RoseK2 part2

Mini-Scleral Design - MSD

• Large RGP• Vaults the cornea, rests on the

sclera.• Creates a fluid filled environment.• Can be used to treat any corneal

condition.• Can be used to treat other anterior

segment conditions.

MSD - Advantages

• Very Stable lens.

• Fluid filled environment.

• Improved comfort.

• Good visual acuity.

Mini-Scleral Design

MSD – Fitting Pearls

Central Feather-

touch.

Intra-limbal

adjustment.

With or without

fenestration or

fenestrations.

Watch edge for

tightening.

Practice Management Issues

• Setting Fees.• Bill for services performed.• Insurances and fee collection.• Appropriate diagnostic and

treatment equipment.– Topography/corneal mapping.– Pachymetry.– Fitting sets.

Refractive Surgery Specific

Moderate – Large Diameter(10.5 mm Standard Diameter, 9.5 mm

to 12.0 mm). Reverse Geometry Transition.

Post Surgical Central BC. Curves

• Paracentral Fitting Curves.

• Asymmetric Corneal Technology (ACT).

A New Option for Keratoconus

Keratoconus Intacs -1 Day PKP -1 Week

Contact Lens Intolerant Keratoconus Steep K ‘s, 45 to 60 Changing refractions, eyes irritated, frequent visits/re-

fits Lenses not providing functional vision

Outright failure Shortened wearing time Inability to achieve 20/40

“keratoconus personality” exacerbated Apprehensive about transplant

Active, younger or risk averse

Objective - Bridge the gap between frustration and (PKP) “the point of no

return”

Reshape the Cornea for CL Success

History

Adjustable Ring

1984

INTACS Design Features• Precision manufactured

to ± 0.01mm: •150° arcs PMMA

•Unique hexagonal cross-section design with 7mm wide optical zone

•Positioning holes for manipulation

• Inserts placement:• In peripheral cornea

•Between stromal layers

Stromal LamellaeStromal Lamellae

6.9 mm

8.1 mm

Stromal LamellaeStromal Lamellae

How INTACS Work…

Inserts placed at 75% corneal depth

Inserts separate corneal lamellae

Separation shortens corneal arc length

Central cornea flattens

Increased flattening achieved with thicker segments

Watch the Pre-op and Post-op mire INTACS Normalize Corneal Shape

The INTACS Procedure

Courtesy David Schanzlin, MD Shiley Eye Inst. UCSD

INTACS – PKP ComparisonINTACS – PKP Comparison

+8.00 (.)-2.00 X 180°-0.75

TransplantIntacs

INTACS - PKP ComparisonPKP

Irreversible Procedure Time: 1 Hour Rehab Time: 12-18

Months

Intraocular Procedure Lifetime Follow-up

required Complications

• Cataract• Glaucoma• Endophthalmitis• Rejection• Expulsive hemorrhage• Corneal ulcer• Neovascularization• Induced astigmatism• Disease recurrence• Risk of viral transference

INTACS

Reversible Out-Patient Procedure

Time: 20-30 Minutes Rehab Time: 1-2 Weeks

(Visual Function Immediate) Corneal Lamellar Procedure Periodic Follow-up Complications

• Unsatisfactory ring placement• Segment extrusion(All easily managed with segment removal)

INTACS - PKP Comparison

PKP

Significant loss of endothelial cells

Permanently weakened cornea with risk of additional trauma

Outcomes: unpredictable, often unstable

INTACS

Endothelial cell loss, not clinically significant1

Provides structural integrity, PKP still an option without complication

Outcomes: predictable, case dependent

1Two-Year Endothelial Cell Assessment following INTACS implantation, Azar et al, J Refract Surg. 2001 Sept-Oct

3 lenses for most of the situations

The most common cones : nipple and ovale

Lenses have to follow as close as possible this very prolate cornea in order to :

– respect the cornea– Stabilize properly– Be comfortable

Need to have « very » steep lenses in the center that get flatter « quickly ».

Good center and periphery

Rose K PrincipleLens changes with the cone

evolution • When a keratoconus is getting more and

more advanced, the apex of the cone is getting steeper but the periphery remains the same.

• For a known apex of the cone, the periphery is often the « same » fom one patient to another : Paul Rose’s Statistic and mathematic models : correlation between BC and slope

Rose K lenses principle

• For each BC that respects the apex of the cone, an unique AEL will be associated to it– Unique Optic Zone– Unique Peripheral curves

World sales indicate that the original AELrepresent 65% of sold lenses

For a 8.70mm diam.

Axial Ege Lift (AEL) Edge Lift (EL)

• Rather than talking about AEL in mm which is difficult to evaluate for the fitter, Paul Rose simplified and reduced this notion to a simple number without unit : Edge Lift (EL)• EL = 0 = standard corresponds to the AEL

associated to the curve• EL > 0 correspond to lenses that are flatter in

periphery than standard• EL < 0 correspond to lenses that are steeper in

periphery than standard

available EL+3.00 à -1.3 / 0.1

•EL Standard “0” 65%

•EL “quick” +1.0 20%

•EL “slow” -0.5 10%

•Others 5 to 10%

The majority of Rose K are done with 3 EL

Trial Box

• Std EL for all lenses (but AEL unique for each BC)

• Powers increase in steep curves : the more advanced is the cone, the more myopia there is important for assessing precisely centration and mobility .

• Diameter decreases when the cone is getting advanced (difficult for large lenses to follow the very flat periphery)

Fitting steps

1. Keratometry from a keratometer or a topograph

7,00 mm 12⁰

6,60 mm 102⁰

Km. 6.80

Cyl. 3,00

2. In the trial box, choose the lens according to the rule :BC = av.K -0.10

3. Assess the contact at the apex of the cone• If too much contact (Flat) decrease BC• If not enough contact (Steep) increase BC

STEEP FLATOPTIMALE

Remarques

• Wait 1 minute before evaluation

• Analyze fluo pattern, lens centered

4. After finding the best BC– If too thin periphery (< 0.6 mm) EL

« quick » +1.0– If too wide periphery (> 0.8mm) EL

« slow » -0.5Too thin Optimal Too wide

5. Centration and mobility

Up riding.steep the lens.and/or reduce diameter .and/or reduce EL

Low riding.Flatten the lens.and/or increase diameter .and/or increase ELOptimal

6. Find the best sphere giving the best

Spherical Aberrations

• Peripheral rays are more refracted than central rays.

Ex : -7.00 in the center, -7.75 in periphery

• Those aberrations induced by the lens are higher when : – Pupil is large– Power of the lens is high

More benefits for high myopic patients

Rose K2 Advantages

• Easy to fit– Only 1 trial box : one lens name– Lens changes with the cone (AEL changes with BC)– Std EL works in main cases– 2 other EL slow and quick cover most of the

modifications– 6 steps fitting

• Maximum physiological respect– Material Z– Special Geometry for the best compromise

physiology/vision

• Vision– Control of the spherical aberrations

Indications

• Pellucid Marginal Degeneration - PMD• Keratoglobus• Post lasik ectasy, Post Graft

PMDDMP Globus Lasik

• reversed design for BC > 7.20• flatter the BC is, more reversed the design is• Larger optical zone • OZ decreases with BC• EL steeper than Rose K•Total diameter larger than graft diameter• Also used on post lasik ectasy

5 Edge Lift

+0.6 /+1.2 / -0.5 / -1.0

1st lens: BC = K’ +0.30 mm

Fitting: 1. Keratometry 2. BC

3. central Fitting 4. peripheral fitting 5. Centration/Mobility (=>Diameter)

6.Power

Ex. 6.80/5.50 5.50 +0.30 = 5.80

BC

plat

OK / serré

serré

EL

périphérie très serrée EL Lent (-)

périphérie serrée EL standard

Périphérie ok EL rapide (+)

Mobility

Look for enough mobility to insure enough tear flow

Mobility ++ Mobility --

increase diameter Decrease diameter decrease BC Flatten BC0

decrease l’Edge Lift increase l’Edge Lift

1st lens = Km - 0.30 mm

Fitting : 1. Keratometry 2. BC 3. central fitting 4. peropheral fitting 5. Centration / mobility

6. Power

Ex. 6.80/5.50 6.15 - 0.30 = 5.85

ROSE K2 Post Graft: Rose K2 PG

• the hardest fitting• irregular cornea shape• High astigmatism, often irregular sensitives eyes

• Optimal

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