase of the nerve size. You can see this orange shape in the screen. All of them are the nerves in a young keratoconus patient. Here you can see the Vogt Striae. They are vertical and in the middle of the cornea. This is kind of difficult to make a video of patient properly because we have so different focus points that you’re going to be able here to see the lines. If you see the video, I’ll make it a really soft compression in the inferior part of the cornea and the lines on the posterior are going to disappear. This is really important for us to see because it’s going to help us to understand that the — is coming. If you make a little depression on the low part, the lines are going to disappear. That means that some tissue is missing in the down part. There you can see. This is really nice to see. You don’t need any technology. Here is Munsen sign. It’s a really high keratoconus in a patient with a previous graft that underwent a new keratoconus in the peripheral area. This was because the grafts in the past were really small. Here you can see the shape of the cornea. When the patient moves, you’ll see the cornea attach in the periphery very clearly. You can see there it’s between the donor and the receptor. This is called, like, donor graft ataxia. What about semiology. You can see a scissor reflex or the sign of Charleux. What if you don’t have a retina scope or don’t see the sign. You will see a patient with CDVA that does not reach 20/20. It has a normal — hole. The patients can’t get the visual acuity. So the KMAX increase, usually this was the first things to understand or think about keratoconus. If you have a patient with more than 47 diopters, you think this is keratoconus. But so far we’re able to see patients with, that they don’t have that much increase in — but they have keratoconus. Be aware of that. It’s important but it’s not everything. And also we have a major astigmatism, more than one between one and the other one. And maybe a reduction of the tachymetry that you see in the studies or even in the microscopy. We have a poll question for you. So far I only did a few just for you to understand. Which of the following options is correct regarding the patho anatomy of the cornea. We have 30 seconds to give this answer. The epithelial thinning, degeneration or rupture of the Bowman’s layer or stromal thinning is option A. And then endothelial cell loss and stromal thinning. And C, epithelial thinning and activation of keratocytes. Which one do you choose. This is something that we don’t listen that much but the anatomy is really important. Most of you chose the correct one, 85 percent. That is really interesting. Because we have the epithelial thinning and rupture and degeneration of the Bowman’s layer and stromal thinning. Very good. Let’s move on. So the diagnostics. This is really important also. The diagnostics is based on the detection of the alteration of the morphology of the cornea and the functional effects this is producing in the cornea. But I really like to give you this advise, take care of each patient as a different one. We have a lot of information but patients need to be cared for individually. For the diagnosis, nowadays, like in young people, we don’t wait for the keratoconus to go further. We nowadays have a lot of technology to help us to identify the diagnostics in the very early stages. That means that we shouldn’t have patients so far developing the keratoconus if we have the opportunity to prevent the damage and the progression. So nowadays, something important to know is that there shouldn’t be much more keratoconus if we’re aware of the diagnosis. So think of bilateral, progressive and asymmetrical. Listen to the family history, the age of the patients, and also the evidence of progression and corneal thinning. What about topography. This is a map of the world where you can see the highest mountains worldwide. I live here where Aconcagua is. I really like to show this to the patient. Where do you live. Which one is the highest mountain in your region. That’s the cone of the area where you live. To go further with the treatment and to understand that during the years we have all of these classifications trying to understand how to describe the keratoconus. First one, we have Amsler with different stages. Then we have the morphologic classification with the phenotypes for me which is most important. The ABCD grading and the — classification. A few words for each of them. We have Rabinowitz classifying the KC based on the cone morphology. And Amsler describing the classification of the different stages of keratoconus using the placid disc. And we use bio microscope findings to generate a classification. We have five stages on the posterior and anterior curvature. And then we have the Vega classification using the distance between the center of the pupil and the corneal ectasia. So the topography is really important to understand. I will show you here what to know about the ABCD grading system that defines the keratoconus according to these parameters. So if we have a really early stage, we only have an increase in the posterior phase and maybe a bit of thinning. If we have a stage 1, we are going to be able to see an anterior curvature increasing, a posterior curvature increasing in the number. And then the thinnest point going thinnest. So this is a really nice classification to be able to deal with the cases and to identify if we have a patient that needs surgical treatment or not. So this is the picture I was telling you before I like to show my patients. But here next to the Andes, this is the highest part of the Andes in this area. It’s called the Aconcagua. If I see a topography map, I show them this. The keratoconus is the highest part of the cornea and this is the part that we need to correct. So what about the phenotypes? This is the classification with the morphology. For me it’s really important for you to understand this is not the same in a patient with asymmetric keratoconus with symmetric ectasia. From the patterns we see here, the asymmetric or para central, we have the snow man, the pato, the croissant, and the imaginary degeneration. And then the central is the bow tie or the nipple shape. Understanding these concepts is really easy to make a surgical planning for later. Just a few pictures of the different ones. Croissant, duck, snow man, nipple, and bow tie. I’m going to show you some cases with these patterns. A few years ago in 2017, we were able to publish this review regarding the refractive corrections for keratoconus patients. If you have stable keratoconus Y you will be able to correct the visual acuity depending on the stage. But we’ll be able to understand this slide in some cases. So if we have a patient in the first stages, we will only use cross linking. If we have a patient with irregularity in the cornea, maybe we need to use an inter-corneal ring. We can also use a graft. After the graft we’re going to be able to understand if the patient keeps on having the progression, maybe we need a — in the peripheral area. And by the end correcting the visual acuity. This is important for you to understand that treatment is personalized. Really important to treat each patient individually. Signs of progression. This has been really important through the last years. Steepening of the anterior corneal surface. Steepening on the posterior corneal surface. And thinning and/or increase in the rate of corneal thickness, changing from the periphery up to the thinnest point. These are the three most important concepts that the consensus trial, like, recommends. But also I will ask you to tell and ask your patient, how do you feel? Do you think your visual acuity is changing. So subjective information from the patient should be also added here in my opinion. So now we have these grades displayed that can show us how near from the flags of keratoconus is our patient. So you have the anterior phase here in this state. The anterior phase here. The posterior one and the pachymetry. You can see the change here and after surgery how it gets better. This is really nice if you have an opportunity to make a followup with the patient to check the numbers and see the different behavior of the cornea. Also from another paper, we have this important information. The first thing we need to do with the patient is to advise, to avoid eye rubbing. Reduce the allergies. If you have progression, you need to consider cross linking. In the child, we don’t wait because the keratoconus in young patients are really aggressive. The youngest patient I have with cross linking is a nine year-old. Everything was perfect and nowadays she has stable refraction. So we are happy that we did the treatment on time. If the patient has not a good correction visual acuity, we have to do something for him or her. If the patient doesn’t have the opportunity to use scleral lens, we have to consider intra-corneal rings. I don’t use PRK, I prefer to use cross linking to avoid progression and intra-corneal rings to increase the visual acuity. So if we have like a stage four, we will go for DALK or PK depending on the patient. The DALK is the best option in terms of graft. The first thing to do in early stages if we’re suspicious, treat the corneal surface. Stop the rubbing and treat the corneal surface with drops. You ask the patient do they eye rub and they say, no, I don’t. And you see the patient inside the consultation doing this or this. It’s really important for you to have the different ways of eye rubbing that the patient has and to understand if they keep on doing this, they will start all the inflammatory process and the keratoconus might continue. What to do? The first thing to do is treatment of the corneal surface and then the cross linking. So Theo Seiler described the first cross linking in 1987. He described the induced cross linking using riboflavin, vitamin B with Dextran. After photo activation and radiation, we have a reaction with the collagen reticulation that is produced under free oxygen radicals. That’s going to make an implement of the intercellular links and form a stable cornea. So we have different power radiation rates. The traditional was 30 minutes radiation. And nowadays we have fast cross linking with 9 milli volts and 10 minutes. It’s the ideal one, the accelerated one because we have the oxygen in the treatment. These are different kinds of cross linking indications like keratoconus, pellucid marginal degeneration. Post ectasia like LASIK and PRK. After infection we have seen cross linking used with or without inter-corneal ring. And also after PK and we have some different techniques of cross linking. So far cross linking. What about the complications. There is a high level of security. You need to do this practice in the surgery room. You need to be very aware of the treatment in the postop evaluation. Contraindications, pachymetry is the traditional one. Nowadays we have seen some exceptions. So another poll question. All of the following are asymmetric or para central patterns of keratoconus except one. Let’s see if you remember. So the duck, usually it’s in the inferior temporal quadrant. Also is the croissant. Also is the margin pellucid degeneration. Or the bow tie. If you remember the graphic, usually it’s in two quadrants, superior and inferior. Let’s see the votes. Very good. 54 percent of you chose the correct option. So this is difficult. But you’re going to be able to check my conference, it’s going to be online. And remember the classification. If you understand which one of them is the keratoconus you have is going to be so easy for you to correct if you use the refraction during the consultation and then to do that perfect surgery for them. So let’s go with the intra-corneal rings. These were from 1949 with Barrquer describing the thickness law. You will have stiffening of the center. So this is the history, the timeline of intra-corneal rings. There are many colleagues doing different innovations through the years and so far in the last ten years we had a lot of changes in the treatment of keratoconus. But always with this concept. Customized treatment. So think about that. What do I think we need to know to make a proper intra-corneal ring implantation? We need to know how to select the patient. What parameters to consider before the surgery. The expectation for the patient and also for the surgeon. What to expect about the intra-corneal ring. Then we need to understand the different types of intra-corneal rings that we have and also the different varieties of measurements. So after all of them, we published many years back the combined intra-corneal ring. But now the most important thing to know is depending where you are, you have different opportunities. This are some countries where the PMMA are not allowed yet. There are some countries where the CAIRS, the stromal intra-corneal rings are not used. I have had the opportunity to use both. Many years using the PMMA and I really like it. I’ve seen many changes in my patients and the opportunity now to use the CAIRS, it’s also a new technology. So we started talking with Susan Jacob about the classification of ICRs during the pandemic. It was during a webinar that we were able to talk. I’m always grateful for her sharing her experience. She taught me a lot about CAIRS and how to think about the keratoconus. And also my pal that developed this intra-corneal ring and for me it’s one of my favorites since it corrects a lot of the — of the patient. This is the classification, CAIRS, and PMMA. The classification, this was the bow tie. It’s not para central or symmetric as you can see. If you ask me, for each patient, I take a look at the refraction and the different angles of the axes and the refraction. If I have to choose, I will choose this kind of regular rings for croissant and degeneration marginal pellucida. And maybe for bow tie. And for that I will use mostly the progressive. But in these two cases, it’s very difficult for me to say, Susan likes to use the CAIRS for those cases. And then we have this snow man. Really difficult to treat. These patients have a huge keratoconus. They will use two asymmetricals or maybe two asymmetricals and one ring. How to choose the patient, the parameters, the type of ring, the surgery type. Let’s check on this with a case. As I was telling you before, I will use the refraction. The topography axis first and then the — axis and then the refractive. How much the patients see in which axis. I decided to make a balance when you have more than 30 degrees between one of these axis, you will choose this progressive asymmetric ring. Now you can see where I put this ring using the axis as the main one. So usually you have this platforms to perform the tunnel. These are femtosecond laser platforms from the different part of the industry. All of them are amazing and very safe and let us perform the tunnels really fast, in 30 seconds you have everything done. But you can perform the surgeries manually, really having a lot of safety and the results are also good. But of course it’s not easy. So here you can see the different platforms. The first one I used half a tunnel. In the second one it’s very safe because it gives the patient like very quiet. This one has a bigger cone and then the other platform this is more — you can see how the tunnel creation is performed. Because of time, I will move on. Here you can see I’m scratching the cornea to perform the corneal cross linking and I can have the ability to see how big is the ring. Usually I go 80 percent of thickness in these patients. I’m performing the cross linking also in the video on your right. Let’s see another patient. We have a high astigmatism in both eyes. We have a progression in the anterior space and all this information is already in the — here you can see the three axes. I’m creating a tunnel. Also using irregular intra-corneal ring to perform the surgery and to make the implantation in the correct area. So after the ring is already implanted, I’ll be able to increase the amount of tissue, in this case I’m using PMMA. In this area. If it’s a progressive cone, I will use the cross linking as our gold standard technique. I’m scratching the tissue using the — light. After the surgery I usually use a contact lens. As you can see here the immediate postop evaluation. You can see the pupil because I use drops to dilate the pupil so the patient has not that much pain. I put a — in the contact lens and it looks really nice. After one month, I did bilateral in this case. You can see the increase in the visual acuity and also the increase in the astigmatism and the corneal shape. After one year with this refraction, the patient wants more. She tolerates contact lens so it’s okay, good enough. But if you need to choose some other option, you’re going to be able to correct the — with an ICL. This is Dr. Zaldivar. As you know we have a huge amount of patients with ICL implantation in our clinic. The first time we planted this lens was Dr. Zaldivar. And we used to do this surgery to correct all the — after the surgery. It’s really sad because you preserve all of the structures. You only add the ICL and the correction is great for the patient. As you can see there, after the implantation, you’re going to be able to center the lens and the surgery is over. The sad thing of this kind of lenses is really important, that is why we use ICL glue to make all of the calculations in the surgery department. Here is the close up. That’s the ring. And then you have here the ICL with the center hole. So let’s move on with the CAIRS, just a few minutes more of this conference. This is a new concept that came or arrived to our lives in the last 4 years. And we already don’t know which one is the definitely inclusion criteria. At the beginning was only for patients with huge keratoconus that you want to avoid the graft. But you want to keep the patient with a better visual acuity. So it’s this kind of patient that you are not able to implant a traditional PMMA — (speaker froze)? >> I’m sorry. I’m back. I had some — I don’t know. Technical problems. I was showing you some — everything is okay Andy? >> Yes. Everything looks great. Thank you. >> Sorry about the problem, I don’t know what happened with the electricity or connection or something. I’m back to this presentation. As I was telling you before. Here I’m going to show you the different cases. Case A and case B. They’re really similar regarding the morphology of the cornea and high astigmatism and high myopia in both. Case one has a really big pachymetry and case B doesn’t. I decided to use case A for P MMA. You have the graphic of the correction. And on the left eye you can see the correction and the different axis. This is a surgery for the intra-corneal ring in the first case. I did a — using the femme toe laser platform. I did a centration of the cornea and after that the implantation of the — space and progressive intra-corneal ring. You can see there the tunnel creation is only 30 seconds using this platform. The most important thing there is to choose the best incision place. Once you have the incision, you can insert the ring through the tunnel. If you see there the size of the tunnel is not that big. It’s a small tunnel. You need to move the ring until you have the perfect position. You can see there in the center, the center between the intra-corneal ring and the center of the cornea. Now, after that, we’re able to see the CAIRS. I did a preparation manually for the first one. You use a donor tissue. You will mark the cornea and use 3 fines to prepare the CAIRS. The 3 fine are already available. You have 6 and 8 and different sizes. If you want it bigger or smaller. Once you have the ring, you’ll be able to see there the slide of stromal cornea. You will have to dry the tissue for — sorry — dry the tissue for 30, 60 minutes. And then you’ll have to do the tunnel radiation. After you perform the tunnel creation, you will be able to introduce that segment in the tunnel. So the difference between one surgical technique and the other one has to do a lot with the kind of material. So the CAIRS are really soft material. So it’s really easy to introduce the segment if it’s dry. If it’s not dry, it’s not possible, it’s really difficult. I’m afraid to move out of this. I will stop share and do it again. There’s some issues with the connection I think. I’ll try to solve it as fast as possible. I have some questions here. I will try to — yes. Everything is all right Andy? Because I had some? >> Yes. We’re happy — >> Okay. Some people from the community were trying to tell me that we’re not listening properly. That’s why I was trying to ask. So I’m trying to be on time with the presentation. So at the end of this, I will try to give you a final message and basically it’s going to be that the CAIRS and also the PMMA intra-corneal links are really good opportunities for us but also we need to know that this special technique is not for everyone. And we need to be very aware of how to choose the patient because this is not for all. What does that mean. You can see here a patient with intra-corneal rings and it’s not proper to put the intra-corneal rings in every patient. If you have a really high progressive keratoconus, you have to use a DALK. The final slide for you is this one. If you have a progressive keratoconus, you have to treat it. If you have more than 400-micron, you can use contact lens, you can use cross linking. If you have less than 400, maybe you will have to choose between CAIRS or DALK. And if you have a non-progressive keratoconus, you have to be aware and follow up with the patient. In the last stages you have to do the DALK, the corneal graft. The conclusion is early diagnosis and treatment of the keratoconus allow us to halt the progression and achieve the prompt visual rehabilitation. This is really important in young people. Promotion and prevention are fundamental. And to emphasize the importance of early detection and proper treatment is also how to deal with the keratoconus. So right now we need to be very aware of that. This is my contact. You can write me, whatever you need, any cases you need the talk about or even the calculations or even if you need advice of how to do the calculations for the cross linking or for the implantation of the ring. Feel free to contact me. So I will stop sharing now and I will start with all the questions and answers. The first question I’m seeing, since which age are you able to perform the cross linking in kids? My youngest patient is 9 years old. I was able do the surgery without problems at all. And it’s perfect. Of course, I did general anesthesia. When we suggested cross linking in the first visit — well, in really young patients, you don’t need to wait. If you see it has a keratoconus in a young patient, we don’t wait time. We don’t tell the patient come back in one year. Because we know this can be really aggressive. And then also, I do that when the patient comes to my consultation with a lot of studies from other years and they tell you I’ve been changing my glasses every 3 months. You can see that there is — Can we control the progression of keratoconus without cross linking? That is the nonsurgical treatment. You need to tell the patient to avoid eye rubbing and use eye drops and also to treat the allergies. I have keratoconus with considerable vision problem from far. How can I correct to get more performance and get a license to conduct? That’s a really traditional question. For this kind of problems with far visual acuity defect, you’ll have to perform the cross linking if you have a progressive cone and intra-corneal ring plantation. After that you can use contact lens or glasses. If you don’t want to use that, you can use the ICL implantation. Is toric soft contact lens have a role in management of irregular astigmatism? Of course. If you have only a few small grade of astigmatism and your keratoconus is not that big, you can use cross linking to avoid the progression and correct the patient with soft contact lens. You don’t need to use a special — to all of them. Usually after a cross linking in children, how many days it takes to recover? It’s painful. It was really painful. Right now we have a lot of techniques to avoid the pain. But it’s, you will have a patient with some issues like, it’s going to be able to tolerate the light. It’s going to be feeling uncomfortable. But it’s only three days or four. I also use topical drops of insulin in kids to reduce pain and increase corneal healing. To go to school after five or seven days. What do you think about cross linking and PDK in session. I don’t have experience. We have a really huge amount of patients with — in Latin America. So I don’t use that. Do you prefer traditional cross linking or intra-phoresis. I use both. In my experience I feel safer using traditional. Ten minutes, fast cross linking. Which one do you prefer, intra-corneal rink or phaco. If you perform a — in patient with high keratoconus without a regular cornea, you will have a patient with no rate of astigmatism or myopia but really bad quality of vision. Be careful of that. Before doing the toric ICO you need to give the patient a visual acuity and quality using the intra-corneal rings. How frequently will you review a patient if you suspect a subclinical keratoconus? Depending on the age. Between 9 and 16, I’ll tell the patients I need to see the patient every 3 months. If it’s between 16 and 20, 22, maybe I will give 6 months. In older person, I will try 6 or 12 months. Visual acuity is stable after the intra-corneal ring. I say patient to come one month, six months and 12 months. The final refraction is after 3 months. Where can I get it in Europe? Send me an email and I will send you all the information regarding the three — so you can have it and they’re very kind. Is there any age limit to consider cross linking? My youngest patient is nine years old. And I haven’t seen younger than that. Do you have some tests, my patient is a pre-keratoconus state or have a tendency to have it in the future. To avoid it? Well. We don’t use the genetic tests. We use only the posterior phase to see if there is a possibility of development. Usually if you have a patient with a family of keratoconus, just try to avoid the eye rubbing and control it every six months. What is your frank opinion of the no rub hypothesis. I agree. We already saw a lot of young patients that had subclinical keratoconus without the eye rubbing and the proper corneal surface treatment, you avoid progression. What to do when the keratoconus progresses after cross linking? I have no experience, oh, one case, because if you have a patient with cross linking that keeps on doing the eye rubbing, for you you need to repeat it. What to do when keratoconus progresses after cross linking? I told you that. What do you do despite surgical intervention if you have a progression? If you have progression, you need do the cross linking. Have you any experience with cross linking [inaudible]. Yes, I did it in young patients. Actually, this week, I perform a CAIRS in a patient that I did this surgery, sub 400 cross linking when he was 10 years old. Now he is 15. He needs a corneal graft because he has a really thin cornea and I did CAIRS implantation in one of the eyes. It’s really good and we need to do it in patients, especially if you have young patients. Is keratoconus progressive after 40 years of age. Yes but not as much as in younger patients. In those patients more than 40 years old, you need to be aware of some other disease like collagen degeneration and other disease. Also, be aware of marginal degeneration. Because usually it begins after 30. In early keratoconus manifestation, which might occur first, posterior or anterior curvature changes? Usually it’s the posterior. If you have a patient with a regular normal — you can have the posterior changes first. Can you do cross linking twice? Yes. I haven’t but yes there is a lot of literature regarding that. How long does the DALK typically last? Well, usually if you perform a DALK, you preserve the endothelium. You have like the most important part of the cornea in this case to avoid rejection is the epithelium. If the DALK is properly performed, it can last forever. You only need to be aware of the peripheral area. If you see that there is a thinning, maybe you need to perform the periphery of cross linking to keep it safe for many years. I think we are done with the questions.

Last Updated: June 6, 2024

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