SPECIAL PROCEDURES

PRE AND POST SURGERY

Surgical procedures that change refracting ability of eye:
1. RK
2. Lasik
3. PRK
4. Keratomileusis
5. Epikeratophaki
6. Keratoplasty
7. Pseudophakia
Different types of refractive surgery
RK
Appearance
Effects

Fitting
problems post
RK due to
Fitting
problems

Other
problems
Recommende
d lens

Fitting

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2.
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6.
7.
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3.
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5.
6.

Radial incisions up to 90% of cornea deep in varying numbers

Small clear optical zone around visual axis
Depend on temporary structural weakening of corneal periphery
Internal ocular pressure moves area outward
Corneal curvature flattened
Unusual corneal contour
Variable vision
Lens instability
Cornea is flat centrally and steep peripherally (opposite of normal)
Lens decentration
Variable vision due to rocking of llens
Inadequate pupil cover
Tear froth
Dimpling
Image flare
Greasing of lens due to irritation of lids
Diurnal variation of vision
Astigmatism
Increased sensitivity of cornea
Traumatic globe rupture
Minimum edge clearance design
Large diameter
Rigid
High DK/L
Good tear exchange
Avoid undue pressure on knee
Similar to fitting of post-keratoplasty patients
Overall diameter = 9.4-11mm
OZ = 7.5-9mm
Initial lens BC = 0.2-.5mm steeper than central K readings
May be central pooling > positive liquid lens > need increased minus
power

Pre operation

Incising periphery

Pressure acting

Post operation

Pre operation

Post operation

LASIK
Keratocytes

1.
2.
3.
4.

Remodel structural proteins to maintain homeostasis

Mediate wound repair
Migrate in response to injury
Die, apoptosis, in response to wounding

Seen with confocal microscope

Following PRK
and LASIK

Complications

Discuss the importance of keratocytes in the cornea and the effects

that LASIK has on kerotocyte density
Active wound healing > activated keratocytes
Long period of corneal remodeling > quiescent keratocytes
Keratocyte density decreases after surgery
Norma age related keratocyte loss = 0.45%/y
LASIK = 4.2%/y
PRK = 3.2%/y
Deficiency of keratocytes may produce changes in corneal
transparency or curvature over tim
Keratocytes produce collagen and proteoglycans necessary to maintain
corneal integrity

PRK
Procedure

Ablation zone

CL fitting

Complications

Ultraviolet excimer laser (193nm) > photoablation > corneal tissue

Superficial tissue vaporized in proportion to length of exposure to laser
Precise, superficial keratectomy > remove layer of tissue without
altering adjacent normal tissue
- Epithelium removed; Bowmans + superficial stroma treated
Optically smooth refracting surface with new contour
6mm
Flattening of cornea > ablation zone
Outside zone > corneal topography unchanged
More straightforward than post-RK fitting
- Midperiphery and periphery unaltered
- Conventional lens designs successful
Removes Bowans membrane
Little known about long-term effects
May be increased risk of infection, RCE, etc.

Keratomileusis and Kereatophakia

Procedure
Thickness volume techniques
Lamellar surgical procedures that involve:
- Donor tissue = keratophakia
- Host tissue = keratomileusis
Tissues frozen and curvature altered using cryolathe
Complications
Changes corneal structure and transparency
Freezing > tissue damage:
- Spacing of fibrils
- Damage to stromal keratocytes
Predictability
Poor
Diagram

Epikeratophakia
Procedure
Attachment of pre-lathed human cornea to eye
Epithelium removed and lenticel placed on top of Bowmans membrane
Wedge shaped annulus > edges of lenticel fitted into pocket
Lenticle sutured
Suture tension = great role in ultimate success
Epithelium grows over
Advantages
No microkeratome needed
No lamination of cornea
Fitting for
Factors to keep in mind:
residual
1. Corneal topography altered significantly
ametropia
- Central K readings not adequate to guide first lens choice
2. Epithelial cell density reduced
- Cells arranged irregularly with weak interdigitations
- Resurfacing and reparation slow
3. Corneal sensitivity reduced
- Increase risk of infection
- Irregular astigmatism
- SPK
- Decreased vision
- RCE
- Healing problems
Lenses
Hard/soft with good oxygen supply
Lens that fulfills all the usual criteria
Differentiate between keratomileusis and epikeratophakia
Keratomileusis
Thickness volume technique
Lamellar surgical procedure
Involves the use of host tissue that is frozen so that curvature can be altered using
cryolathe
Results in changes in the corneal structure and transparency
Epikeratophakia
Attachment of pre-lathed human cornea to the eye
No lamination
Epithelium removed and lenticle placed on Bowmans
Wedge shaped annulus created and fitted into pockets
Sutured into place

Keratoplasty
Definition
Success rates
Complications
Penetrating
keratoplasty
uses
Conditions
that benefit
from
keratoplasty
Fitting CL

1.
2.
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2.

Corneal transplantation
Good
77-100% of grafts remain clear
Regular and irregular astigmatism
Anisometropia
Optical (most common reason = keratoconus)
Tectonic (grafting for repair of structural changes in cornea; eg.
Marginal thinning)
3. Therapeutic (trauma)
4. Cosmetic
1. Keratoconus
2. Fuchs endothelial dystrophy
3. Previous graft failure
4. Bullous keratopathy
5. Interstitial and herpes keratitis
6. Stromal dystrophies
2 main directions
Therapeutic
Optical
Optical:
Topography and physiology of corneal graft not normal
Eye lacks inbuilt safety margins of normal eye
Changes that are likely:
- Graft thicker than normal eye once settled down (0.6mm vs
0.5mm)
Polymegathism:
- Normal: central sensitivity greater than peripheral
- Keratoplasty: reverse
- Corneal sensitivity decreased + sensitive lids > fitting not easier

Fitting RGP

Graft topography
No regular grafts
Certain characteristics of graft make CL fitting difficult:
1. Most grafts steeper than host cornea and protrude in nipple-like
manner
2. All grafts toroidal > Cl give better sight than specs
3. Graft can be tilted > bubbles under lens in join area
4. Graft eccentricity > lens designed to centre on graft may e off eyes
visual axis
Changes in corneal topography > conventional designs wont centre
near visual axis
To obtain centration:
a. Fit larger lenses (10-12mm)
b. Bicurve/tricurve design
c. Objective > span both graft and junction
d. OZ must be larger than diameter of graft (grafts = 7-8mm)
Point out that many lenses will have to b e tried before adequate lens
found
K readings not helpful > exact parameters best determined by using
diagnostic lenses

ORTHOKERATOLOGY
Definition

Initial idea

New reverse
geometry
lenses

Fluorescein
pattern

Procedure

Disadvantage
s

Advantages

Theories On The
Stiff lens
Massaging
action
Hydraulic
pressure
Decreased
ciliary spasm
Corneal
sphericalizatio
n
Axial length
reduction
Other factors

Application of series of rigid lenses that flatten central corneal

curvature resulting in reduction/elimination of myopia and astigmatism
Fit lenses flatter than flat K reading to achieve central corneal
flattening
0.37-0.5D flatter than flattest K (0.08-1mm)
Reductions in myopia = 1.5-0.5D
Plateau reached at 6 months
Usual lenses: BC steepest and peripheral curves become flatter
Reverse geometry lens:
- Second curve steeper than BC
- Peripheral curves are based on second curve and not BC
- BC of first diagnostic lens is 1-1.5D flatter than flattest K
Apical touch surrounded by annulus of fluorescein
- Annulus = steep secondary curve
Steep area is surrounded by area of lens bearing = PC
- NB: achieve and preserve clear channel of tear exchange
between PC and 2 zone tear reservoir
Corneal apex flattens > lens sits closer to cornea = close alignment
Fit flatter and flatter lenses
Change power as cornea flattens and tear lens changes shape
Plateau: no increased reduction in myopia
Retainer lens
Time consuming
Not permanent
Some reports of permanent corneal damage
No highly predictive indicators for ortho-k success
Safe
Efficacious

Mechanism Of Orthokeratology
Thick stiff rigid lens creates mechanical pressure to flatten cornea
Movement of lens and massaging action of lid yield flattening of cornea

Tear lens between cornea and CL creates uniform pressure gradient

over cornea
CL provides less prismatic effect, and larger depths of field/focus >
considered to reduce ciliary spasm
Effect of CL is central corneal flattening with paracentral corneal
steepening
Results in decreased corneal eccentricity (cornea becomes spherical)
CL retards axial elongation to reduce myopia

Ocular rigidity
Anterior chamber depth reduction
Corneal thickness changes
Crystalline lens changes
Alterations in corneal metabolism

Accelerated Ortho-K
Traditional

method

Reverse geometry

lenses

Fit

Procedure

Important facts to
remember

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5.

Most of myopia reduction in first 9-18 months

Method: fit flatter and flatter lenses as process progresses
Flatter lenses = poor centration + edge lift
Periphery: up to 7D steeper than BC
Accelerate ortho-k: effects in first 3 months
First trial lens = 1.5-2D flatter than flat K
Fit central 4-5mm of bearing
Surrounded by 2-3mm of mid-peripheral tear pooling
1-2mm movement
Centration critical
- May need to use lenses as large as 11.5mm
Determine appropriate BC
Determine CL power by over-refraction
Px wears overnight
As refractive changes occur, lens changes (may occur within days)
- Subsequent lenses = 0.25 0.50D flatter than previous lens
No further change elicited > retainer phase
- (maintainer of corneal shape)
- Lasts ortho-k lens
Overnight lens wear > associated oxygen reduction
Patient expectation > do not promise 5D myopia 6/5
Lenses may bind overnight
Limitations in refractive error reduction = 2-3D
Make changes gradually

Ortho keratology
Application of a series of rigid contact lenses that flatten the central curvature resulting in the
reduction/ elimination of myopia and astigmatism
Standard ortho keratology
Initial idea was to use the technique of fitting lenses flatter than the flattest K to achieve
corneal flattening
Lenses approximately 0.37 0.5D flatter than flattest K
Decrease in myopia 1.5 to 0.5D. Average 1D
Usual design of hard lens where the base curve is steepest and peripheral curves more
flatter
Most of the myopia reduction in the first 9-18 months
Fit the lens flatter and flatter as the process progresses
Flatter lenses causes poor centration and edge lift
Accelerated ortho keratology
Using reverse geometry lenses
Reverse geometry lenses have a second curve that is steeper, peripheral curves are based
on secondary curve, not base curve
Reverse geometry lenses = accelerated otho keratology results within 3 months
The lenses can be fitted much flatter than usual
The fit is important central 4-5mm bearing
2-3mm mid peripheral pooling
1-2mm movement
Determine the base curve, power with over refraction
Lenses made flatter 0.25-0.5D
No further change = retainer lens to maintain corneal shape. Centration is very important

At some time plateaue is reached, there will be no reduction in myopia

Simplified clinical approach to orthokeratology fitting
Patient selection
Determine motivation
Patient must understand
and education
financial commitment (no
Frequent visits necessary
guarantees or refunds)
Px must make time
commitment for FU visits
Preliminary
1. Unaided VA
Thorough case Hx to
testing
2. Corneal curvature
determine
3. Obj + Subj refraction
contraindicationis
4. Slit lamp
Baseline testing
Diagnostic CL
Empirically
Conventional lens design: 0.50D
fitting
flatter than flat K
Lens selection

Reverse geometry lenses:

Fluorescein pattern
1.50D-2.00D flatter than flat K
assessment for fit (BC)
determination
Contact lens
Conventional tricurve lens
order
design
OK series design
Dispensing day
Lenses dispensed
Aided VA
Wear schedule
OR
Fit assessment
FU visit
1. Conventional lens design,
1. Case Hx (include wear time)
1w
2. Aided VA
2. OK series design, 2-5d
3. OR
3. FU testing (with lens)
4. Fit assessment
4. FU test (w/o lenses)
5. Unaided VA
5. Lens change
6. Measure corneal curvature
7. Obj + Subj refraction
8. Slit lamp
Retainer lens
Final lens
Determine fit
Determine wear schedule
Factors affecting
VA
improvement
Myopia
Astigmatism

Eccentricity

patient suitability
Mean improvement in Snellen VA = 5-6 lines
Px worse than 6/36 wont become 6/6
Only moderate amounts treated
3-4D
Reverse geometry lenses dont reduce ATR astig and may induce it
WTR more amenable to being reduced (moderate)
Only corneal astigmatism reduced

Suitable patients should have:

1. < 4D myopia
2. Mild astigmatism < 1.50D
3. No ATR/oblique astig
Higher initial e-value, greater refractive change possible (in dispute)
Eccentricity related to outcome of OK (rule of thumb)
- For every 0.2 change in e, expect 1D of reduction in myopia

Absolute contraindications:
1. Keratoconus
2. Corneal dystrophies
3. Anterior segment disease
Relative contraindications:
1. Dry eyes
2. 3 and 9 o clock staining
List the absolute and relative contraindications to orthokeratology.
Trial lens fitting:
Empirical
Trial lenses

FL pattern
analysis

Uses computer program

Recommended
Use trial lenses as usual (import)

a. 3-zone lenses:
- OK series BC
- RC edge
b. 4-5 zone lenses:
- ElHage
BC, RC PC edge
- Driem lens
- Wave design
- Paragon CRT
- Scioptic EZM
- BE lens
Commonalities:
a. Lens must centre
b. Touch in centre (pupil zone)
c. Alignment zone = wide band of close alignment
d. RC narrow and deep (4-5 zone lenses)/ wide and tapered (EZM and
BE)

Assessing post-trial topography:

1 Bulls eye

Ideal fit

Smiley face

Flat
Decentred superiorly

Smiley face
with fake
central island

Too much bearing resulting in

epithelial damage

Central island

Steep/tight lens

Frowny face

Decentred laterally/inferiorly
Tight alignment curve/lens
diameter too small

Centre divot

Apical touch leading to epithelial

disruption centrally
Drop of lubricant resolves

Post trail topography

Discuss different topographical maps that can be induced by reverse geometry lens
wear
Factors to consider for lens material selection
Lens
Advantages
material
Hydrogel
1. More forgiving fit
2. Decreased fitting time
3. Usually immediate comfort
4. Experience with extended wear
Rigid

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9.

Clearer vision
Increased tear exchange
Decreased hypoxia
Decreased acute red eye
Do not cover limbus
Decreased contamination
Deposits removable
UV blocking available
Unlimited parameters

Disadvantages
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2.
3.
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6.
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2.
3.
4.
5.

Deposits/contamination
Hypoxia
Neovascularization
Acute red eye
Increased cost of lens care
Limited parameters
Occasionally decentre
Occasional poor fit
Increased fitting time
Adaptation period
Limited experience with
extended wear