hornhaut ausgewählte blickdiagnosen¤sentationen/plenum_3/fr… · myopia and astigmatism...

Hornhaut – ausgewählte Blickdiagnosen

Dr. med. Thomas Müller

Who is who?

Bindehaut

Hornhautepithel

Hornhautstroma

Hornhautendothel

Funktionen

Meeney, A., and H. S. Mudhar. "Histopathological reporting of corneal pathology by a biomedical scientist: the Sheffield Experience." Eye 27.2 (2013): 272.

Bindehaut

Hornhautepithel

Hornhautstroma

Hornhautendothel

Themen

Meeney, A., and H. S. Mudhar. "Histopathological reporting of corneal pathology by a biomedical scientist: the Sheffield Experience." Eye 27.2 (2013): 272.

Hornhautverkrümmung: 2.3D

Hornhautverkrümmung: 5D

A) Exzision und Direktverschluss

B) Exzision and Deckung mit Bindehauttransplantat

C) Exzision und Deckung mit Amnionmembran

Welche Operationsmethode hat das geringste Rezidivrisiko?

präperativ

präperativ

1 Monat

1 Monat

Auch ein Pterygium?

Histopathologie

Konjunktivale Amyloidose

präoperativ 1 Monat

Bindehaut

Hornhautepithel

Hornhautstroma

Hornhautendothel

Themen

Meeney, A., and H. S. Mudhar. "Histopathological reporting of corneal pathology by a biomedical scientist: the Sheffield Experience." Eye 27.2 (2013): 272.

Bild

OD OS

Bild

Map-Dot-Fingerprint-Dystrophie

OD OS

- Befeuchtung, Augensalben zur Nacht

- Therapeutische Kontaktlinse

- Phototherapeutische Keratektomie

Behandlung (einer wiederkehrenden Hornhauterosion)

Was ist das?

- Aciclovir Augensalbe 5x/Tag für 1 Woche

- Bei schwereren Fällen zusätzlich Valtrex 2x500mg Tabletten

Herpes simplex Keratitis - Behandlung

Auch Herpes?

Pseudodendriten bei neurotropher Keratopathie

Was ist das?

Salzmann Knoten

Das, Sujata, et al. "Long-term outcome of excimer laser phototherapeutic keratectomy for treatment ofSalzmann's nodular degeneration." Journal of Cataract & Refractive Surgery 31.7 (2005): 1386-1391.

Bindehaut

Hornhautepithel

Hornhautstroma

Hornhautendothel

Themen

Meeney, A., and H. S. Mudhar. "Histopathological reporting of corneal pathology by a biomedical scientist: the Sheffield Experience." Eye 27.2 (2013): 272.

Was ist das?

Klinischer Verlauf

2 Tage 2 Wochen

1 Monat

Persistierender Epitheldefekt

Nach lateraler Tarsorraphie

- Abstrich zur Diagnostik im Labor

- Bakterien, Viren oder Pilze

- Anfangs stündliche Tropftherapie mit 2 Antibiotika

- Sobald Resultate vom Labor mit Resistenzprüfung -> Anpassung der

Therapie

- Kortisontropfen nach 48h und klinischer Besserung

Infektiöse Hornhautulcera («Geschwüre»)

Iris Melike 260178

OD OS

- Patient sieht zunehmend schlechter

- Hornhautverkrümmung habe gemäss Optiker stark zugenommen in

den letzten Jahren

- Sehschärfe trotz neuer Brille nicht auf 1.0 korrigierbar

Symptome

Topographie

Kmax 56.5D Kmax 60.6D

Iris Melike 260178

Vogt striae

OD OS

- Fortschreitende Aufsteilung und Verdünnung der Hornhaut

- Beginn im Kindesalter, meist spontane Stabilisierung zwischen 30

und 35 Jahre

Keratokonus

Hydrops

Behandlung bei Keratokonus?

- Stabilisierung der Hornhaut durch Quervernetzung (Crosslinking)

Crosslinking

Bindehaut

Hornhautepithel

Hornhautstroma

Hornhautendothel

Themen

Meeney, A., and H. S. Mudhar. "Histopathological reporting of corneal pathology by a biomedical scientist: the Sheffield Experience." Eye 27.2 (2013): 272.

OD OS

A) Posteriore polymorphe Hornhautdystrophie

B) Fuchs Endotheldystrophie

Welche Diagnose vermuten Sie?

Posteriore polymorphe Hornhautdystrophie

OS OS

Resultate

präoperativ 1 WocheFV 0.1 FV 0.8

2140 cells/mm2

Cells not countable

Fragen?

Reserve

• Refractive options

• Indications

• Safety

Contents

5

3

5

4

Refractive options

Corneal refractive laser Phakic IOL

5

5

Refractive options

Corneal refractivelaser

Phakic IOL

5

6

Laser options

Corneal refractive laser

Femto-Lasik(Laser in situ

keratomileusis)

Trans-PRK(TransepithelialePhotorefraktiveKeratektomie)

5

7

Femto-Lasik

5

8

Trans-PRK

Refractive Laser - Indications

Femto-Lasik

Myopia up to -8D

Hyperopia not recommended

Astigmatism up to -5D

TransPRK

Myopia up to -6D

Hyperopia not recommended

Astigmatism up to -5D

Remaining stromal thickness at least 300μm

Hyperopic regression

Mechanisms of Optical Regression Following Corneal Laser Refractive Surgery: Epithelial and Stromal Responses - Scientific Figure on ResearchGate.

Hyperopic ablation profile

• Dry eye

• Glare and halos at night

• Regression

• Ectasia

Refractive laser - side effects/complications

Refractive options

Corneal refractive laser Phakic IOL

Phakic IOL

Phakic IOLs

Retropupillary(ICL)

Anterior chamber(Artisan)

Phakic ICL - ICL

Body / Haptic

2 peri-optic full thickness holes (360 µm)

2 full thickness holes in the footplates (360µm) (Proper

orientation in the eye)

Optical Zone

KS-Aquaport ™

ICL-Implantation

• Myopia up to -18D

• Astigmatism up to -6D

• Hyperopia up to +10D

• Important precondition: Anterior chamber depth > 2.8mm

• Advantage: corneal shape unchanged

Phakic IOL - indications

Spherical aberration

Effect of myopic correction

Ablation profile -6.5DTotal spherical aberration

(Z40): 0.30

Total spherical

aberration (Z40):

0.423

Preoperativ

ely

Postoperativ

ely

Target: between 250 and 750µm

Vault

• Cataract

• Intraocular pressure

• Endothelial cell density

ICL – safety

• FDA study (516 eyes): 5.9% with anterior subcapsular cataract, of

which 1.3% of the eyes clinically significant cataract after 5 years1

• Most current version (with central hole): cataract incidence of 0.49%

(weighted follow-up 13 months)2

→Very low cataract incidence with newest ICL generation

→Long term data missing

ICL - cataract

1Sanders, Donald R. "Anterior subcapsular opacities and cataracts 5 years after surgery in the visian implantable collamer lens FDA trial." Journal of Refractive Surgery 24.6 (2008): 566-570.2Packer, Mark. "The Implantable Collamer Lens with a central port: review of the literature." Clinical Ophthalmology (Auckland, NZ) 12 (2018): 2427.

• No incidence of pigment dispersion, ocular hypertension, or

glaucoma

ICL – Intraocular pressure

Packer, Mark. "Meta-analysis and review: effectiveness, safety, and central port design of the intraocular collamer lens." Clinical ophthalmology (Auckland, NZ) 10 (2016): 1059.

• Study with longest follow-up (12-years) on 144 eyes: initial 6.46%

decrease in first year followed by an annual decrease of 1.20%

→ only slighty above physiological decrease (~0.6% per

year)1

→ Yearly ECD measurement recommended

ICL - Endothelial cell density

1Bourne, William M., Leif R. Nelson, and David O. Hodge. "Central corneal endothelial cell changes over a ten-year period." Investigative ophthalmology & visual science 38.3 (1997): 779-782.

When to choose which option?

Myopia

Cornealrefractive laser

ICL

No refractivesurgery

recommended

When to choose which option?

Hyperopia

ICL

No refractivesurgery

recommended

• 25 year old patient

• Subj. Refraction: OD -4.25/-0.5/5° OS -

3.75/-0.25/178°

• Unremarkable exam

• Central corneal thickness 550µm

• Belin Ambrosio Display unremarkable

Case 1

A ICL

B Corneal refractive laser

C Don’t do refractive surgery

Case 1 – what would you do?

When to choose which option?

Myopia

Cornealrefractive

laser

ICL

No refractivesurgery

recommended

• 35 year old patient

• Subj. Refraction: OD +4.25/-0.5/5° OS

+3.75/-0.25/178°

• Anterior chamber depth: 2.6mm

• Unremarkable exam

• Central corneal thickness 490µm

• Belin Ambrosio Display unremarkable

Case 2

A ICL

B Corneal refractive laser

C Don’t do refractive surgery

Case 2 – What would you do?

When to choose which option?

Hyperopia

ICL

No refractivesurgery

recommended

• 36 year old patient

• Subj. Refraction: OD -10sph OS -9.5sph

• Unremarkable exam

• Anterior chamber depth: 3.3mm

• Central corneal thickness 520µm

• Belin Ambrosio Display unremarkable

Case 3

A ICL

B Corneal refractive laser

C Don’t do refractive surgery

Case 3 – What would you do?

When to choose which option?

Myopia

Cornealrefractive laser

ICL

No refractivesurgery

recommended

• Corneal refractive laser: good option for correction of low to medium

myopia and astigmatism

• Phakic lens implantations leaves cornea unchanged and is therefore

ideal for medium to high myopia and astigmatism

• Hyperopia corrections with corneal refractive laser are prone to

regression

→ phakic lens is the method of choice (if anterior chamber deep

enough)

Take home