Utility of epithelial and stromal thickness maps on surgical decision-making

for corneal collagen crosslinking procedure in keratoconus patients

Maria A Henriquez MD, MSc, PhD, Claudia Pomatanta, Rolando P Rojas,

Luis jr Izquierdo, MD
 Dra. Maria.Henriquez-Izquierdo

I do not have any financial interest to disclose

 Dra. Maria.Henriquez-Izquierdo

Why this study was undertaken?

• Although stromal thickness is the ideal measurement when deciding CXL
protocols, it is not always the most used.

• Not all doctors have an AS-OCT, so they use Scheimpflug instead.

• Stromal thickness is not always corroborated after corneal de-epithelialization

when epi-off CXL is performed.

• Instead, many doctors assume an average epithelial thickness of 50 um, perhaps

inappropriate.
 Dra. Maria.Henriquez-Izquierdo

Purpose
• This study assesses the effect on surgical decision-making of the type of corneal
collagen crosslinking (CXL) protocol in keratoconus eyes, depending on
pachymetric or stromal thickness map.

Methods
• A prospective, consecutive case-series study was performed between January 2022 to January 2023.
 Dra. Maria.Henriquez-Izquierdo

Scheimpflug AS-OCT
n= 245 (Pentacam) (MS-39)
Keratoconus Thinnest Minimum
eyes pachymetry stromal thickness

Epi-off CXL < 400 um TE -CXL

TE- CXL < 450 um
TE- CXL UTILITY
d

Percentage of eyes
ate

> 400 um
oc

in which the
al l

Corneal surgical plan was

pachymetry changed due to
< 400 um stromal map
> 450 um information

Epi-off
>400 um Epi-off CXL

Same day
 Dra. Maria.Henriquez-Izquierdo

UTILITY The percentage of cases in which epithelial/stromal thickness data

OF THE AS-OCT altered surgical decision-making

EPI OFF TE-CXL Stromal map

Scheimpflug AS-OCT ( MS-39)
 Results
Differences on Thynnest pachymetry between devices
Bland Altaman plot showing the differences on Thinnest Pachymetry

Differences in the thinnest pachymetry

95% CI
+ 20.05 to – 34.63um
Thinnest pachymetry Mean +/- SD

AS-OCT 456.53 +/- 49.40

Wilcoxon signed rank test with continuity correction ( p <.001) Scheimpflug 463.82 +/- 46.21

There was a statistical significant differences on thinnest pachymetry between the Scheimpflug and the AS-OCT ( p <.001).
 Dra. Maria.Henriquez-Izquierdo

t r y
Pachymetry according to KC severity y me
c h
pa
Grade Grade st Grade
Grade
ne
n
Thinnest corneal pachymetry (um)

t h i
the
ate
ti m
e rs
v
ic eo
v
g de
flu
p
AS-OCT m Scheimpflug AS-OCT Scheimpflug AS-OCT Scheimpflug AS-OCT Scheimpflug
e i
c h
S
Scheimpflug technology present significant thicker corneas when compared to AS-OCT (p = 0.04).
 Dra. Maria.Henriquez-Izquierdo
Surgical planning
Using Scheimpflug ( Thinnest pachymetry)
120
Stromal thickness
was assesed with > 400 um
the AS-OCT 100
5.75
Percentage of eyes
< 400 um
80 Stromal thickness
5.62% of the eyes was assesed with
were selected for 60
the AS-OCT
an Epi-off CXL, 94.37
5.62% 94.25
of the eyes were selected for an Epi-off
when in reality 40 CXL, when in reality their corneal stroma was
their corneal 5.75%a of
thick enough for them to undergo the eyes
TE-CXL.
stroma was thick were selected for a
20 > 400 um
enough for them TE-CXL, when in
to undergo a TE- < 400 um reality their stromal
0 5.62
CXL. thickness was thick
Epi-off CXL TE-CXL enough for them to
< 400 > 400 undergo an Epi-off
CXL.
 Dra. Maria.Henriquez-Izquierdo
Dra. Maria.Henriquez-Izquierdo

UTILITY OF THE AS-OCT

(Epithelial and Stromal maps)
Change the surgical planing 5.62%

EPI OFF TE-CXL

by Scheimpflug By Scheimpflug

5.75%
Results KC
Maximum epithelial thickness get thicker
Minimum epithelial thickness get thinner

Maximum Epithelial Thickness Minimum Epithelial Thickness

Significant thinning of the minimum epithelial thickness

Significant thickening in Maximum epithelial thickness as the severity of KC increases
as the severity of KC increases
Results KC
Minimum stromal thickness get thinner
Min-Max epithelial differences get thicker

Significant thinining of the minimum stromal thickness Significant increase in Min-Max difference of epithelial
as the severity of KC increases thickness as the severity of KC increases
Scheimpflug (Pentacam) AS-OCT (MS-39)

Thinnest Pachymetry 77 um !!!! Thinnest Pachymetry

363 um Difference between 286 um
devices
TE-CXL
Sub400 CXL protocol
Results
Maximum epithelial
Minimum pachymetry thickness
286 um

Minimum Stromal Thickness

210 um
 Dra. Maria.Henriquez-Izquierdo

Conclusions
• AS-OCT and Scheimpflug technology shows significant differences on thinnest
pachymetry meaurements
These differences are greater as the KC severity increases.
Scheimpflug technology shows thicker pachymetry compare with the AS-OCT.

• Data from AS-OCT shows specific changes as KC severity increases

Maximum epithelial thickness get thicker
Minimum epithelial and stromal thickness get thinner

• Data from stromal map coming from the AS-OCT affects the surgical planning of
the type of CXL protocol in at least 5% of cases.
Thank you
@dra.maria.henriquez_izquierdo
mariahenriquez1610@gmail.com
www.oftalmosalud.com.pe
 Scheimpflug AS-OCT
(Pentacam) (MS-39)
Thinnest Minimum stromal
Keratoconus pachymetry thickness
eyes
N=245
< 400 um TE -CXL
< 450 um
TE- CXL
UTILITY
d
ate

> 400 um
oc
al l

Corneal Percentage of eyes

in which the surgical
pachymetry plan was changed
< 400 um due to stromal map
> 450 um information
Epi-off
>400 um Epi-off CXL

Same day