CORNEA EWAP SEPTEMBER 2023 41 want to see old refraction and old topographies, if possible, to confirm stability. It would help address if you’re doing the cornea or the lens first, he said. Dr. Shamie said they had previous data that showed progression. She said the plan was to crosslink first, then wait to allow stabilization to obtain measurements for cataract surgery. Case 4: Older patient with stable keratoconus for cataract eval This case of a high myope with stable keratoconus (OD: –11–1.00x080, OS: –12–2.75x123) was presented by Audrey Talley Rostov, MD. In cases like this, she tends to use the Barrett True K formula for IOL calculations, but she mentioned the Kane formula as well. Dr. Rostov asked the panel if they would consider a toric IOL in this patient. Dr. Garg said he’d want to know if they had good vision in glasses in the past; if not, he would steer away from a toric. Contact lenses are an option as well, but Dr. Rostov said many of her older patients want to get away from contact lens use. Dr. Rostov ended up implanting a toric IOL, using the femtosecond laser for axis alignment. She said that keratoconus patients receiving toric IOLs aren’t necessarily expecting perfection, but IOL alignment is important, and she avoids multifocal and EDOF IOLs. Dr. Garg said that it’s not just about nailing the cylinder in these cases, it’s about nailing the sphere and trying to avoid ending up hyperopic. Case 5: Young patient with keratoconus wants refractive options A 28 - year - old male firefighter with a history of congenital anterior polar cataracts, keratoconus (right eye more advanced), and a history of contact lens intolerance wanted to know what his refractive surgery options were. Karolinne Rocha, MD, PhD, presented the case, sharing that his uncorrected visual acuity in his right eye was count fingers ( MR x – 3.5 – 4.5 x 070, correctable to 20/60). His K max was 54 D and progressed to 58 D 6 months later. Dr. Rocha said she decided to do a combined Intacs (CorneaGen) and crosslinking procedure. Even though the magnitude of his astigmatism was still high after Intacs, she said with glasses he could see 20/30. A couple of years later he returned with his cataract worse and visually significant, and Dr. Rocha said she used the Kane Keratoconus formula to calculate for a toric IOL. Using a monofocal T9 (6.00) toric IOL, there was still residual cylinder, but Dr. Garg said that these patients are often accepting of some residual astigmatism. His final refraction, according to Dr. Rocha, was +0.75+2.5x165 20/25. “Combined procedures have been shown to have a greater effect in the treatment and improvement of visual acuity and quality in patients with keratoconus. Concurrent or sequential procedures are great alternatives to patient intolerance to contacts,” she said. Case 6: Patients in their 40s with keratoconus want to know if they’re a good candidate for crosslinking Ramy Riad Fikry, MD, PhD, shared two cases where patients in their 40s were seeking a second opinion on whether they should have crosslinking. One was a 40-year-old man who didn’t have a family history of keratoconus and learned of his diagnosis when he was seeking out refractive surgery. The patient was followed up with after his initial second opinion consultation after 6 months, showing a stable condition in both eyes. Dr. Fikry said he tested the patient’s corneal biomechanics and other metrics that would detect changes before loss of lines, finding the patient was stable without the need for further intervention. The second case, however, showed significant progression and proceeded with crosslinking treatment. EWAP Editors’ note: Dr. Beckman practices at Comprehensive EyeCare of Central Ohio, Westerville, Ohio, and disclosed no relevant financial interests. Dr. Fikry practices at Cairo University, Cairo, Egypt, and disclosed no relevant financial interests. Dr. Garg is Professor of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California, and disclosed no relevant financial interests. Dr. Rocha is Associate Professor of Ophthalmology, Medical University of South Carolina, Charleston, South Carolina, and disclosed no relevant financial interests. Dr. Talley Rostov practices with Northwest Eye Surgeons, Seattle, Washington, and disclosed no relevant financial interests. Dr. Santhiago is Professor of Ophthalmology, University of Sao Paulo, Sao Paulo, Brazil, and disclosed no relevant financial interests. Dr. Shamie practices at Maloney-Shamie Vision Institute, Los Angeles, California, and has interests with Alcon, Bausch + Lomb, CorneaGen, Glaukos, RxSight, and Johnson & Johnson Vision. Dr. Sorkin practices at Tel Aviv University, Tel Aviv, Israel, and disclosed no relevant financial interests. Dr. Trattler practices at the Center for Excellence in Eye Care, Miami, Florida, and has interests with Alcon, Allergan, ArcScan, Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision, Oculus, and STAAR Surgical.
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