Curso de Atualização em Implante de Anel de Ferrara

Curso de Implante de

Anel de Ferrara

Curso de Implante de

Anel de Ferrara

1950 1950 -- Barraquer, J., Intracorneal implantsBarraquer, J., Intracorneal implants

1966 1966 -- Blavatskaya Blavatskaya -- Corneal rings from corneal tissueCorneal rings from corneal tissue

1986 1986 -- Simon, G. Simon, G. -- Silicon RingsSilicon Rings

1987 1987 -- Fleming Fleming -- Adjustable ringsAdjustable rings

1991 1991 -- NosNoséé, W , W -- Single piece rings for low myopiaSingle piece rings for low myopia

19911991-- Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia19911991-- Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia

1996 1996 -- Ferrara, P. Ferrara, P. -- Ring segments for KeratoconusRing segments for Keratoconus

1997 1997 -- Colin, J.Colin, J.-- Ring segments for KeratoconusRing segments for Keratoconus

Barraquer, J., Intracorneal implantsBarraquer, J., Intracorneal implants

Corneal rings from corneal tissueCorneal rings from corneal tissue

Silicon RingsSilicon Rings

Adjustable ringsAdjustable rings

Single piece rings for low myopiaSingle piece rings for low myopia

Ferrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopiaFerrara, P., Single piece rings for high myopia

Ring segments for KeratoconusRing segments for Keratoconus

Ring segments for KeratoconusRing segments for Keratoconus

BARRAQUERBARRAQUER’’ ss

MYOPIA CORRECTION MYOPIA CORRECTION

Remove tissue of the center of the cornea;Remove tissue of the center of the cornea;

Add tissue to the periphery of the cornea.Add tissue to the periphery of the cornea.

HYPEROPIA CORRECTIONHYPEROPIA CORRECTION

Add tissue to the center of the corneaAdd tissue to the center of the cornea

Remove tissue from the periphery of the corneaRemove tissue from the periphery of the cornea

THICKNESS LAWTHICKNESS LAW

MYOPIA CORRECTION MYOPIA CORRECTION

Remove tissue of the center of the cornea;Remove tissue of the center of the cornea;

Add tissue to the periphery of the cornea.Add tissue to the periphery of the cornea.

HYPEROPIA CORRECTIONHYPEROPIA CORRECTION

Add tissue to the center of the corneaAdd tissue to the center of the cornea

Remove tissue from the periphery of the corneaRemove tissue from the periphery of the cornea

BLAVATSKAYABLAVATSKAYA

The larger (diameter) the ring the lesser the The larger (diameter) the ring the lesser the

correctioncorrection

The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction

BLAVATSKAYABLAVATSKAYA’’ S LAWS LAW

The larger (diameter) the ring the lesser the The larger (diameter) the ring the lesser the

correctioncorrection

The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction The thicker the ring the greater the correction

Material PMMAMaterial PMMA

YELLOW FILTERYELLOW FILTER

Apical Diameter 5mmApical Diameter 5mm

Triangular cross section= prismatic Triangular cross section= prismatic

effecteffect

Flat Basis width 0,6 mmFlat Basis width 0,6 mm

Variable arch lengh and thicknessVariable arch lengh and thickness

Triangular cross section= prismatic Triangular cross section= prismatic

Variable thicknessesVariable thicknessesVariable thicknessesVariable thicknesses

Asphericity (Q)Asphericity (Q)Asphericity (Q)Asphericity (Q)

CORNEAL ASPHERICITYCORNEAL ASPHERICITY

OblateOblate

0,50,5

CORNEAL ASPHERICITYCORNEAL ASPHERICITY

HyperprolateHyperprolateProlateProlate

00 --11 --22--0,230,23

INDICATIONSINDICATIONS

�� CORNEAL IRREGULARITIESCORNEAL IRREGULARITIES

�� PRIMARYPRIMARY

��KERATOCONUSKERATOCONUS

PELUCID MARGINAL DEGENERATIONPELUCID MARGINAL DEGENERATION

�� IATROGENYIATROGENY

��PKPPKP��PKPPKP

PRK; LASIK; RKPRK; LASIK; RK

TRAUMATRAUMA

�� REFRACTIVEREFRACTIVE

INDICATIONSINDICATIONS

CORNEAL IRREGULARITIESCORNEAL IRREGULARITIES

PELUCID MARGINAL DEGENERATIONPELUCID MARGINAL DEGENERATION

INDICATIONSINDICATIONSINDICATIONSINDICATIONS

CONTRAINDICATIONSCONTRAINDICATIONS

11.. VeryVery advancedadvanced keratoconuskeratoconus11.. VeryVery advancedadvanced keratoconuskeratoconus

andand significantsignificant apicalapical opacityopacity

22.. HydropsisHydropsis;;

33.. ThinThin corneas,corneas, withwith thicknessthickness

tracktrack;;

44.. PatientsPatients withwith intenseintense

beforebefore thethe

implant)implant)

CONTRAINDICATIONSCONTRAINDICATIONS

keratoconuskeratoconus withwith curvaturescurvatures overover 6060 dioptersdiopterskeratoconuskeratoconus withwith curvaturescurvatures overover 6060 dioptersdiopters

opacityopacity andand scarringscarring;;

thicknessthickness belowbelow 300300 micramicra inin thethe

atopiaatopia (these(these shouldshould bebe treatedtreated

FERRARA RING NOMOGRAMFERRARA RING NOMOGRAM

Evolution of the NomogramEvolution of the Nomogram

First generation (1997 First generation (1997

Second generation (2002 Second generation (2002

equivalentequivalent

Third generation (2006 Third generation (2006


(criteria for ring selection)(criteria for ring selection)

Third generation (2006 Third generation (2006

astigmatismastigmatism

Fourth generation (May 2009 to now): Fourth generation (May 2009 to now):

(Q)(Q)



-- 2002): keratoconus grade2002): keratoconus grade

Second generation (2002 Second generation (2002 -- 2006): spherical 2006): spherical

-- 2009): topographic 2009): topographic


-- 2009): topographic 2009): topographic

Fourth generation (May 2009 to now): Fourth generation (May 2009 to now): asphericity asphericity


Second generation (2002 Second generation (2002

equivalentequivalentequivalentequivalent

Eye 1Eye 1

Refraction: Refraction: --10.00 D10.00 D

Are these the same?Are these the same?

NO !NO !

cornea hypercorrection in axial myopia cornea hypercorrection in axial myopia


Second generation (2002 Second generation (2002 -- 2006): spherical 2006): spherical

Eye 2Eye 2

Refraction: Refraction: --10.00 D10.00 D

Are these the same?Are these the same?

NO !NO !

cornea hypercorrection in axial myopia cornea hypercorrection in axial myopia


Third generation (2006 Third generation (2006 --

astigmatismastigmatismastigmatismastigmatism

Eye 1Eye 1

Keratometry: 42.00 x 47.00 DKeratometry: 42.00 x 47.00 DKeratometry: 42.00 x 47.00 DKeratometry: 42.00 x 47.00 D

Are these the same ?Are these the same ?

NO !NO !


2009): topographic 2009): topographic

Eye 2Eye 2

Keratometry: 52.00 x 57.00 DKeratometry: 52.00 x 57.00 D

Are these the same ?Are these the same ?

NO !NO !

Keratometry: 52.00 x 57.00 DKeratometry: 52.00 x 57.00 D

Asphericity (Q)Asphericity (Q)

NOMOGRAMNOMOGRAM

Concept related to the shape of the cornea;Concept related to the shape of the cornea;

““ NormalNormal”” cornea: mild prolate;cornea: mild prolate;

Range: oblate (hiperopes Range: oblate (hiperopes


Range: oblate (hiperopes Range: oblate (hiperopes

to prolate (myopes to prolate (myopes -- keratoconus)keratoconus)

Q values: Q values: tt --0.23 0.23 ±± 0.08 0.08

GonzGonzáálezlez--MMééijome JM, Cerviijome JM, Cerviñño A, ET AL. Asfericidad corneal en una poblo A, ET AL. Asfericidad corneal en una pobláá

2004;79:3852004;79:385--392.392.


NOMOGRAMNOMOGRAM

Concept related to the shape of the cornea;Concept related to the shape of the cornea;

cornea: mild prolate;cornea: mild prolate;

Range: oblate (hiperopes Range: oblate (hiperopes -- post myopic ablation) post myopic ablation)


Range: oblate (hiperopes Range: oblate (hiperopes -- post myopic ablation) post myopic ablation)

keratoconus)keratoconus)

0.08 0.08 (young adults, at 4,5 mm)(young adults, at 4,5 mm) YebraYebra--Pimentel E, Pimentel E,

áácion de adultos jcion de adultos jóóvenes. Implicaciones clvenes. Implicaciones clíí nicas. Arch Soc Esp Oftalmol nicas. Arch Soc Esp Oftalmol

HOW THE FERRARA RING WORKSHOW THE FERRARA RING WORKS

Asphericity law

Addition in the cornea

change – frequently without

concomitant significant corneal

Ring diameter = how

flattened, the astigmatism

asphericity will be changed


cornea periphery = asphericity

without

corneal flattening;

much the cornea will

astigmatism and

changed


Asphericity lawAsphericity law

Ring arc length = how

keratometry and astigmatism

changed. The shorter thechanged. The shorter the

astigmatic correction, the

asphericity change.


how much the asphericity,

astigmatism will be

segment, the greater thesegment, the greater the

the lesser the

NOMOGRAMNOMOGRAM

The asphericity is the best parameter, at the The asphericity is the best parameter, at the

present moment, for ring selection;present moment, for ring selection;

There is a tendency to implant There is a tendency to implant

achieve the same (or better) correction than was achieve the same (or better) correction than was

achieved in the past;achieved in the past;

QQ value = value = QQuality of visionuality of vision

NOMOGRAMNOMOGRAM

The asphericity is the best parameter, at the The asphericity is the best parameter, at the

present moment, for ring selection;present moment, for ring selection;

There is a tendency to implant There is a tendency to implant ““ lessless”” tissue to tissue to

achieve the same (or better) correction than was achieve the same (or better) correction than was

uality of visionuality of vision

140 arc = PMD140 arc = PMD

-- Q 0 or positiveQ 0 or positive

-- Low K valuesLow K values

210 arc = Nipple210 arc = Nipple

-- Q negative (hyperprolate Q negative (hyperprolate

cornea)cornea)

160 arc = 90% of keratoconus (160 arc = 90% of keratoconus (““ standardstandard”” ring)ring)

--

hyperprolate cornea)hyperprolate cornea)

Q negative (hyperprolate Q negative (hyperprolate

ring)ring)

Q negative (prolate to Q negative (prolate to

General GuidelinesGeneral Guidelines

NOMOGRAMNOMOGRAM

IT MUST BE DETERMINED:

1. The type of keratoconus:

Central

Nipple

Oval (paracentral)Oval (paracentral)

PMD

2. The corneal asphericity (Q)

3. The pachymetry at the corneal steepest axis and

probable ring track

General GuidelinesGeneral Guidelines

NOMOGRAMNOMOGRAM

Central

Oval (paracentral)Oval (paracentral)

2. The corneal asphericity (Q)

3. The pachymetry at the corneal steepest axis and

1. Type of keratoconus1. Type of keratoconus

NOMOGRAMNOMOGRAMNOMOGRAMNOMOGRAM

1. Type of keratoconus1. Type of keratoconus

NOMOGRAMNOMOGRAM

CentralCentral

(Nipple(Nipple))

NOMOGRAMNOMOGRAM

OvalOvalOvalOval

NOMOGRAMNOMOGRAMNOMOGRAMNOMOGRAM

-0,07

-0,569999993

-0,340000004-0,310000002

150 200 250 150-150

-0,800000012

-0,730000019

-0,99000001-1,019999981

-0,860000014

150-200 150-250 200-200 200-250 250-250

variation according to ring thicknessvariation according to ring thickness

Single Segments (Single Segments (µµm)m) ∆∆Q Q

150150 -- 0.07 0.07

200200 -- 0.310.31

250250 -- 0.340.34

Paired Segments (Paired Segments (µµm)m)

150 150 –– 150 150 -- 0.570.57

150 150 –– 200 200 -- 0.730.73

150 150 –– 250 250 -- 0.800.80

200 200 –– 200 200 -- 0.860.86

200 200 –– 250 250 -- 1.021.02

variation according to ring thicknessvariation according to ring thickness

Q Q ∆∆KK pp valuevalue

0.07 0.07 0.78 D 0.78 D 0.0420.042

0.310.31 1.82 D1.82 D < 0.001< 0.001

0.340.34 2.74 D 2.74 D < 0.001< 0.001

0.570.57 3.40 D3.40 D < 0.001< 0.001

0.730.73 4.35 D4.35 D < 0.001< 0.001

0.800.80 3.86 D 3.86 D 0.0010.001

0.860.86 5.65 D5.65 D < 0.001< 0.001

1.021.02 6.27 D 6.27 D < 0.001< 0.001

NOTENOTE:: (THIS(THIS ISIS VALIDVALID FORFOR

segmentsegment oror pairpair ofof segmentssegments

postoperativepostoperative corneacornea asphericityasphericitypostoperativepostoperative corneacornea asphericityasphericity

thisthis happenshappens soso itit isis advisableadvisable

choosechoose aa pairpair ofof segmentssegments

fitsfits thisthis conditioncondition eveneven ifif

achievedachieved KERATOMETRICKERATOMETRIC

correctioncorrection isis smallersmallercorrectioncorrection isis smallersmaller

thanthan thethe desireddesired oneone..

FORFOR ALLALL MAPS)MAPS)

segmentssegments SHOULDSHOULD notnot turnturn thethe expectedexpected

asphericityasphericity (Q)(Q) significantlysignificantly belowbelow --00..2323asphericityasphericity (Q)(Q) significantlysignificantly belowbelow --00..2323

advisableadvisable

segmentssegments thatthat

ifif thethe

AVOID POSTOPERATIVE OBLATE CORNEAS !AVOID POSTOPERATIVE OBLATE CORNEAS !

NippleNipple

NOMOGRAMNOMOGRAM

NippleNipple

NOMOGRAMNOMOGRAM

Q change induced by the 210 Q change induced by the 210

ringring

210210//150150 -- 00..3636

Nipple ConesNipple Cones

NOMOGRAMNOMOGRAM


NOMOGRAMNOMOGRAM


The 210 ringThe 210 ring


The 210 ringThe 210 ring

Pellucid Marginal DegenerationPellucid Marginal Degeneration

NOMOGRAMNOMOGRAM

Pellucid Marginal DegenerationPellucid Marginal Degeneration

NOMOGRAMNOMOGRAM

ITIT MUSTMUST BEBE DETERMINEDDETERMINED::

NOMOGRAMNOMOGRAM

ITIT MUSTMUST BEBE DETERMINEDDETERMINED::

TheThe pachymetrypachymetry atat thethe cornealcorneal

probableprobable ringring tracktrack

((55 mmmm opticaloptical zone)zone)

IncisionIncision ((8080%% depth)depth)::

11 segmentsegment:: atat 9090

ringring atat thethe steepeststeepest axisaxis

22 segmentssegments:: atat thethe

NOMOGRAMNOMOGRAM

cornealcorneal steepeststeepest axisaxis andand

909000

axisaxis –– thethe tiptip ofof thethe

axisaxis

thethe steepeststeepest axisaxis

WHYWHY THETHE INCISIONINCISION SHOULDSHOULD BEBE ATAT

NOMOGRAMNOMOGRAM

SuperficialSuperficial stromastroma

8080%% DEPTH?DEPTH?

NOMOGRAMNOMOGRAM

DeepDeep stromastroma

NOTENOTE::(THIS(THIS ISIS VALIDVALID FORFOR ALLALL

PACHYMETRYPACHYMETRY’’ SS LAWLAW

TheThe thickestthickest segmentsegment ofof aa

segmentssegments cannotcannot exceedexceed

thicknessthickness ofof thethe corneacornea

bedbed..

thisthis happenshappens soso oneonethisthis happenshappens soso oneone

choosechoose aa pairpair ofof segmentssegments

fitsfits thisthis conditioncondition eveneven

achievedachieved correctioncorrection isis smallersmaller

thanthan thethe desireddesired oneone..

ALLALL MAPS)MAPS)

aa pairpair ofof

exceedexceed halfhalf

corneacornea inin itsits

oneone hashas totooneone hashas toto

segmentssegments thatthat

eveneven ifif thethe

smallersmaller

IncisionIncision

544 micra544 micra

superiorsuperiorinferiorinferior

SUMMARYSUMMARY

GENERAL RULESGENERAL RULES

NOMOGRAMNOMOGRAM

Q preoperative Q preoperative -- Q change induced by the ringQ change induced by the ring

-- 0.23 (TARGE FINAL Q VALUE)0.23 (TARGE FINAL Q VALUE)

SUMMARYSUMMARY

GENERAL RULESGENERAL RULES

NOMOGRAMNOMOGRAM

Q change induced by the ringQ change induced by the ring = =

0.23 (TARGE FINAL Q VALUE)0.23 (TARGE FINAL Q VALUE)

ASPHERICITY _ RING SELECTIONASPHERICITY _ RING SELECTION

VI. NOMOGRAMVI. NOMOGRAM

Oblate corneas (Q < -0.23):

single 140 or 160 (arc) segments

Moderately prolate corneas

single or paired 160 (arc)

Hyperprolate corneas

paired 160 (arc) segments or

ASPHERICITY _ RING SELECTIONASPHERICITY _ RING SELECTION

VI. NOMOGRAMVI. NOMOGRAM

:

segments

corneas (- 0.23 < Q < -1

segments

(Q > - 1

or 210 segment if nipple

VII. SURGICAL TECHNIQUEVII. SURGICAL TECHNIQUE

ManualManual

FemtosecomdFemtosecomd

VII. SURGICAL TECHNIQUEVII. SURGICAL TECHNIQUE

ManualManual

FemtosecomdFemtosecomd

MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER

O QuickTime™ e um descompressor

são necessários para ver esta imagem.

ero DP, Alio JL, El Kady B, Coskunseven E, Morbelli H

Refractive and aberrometric outcomes of intracorneal ri

femtosecond-assisted procedures. Ophthalmology. 2009 Sep;116(9):1675

MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER

O QuickTime™ e umCodec YUV420 descompressor


Morbelli H, Uceda-Montanes A, Maldonado MJ, Cuevas D, Pascua

ntracorneal ring segments for keratoconus: mechanical versus

assisted procedures. Ophthalmology. 2009 Sep;116(9):1675-87.

MANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASERMANUAL X FEMTOSECOND LASER













FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL

O QuickTime™ e umDV/DVCPRO - NTSC descompressor


FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL

O QuickTime™ e umDV/DVCPRO - NTSC descompressor


FERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOLFERRARA RING +PHAKIC IOL

FERRARA RING +TORIC ICLFERRARA RING +TORIC ICL



FERRARA RING +TORIC ICLFERRARA RING +TORIC ICL



FERRARA RING +TORIC IOLFERRARA RING +TORIC IOLFERRARA RING +TORIC IOLFERRARA RING +TORIC IOL

VIII . CLINICAL CASESVIII . CLINICAL CASES

20/200 20/200 --6.006.00--2.50x102.50x10

PREOPPREOP

POSTOPPOSTOP

20/40 pl20/40 pl--5.000x505.000x50

SURGICAL PLANNING ?SURGICAL PLANNING ?

20/40 pl20/40 pl--5.000x505.000x50



20/400 +3.0020/400 +3.00--6.00x85 6.00x85

Cataract + PMDCataract + PMD

PREOPPREOP

POSTOPPOSTOP

20/30 +0.5020/30 +0.50--3.00x853.00x85


20/30 +0.5020/30 +0.50--3.00x853.00x85



Nipple Nipple

20/60 20/60 --8.508.50--1.50x140 1.50x140

PREOPPREOP

POSTOPPOSTOP

20/40 20/40 ----0.500.50--1.50x401.50x40


20/40 20/40 ----0.500.50--1.50x401.50x40


•• -- RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE

COMPLICATIONSCOMPLICATIONS

•• -- RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE

•• -- RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM

-- RELATED TO THE RINGRELATED TO THE RING•• -- RELATED TO THE RINGRELATED TO THE RING

RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE

COMPLICATIONSCOMPLICATIONS


•• RELATED TO THE SURGICAL TECHNIQUERELATED TO THE SURGICAL TECHNIQUE

-- Extrusion 0.1% Extrusion 0.1% •• -- Extrusion 0.1% Extrusion 0.1%

•• -- Infection 0.08%Infection 0.08%

•• -- Bad centration of the segmentBad centration of the segment

•• -- MigrationMigration

•• -- RotationRotation•• -- RotationRotation

•• -- Misplacement or asimmetry of the Misplacement or asimmetry of the

segmentssegments


Bad centration of the segmentBad centration of the segment

Misplacement or asimmetry of the Misplacement or asimmetry of the

EXTRUSIONEXTRUSION

ExtrusionExtrusion

EXTRUSIONEXTRUSION

Shallow tunnelShallow tunnel

EXTRUSIONEXTRUSIONEXTRUSIONEXTRUSION

INFECTIONINFECTIONINFECTIONINFECTION

MIGRATIONMIGRATIONMIGRATIONMIGRATION

ASYMMETRY of SEGMENTSASYMMETRY of SEGMENTSASYMMETRY of SEGMENTSASYMMETRY of SEGMENTS

WRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RINGWRONG PLACEMENT OF THE RING

RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM

(corneal bio(corneal bio

11--OvercorrectionOvercorrection

22--UndercorrectionUndercorrection

RELATED TO THE NOMOGRAMRELATED TO THE NOMOGRAM

(corneal bio(corneal bio--mechanics)mechanics)

OvercorrectionOvercorrection

UndercorrectionUndercorrection

RELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RING

Halos and GlareHalos and Glare

Periannelar depositsPeriannelar deposits

NeovascularizationNeovascularizationNeovascularizationNeovascularization

RELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RINGRELATED TO THE RING

Halos and GlareHalos and Glare

Periannelar depositsPeriannelar deposits

NeovascularizationNeovascularizationNeovascularizationNeovascularization

YELLOW RINGYELLOW RING

Preop CPreop C


Preop CPreop C--QuantQuant


Postop CPostop C


Postop CPostop C--QuantQuant

METHODSMETHODS

SampleSample:: 10731073 eyeseyes ofof 810810 patientspatients consecutivelyconsecutively

toto JulyJuly 20082008

TwoTwo groupsgroups (type(type ofof ringring implanted)implanted)

GroupGroup II –– patientspatients implantedimplanted withwith

GroupGroup IIII –– patientspatients implantedimplanted

StudiedStudied parametersparameters::

UncorrectedUncorrected visualvisual acuityacuity (UCVA)(UCVA)

BestBest--correctedcorrected visualvisual acuityacuity (BCVA)(BCVA)

KeratometryKeratometry (K)(K)

AsphericityAsphericity (Q)(Q)AsphericityAsphericity (Q)(Q)

PachymetryPachymetry atat thethe thinnestthinnest pointpoint

METHODSMETHODS

consecutivelyconsecutively operatedoperated fromfrom JanuaryJanuary

implanted)implanted)::

withwith thethe 160160--degreedegree ofof arcarc ringring (n=(n=972972

withwith thethe 210210--degreedegree ofof arcarc ringring (n=(n=101101

(UCVA)(UCVA)

(BCVA)(BCVA)

pointpoint (PTP)(PTP) ofof thethe corneacornea.. (Pentacam)(Pentacam)

METHODSMETHODS

MeanMean patientpatient ageage:: 2929..22 ±± 99..44 (Group(GroupMeanMean patientpatient ageage:: 2929..22 ±± 99..44 (Group(Group

FollowFollow--upup:: 2323..88 ±± 1212..22 (Group(Group I)I) andand

AllAll patientspatients completedcompleted atat leastleast sixsix monthsmonths

StatisticalStatistical analysisanalysis::StudentStudent´́ ss tt testtest

(SPSS,(SPSS, Chicago,Chicago, IL)IL)..

METHODSMETHODS

(Group(Group I)I) andand 3030..22 ±± 88..77 (Group(Group II)II);;(Group(Group I)I) andand 3030..22 ±± 88..77 (Group(Group II)II);;

andand 2222..99 ±± 1515..11 monthsmonths (Group(Group II)II)..

monthsmonths ofof followfollow--upup;;

testtest forfor pairedpaired datadata -- SPSSSPSS softwaresoftware

RESULTSRESULTS

GROUP IGROUP IGROUP IGROUP I

PreopPreop PostopPostop

UCVAUCVA 20/22020/220 20/8020/80 0.0000.000

BCVABCVA 20/10020/100 20/4020/40 0.0000.000

Sph. Eq. (D)Sph. Eq. (D) --3.993.99 --2.262.26 0.0000.000

Asphericity Asphericity --0.880.88 --0.350.35 0.0000.000

Keratometry (D)Keratometry (D) 49.1849.18 45.7245.72 0.0000.000Keratometry (D)Keratometry (D) 49.1849.18 45.7245.72 0.0000.000

Pachymetry (Pachymetry (m)m) 448448 465465 0.0000.000

RESULTSRESULTS

GROUP IIGROUP IIGROUP IIGROUP II

pp PreopPreop PostopPostop pp

0.0000.000 20/35020/350 20/13020/130 0.0010.001

0.0000.000 20/11020/110 20/6020/60 0.0000.000

0.0000.000 --8.528.52 --4.144.14 0.0000.000

0.0000.000 --1.171.17 --0.560.56 0.0000.000

0.0000.000 51.9251.92 48.1048.10 0.0000.0000.0000.000 51.9251.92 48.1048.10 0.0000.000

0.0000.000 418418 435435 0.0000.000

RESULTSRESULTS

Preoperative and postoperative UCVAPreoperative and postoperative UCVA

350

400

210220

150

200

250

300

6080

0

50

100

I II

RESULTSRESULTS

Preoperative and postoperative UCVAPreoperative and postoperative UCVA

400

250

200 PreopPostop

100

III IV

800

RESULTSRESULTS

Preoperative and postoperative BCVAPreoperative and postoperative BCVA

300

400

500

600

700

6035

94

400

100

200

I II

800

RESULTSRESULTS

Preoperative and postoperative BCVAPreoperative and postoperative BCVA

400PreopPostop

5590

III IV

RESULTSRESULTS

Complications (treatment)Complications (treatment)

Undercorrection (implantation of additional segment)Undercorrection (implantation of additional segment)

Overcorrection (segment removal followed for reimplantation)Overcorrection (segment removal followed for reimplantation)

Extrusion (segment removal)Extrusion (segment removal)

Malposition (segment repositioning)Malposition (segment repositioning)

Progressive corneal steepening (keratoplasty)Progressive corneal steepening (keratoplasty)

Ring neovascularization (bevacizumab)Ring neovascularization (bevacizumab)

TOTALTOTAL

RESULTSRESULTS

Complications (treatment)Complications (treatment) Eyes (%)Eyes (%)

Undercorrection (implantation of additional segment)Undercorrection (implantation of additional segment) 16 (1.49)16 (1.49)

Overcorrection (segment removal followed for reimplantation)Overcorrection (segment removal followed for reimplantation) 11 (1.02)11 (1.02)

Extrusion (segment removal)Extrusion (segment removal) 6 (0.56)6 (0.56)

Malposition (segment repositioning)Malposition (segment repositioning) 4 (0.37)4 (0.37)

Progressive corneal steepening (keratoplasty)Progressive corneal steepening (keratoplasty) 2 (0.18)2 (0.18)

Ring neovascularization (bevacizumab)Ring neovascularization (bevacizumab) 2 (0.18)2 (0.18)

41 (3.82%)41 (3.82%)

Preoperative Preoperative 1 month1 month 1 year1 year

KKMAXMAX52.95 52.95 ±± 6.78 6.78 49.36 49.36 ±± 6.666.66 47.69 47.69 ±± 5.435.43

KKMINMIN47.86 47.86 ±± 5.195.19 45.27 45.27 ±± 5.395.39 44.03 44.03 ±± 4.524.52

KKMEANMEAN50.36 50.36 ±± 5.685.68 47.29 47.29 ±± 5.915.91 45.79 45.79 ±± 4.854.85

UCVAUCVA 0.12 0.12 ±± 0.140.14 0.25 0.25 ±± 0.190.19 0.33 0.33 ±± 0.230.23

2 years2 years 3 years3 years 4 years4 years 5 years5 years

5.435.43 47.77 47.77 ±± 5.265.26 47.81 47.81 ±± 5.875.87 48.07 48.07 ±± 6.266.26 48.09 48.09 ±± 5.925.92

4.524.52 44.29 44.29 ±± 4.464.46 44.04 44.04 ±± 4.854.85 44.82 44.82 ±± 5.575.57 44.45 44.45 ±± 5.975.97

4.854.85 45.96 45.96 ±± 4.654.65 45.83 45.83 ±± 5.085.08 46.44 46.44 ±± 5.905.90 46.24 46.24 ±± 5.895.89

0.29 0.29 ±± 0.180.18 0.34 0.34 ±± 0.230.23 0.42 0.42 ±± 0.310.31 0.31 0.31 ±± 0.230.23

Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10

Leonardo Torquetti, Guilherme Ferrara, Paulo Ferrara

Ferrara intrastromal corneal ring segments implantation in keratoconus patients: 10-year follow-up.

Leonardo Torquetti, Guilherme Ferrara, Paulo Ferrara

KERATOMETRY


KERATOMETRY


VISUAL ACUITY (UCVA


VISUAL ACUITY (UCVA – BCVA)






Calculated exponential cell loss rate over the Calculated exponential cell loss rate over the

mean interval of followmean interval of follow

1.4% per year1.4% per year

Calculated exponential cell loss rate over the Calculated exponential cell loss rate over the

mean interval of followmean interval of follow--up (4 years):up (4 years):

1.4% per year1.4% per year

Endothelial Cell Loss (per year) in:Endothelial Cell Loss (per year) in:

Young normal eyes:Young normal eyes:

PreoperativePreoperative

UCVAUCVA 20/18520/185

BCVABCVA 20/12520/125BCVABCVA 20/12520/125

Apex PachymetryApex Pachymetry 457.7457.7

Asphericity (Q)Asphericity (Q) --0.950.95

Keratometry (K)Keratometry (K) 45.4145.41

PreoperativePreoperative PostoperativePostoperative

20/6620/66 p = 0.005p = 0.005

20/4020/40 p = 0.008p = 0.00820/4020/40 p = 0.008p = 0.008

466.2466.2 p =0.025p =0.025

--0.230.23 p = 0.006p = 0.006

42.8842.88 p = 0.000p = 0.000

WAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RINGWAVEFRONT X FERRARA RING

Easy procedureEasy procedure

Topical anesthesiaTopical anesthesia

Quick recoveryQuick recovery

X. CONCLUSIONX. CONCLUSION

Reversible and reajustableReversible and reajustable

Do not interfere with PKPDo not interfere with PKP

Improves contact lens toleranceImproves contact lens tolerance

Independent of tissue donationsIndependent of tissue donations

Low rate of complicationsLow rate of complicationsLow rate of complicationsLow rate of complications

Improves UCVA and BSCVAImproves UCVA and BSCVA

Reduces ocular aberrationsReduces ocular aberrations

DELAYS OR STOPS konus evolutionDELAYS OR STOPS konus evolution


•• -- The surgical technique is safe and The surgical technique is safe and


•• -- The surgical technique is safe and The surgical technique is safe and

reproducible;reproducible;

•• -- The technique has a longThe technique has a long

•• -- There is stabilization of the disease after There is stabilization of the disease after

Ferrara ring implantation.Ferrara ring implantation.

The surgical technique is safe and The surgical technique is safe and


The surgical technique is safe and The surgical technique is safe and

The technique has a longThe technique has a long--lasting effect;lasting effect;

There is stabilization of the disease after There is stabilization of the disease after

Ferrara ring implantation.Ferrara ring implantation.

THANK YOU!THANK YOU!THANK YOU!THANK YOU!

Health & Medicine

Curso de Atualização em Implante de Anel de Ferrara