 Good morning, and welcome to our first Grand Rounds of the academic year. This is the time of year when we're Welcoming our visiting medical students, and we're utilizing them for fantastic Grand Rounds presentations It's always interesting to see Which one of the med students are really long-winded that helps us to know whether we should have them present in the future So we have three students today Nicholas Bahanan. Is that correct? I Asked like 30 seconds ago. Okay He's a fourth-year medical student here at the University of Utah The second presenter is Scott Buticofer. I can pronounce his name because I've worked with him for the past two weeks And then finally Rachel Simpson, thank you for an easy name University of Arizona will finish it off And if you need any assistance with AV stuff, we usually jump up and help you so don't feel too bad and The whole thing just turned off for a moment Right. Thank you for this opportunity I'll be discussing advances in keratoconus treatment today I'll start with a brief introduction to keratoconus and then jump right into the treatments We'll go mild then moderate then severe and give a brief conclusion So keratoconus is a progressive ectatic disorder of the cornea characterized by bilateral asymmetric non-inflammatory degeneration that results in central and paracentral thinning and high myopia and irregular astigmatism The disease usually presents in the teens or early 20s with irregular astigmatism high myopia and Usually progresses until the 30s early 40s when it stabilizes the pathophysiology is unknown But is associate it is associated with contact lens micro trauma atp and eye rubbing I Can't talk about keratoconus without mentioning family factors because this is my father This is my son my father brother and an ant Are all flicked with keratoconus and So growing up there was a constant discussion about Cornea transplantation and what not so there is a positive family family history present in 60% of cases The hereditary pattern is not currently known, but the prevalence among first-degree relatives 15 to 67 times higher than the general population So now let's jump into the treatments first for mild keratoconus The biggest problem in mild keratoconus is the reduced visual acuity due to mild thinning in early disease this reduced visual acuity can be corrected initially with spectacles and soft contact lenses but rigid gas permeable lenses are required to correct irregular astigmatism when it develops and Specialized there are many specialized Fit methods for RGPs and I wanted to talk about a couple of those and Bill Cosby at least if you believe the National Enquirer has care the corner The first method RGP fit method is called piggyback the piggyback method This involves the placement of a soft contact lens on the on the cornea with an additional RGP lens Placed anteriorly as shown in the image Another method is a hybrid lens which consists of a central rigid gas permeable lens with a peripheral soft contact skirt This provides greater comfort But continues to have the problem of limited oxygen permeability For highly irregular corneas, it's difficult to achieve a proper fit and that results in a frequent RGP loss A last resort for contact use is the scleral contact lens consisting of a central optic vault But there are central optic which vaults over the cone from limbus to limbus Which allows the tear film to collect and correct for the irregular pattern of the cornea It also has a flat periphery which lies out over the sclera. These contacts are obviously very large difficult to fit and Difficult to wear and they're also very expensive Let's move to moderate keratoconus Moderate keratoconus is difficult to treat and this is An area where there's a lot of advancement in treatment modalities The difficulty arises from the fact that best corrective visual acuity is worse than 2020 But there's only mild corneal thinning and no scar so it makes it difficult to justify corneal transplantation and Steve Hulkin an Olympic bobsledder Benefited from one of these treatments. I'll talk about today When when approaching moderate keratoconus, it's important to recognize the critical disease Aspects these these three aspects of the disease are important to address with any treatment Treatment options that you pursue first is irregular to astigmatism and manifest cylinder the rate of ectatic progression and the degree of myopia So the first treatment I'd like to discuss is collagen crosslinking. This involves the formation of covalent bonds between the collagen molecules increasing the strength of the collagen scaffold and creating greater corneal stiffness the collagen crosslinking procedure involves epithelial debridement initially to Maximize the absorption of UVA light which which occurs in the anterior 200 to 300 micrometers of the cornea Ribal fleven drops are then administered followed by the UVA light exposure In that range of that that's mentioned there studies show that high energy short duration Treatments are promising on the order of the 30 milliwatts per centimeter squared for three minutes Multiple studies show that Disease progression can be slowed and even stopped with corneal collagen crosslinking There is minimal improvement in the prescription and Long-term results and safety are not yet well established and therefore the FDA approval is still pending But we'll likely likely come through the next couple of years The next treatment is intra corneal Intrastromal corneal ring segments. These are C-shaped polymethyl methacrylate rings that are implanted in the deep corneal stroma They provide space or elements between lamellar bundles shorten the arc length and flatten the central cornea they reduce manifest cylinder and irregular stigmatism and There's some controversy that exists over whether they really provide any slowing of the disease progression a specific specific ICRS For care to conus is in text severe care to conus has a larger diameter and therefore can be planted implanted closer to The visual axis reports show up to 12 diopters of corneal flattening Which allows for improved corrected distant visual acuity? contact tolerance other treatment options not yet available in the United States, but it's a promising treatment Next we have photorefractive keratectomy after penetrating keratoplasty PRK uses an eczema laser photoablation To remodel the anterior central cornea and allow for better vision The problems are that it only corrects regular stigmatism. So if the donor cornea has a regular stigmatism It doesn't it's not really useful It's also difficult to predict refractive outcome and the host cornea the underlying problem the host cornea still has a care to conus and There are varying degrees of wound healing and whenever you deal with the corneal transplant. They're Important to remember that Iatrogenic ectages after PKP have been reported Customized aphiric Topography guided PRK shows promise elsewhere in the world. It's not yet in the United States Next treatment option is faking intraocular lenses These have the advantage of being independent of the cornea. They're predictable safe. They can correct large amounts of myopia But they have no effect on the cylinder and no effect on the disease progression Newer newer brands newer advances in the interocular lens of the Toric iris claw and Artiflex lenses which correct both myopia and cylinder They're available in Europe currently and again. They still do not slow the progression of the disease So considering the the the three critical disease aspects that we discussed earlier each each of the treatment modalities we've discussed addresses one or more of these factors and so the Next logical step in the progression is the combination of these therapies in order to achieve The best treatment possible and there have been many reports of successful combination therapies with these treatments So I'll move to severe keratoconus Severe keratoconus is characterized by severe corneal thinning with steepening greater than 55 diopters Corneal scarring is present and Visual acuity cannot be corrected greater than 20 25 with with the RGP lenses Surgery is really considered when contact lenses fail Don't know if you're familiar with the movie Princess bride, but Classic and the actor who played an ego Montoya Benefited from one of these treatments that we'll talk about So penetrating keratoplasty is still the standard of care involves the removal of the central seven to nine millimeters of the Effective cornea which is then replaced with donor corneal tissue PKP provides a clear cornea and has good graft survival with reports of 98.8 percent at ten years and an average survival of 17.3 years Problems persist afterward with a regular astigmatism with visual rehab being accomplished through stitch removal spectacle use and RGP lenses advances in corneal transplantation Include deep anterior lamellar keratoplasty or DA okay This involves removal of the central corneal stroma without compromising the corneal endothelium or Disney's membrane It has a lot of advantages Obviously keeps the globe closed and reduces the risks associated with that It also leaves the endothelial layer undisturbed and therefore Reduces the risk of endothelial rejection So and that would be important, especially in younger patients who have to live with their graph for a long time Graph survival has been modeled with computer models and the average predicted lifespan of a graft is 49 years Which is an improvement over the established 17.3 with PKP The the outcomes are comparable and there is the improved visual rehab associated with it The disadvantage the big disadvantage with the alk is that it's a difficult surgery to perform especially the stuff that involves big bubble separation of Desiree's membrane from the corneal stroma There are a lot of techniques reported in the literature But none have simplified the process such that it mainstream adaptation Can happen. I think that once that once The procedure is simplified that it will be adopted in the next advancement I'd like to talk about is interlaced enabled keratoplasty. This involves femtosecond laser use to create Variations in wound configuration as shown on this side of the slide these these different configurations provide greater surface area for healing in the corneal in the corneal graph and The greater surface area means faster wound healing and earlier suture removal paring IEK with the alk The best spectacle corrective visual acuity and complication rates are very similar IEK produces a better visual recovery, but at a significant cost increase and DALK has been associated with less astigmatism and higher order aberrations. So the question is Is IEK worth the money? So conclusions that that I draw from from my study of keratoconus First there have been many advances in the past decade College and cross-linking is the most promising In my opinion as it theoretically provides the possibility of stopping progression in that early stage And then hopefully maintaining that that halt or arrest in progression until until the progression of the diseases is passed Combination therapies are available for later stages which provide a greater scope of treatment and Despite the advances in corneal transplantation PKP remains the standard of care bibliography Thank you for your attention Yeah contact lens microtrauma ATP and I rubbing interesting studies involving patients with Down syndrome who have a Predilection for eye rubbing rigorous eye rubbing and an increased rate of care to conus among those particular patients