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