Improving Refractive Outcomes in Keratoconic Eyes

Two recent meta-analyses help inform management strategies.

Abdulkader Almosa, BS, BGS, and Zaina Al-Mohtaseb, MD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Recent research assessed how to improve refractive outcomes in eyes with keratoconus A meta-analysis of 14 clinical studies found that the implantation of corneal allogeneic intrastromal ring segments significantly improved the distance visual acuity of patients with keratoconus A meta-analysis of 16 observational studies found that posterior chamber ICLs (both the Visian and EVO models, STAAR Surgical) significantly improved the vision of patients with keratoconus Visual and Topographic Outcomes After Corneal Allogeneic Intrastromal Ring Segments for Keratoconus: A Systematic Review and Meta-Analysis Friedrich M, Auffarth GU, Soiberman U, Augustin VA, Khoramnia R, Son HS1Industry support for this study: None ABSTRACT SUMMARY This systematic review and meta-analysis evaluated visual, refractive, and topographic outcomes after the implantation of corneal allogeneic intrastromal ring segments (CAIRS) in keratoconic eyes. The investigators screened major medical literature databases and included 14 peer-reviewed clinical studies comprising 442 eyes total. The primary outcome was the change in patients’ corrected distance visual acuity (CDVA), with secondary outcomes including their uncorrected distance visual acuity (UDVA), spherical equivalent (SE), refractive cylinder, keratometry parameters, higher-order aberrations (HOAs), and postoperative complications. STUDY IN BRIEF A systematic review and meta-analysis of 14 clinical studies (442 eyes) found that the implantation of corneal allogeneic intrastromal ring segments (CAIRS) significantly improved the uncorrected and corrected distance visual acuity of patients with keratoconus and reduced their keratometric values with a low rate of complications. WHY IT MATTERS CAIRS are a minimally invasive, tissue-based alternative to synthetic intrastromal corneal ring segments and keratoplasty in select keratoconus patients. The improvements in visual, refractive, and topographic outcomes combined with a favorable safety profile demonstrated in this study suggest that CAIRS could offer a way to improve the vision of patients with keratoconus while also reducing their dependence on contact lenses. Pooled analysis demonstrated a mean improvement in patients’ CDVA and UDVA of 0.37 logMAR and 0.43 logMAR, respectively—approximately 4 Snellen lines. The SE improved by 4.59 D, and maximum keratometry was reduced by 4.49 D. Reductions were also observed in mean keratometry values and total HOAs, and the thinnest pachymetry reading remained relatively stable. One reported severe adverse event (0.2%) involved acute graft rejection and required CAIRS explantation.

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Predicting Progression to GA Using Imaging Biomarkers

Several OCT findings can help clinicians better understand a patient’s risk of progression to sight-threatening disease.

Kelly Donovan, MD, PhD, and Eleonora M. Lad, MD, PhD

Retina Today

KEY TAKEAWAYS In the clinic, the most granular assessment of retinal anatomy is derived from OCT, which has generated most modern imaging biomarker candidates. Promising dry AMD imaging biomarkers include drusenoid lesions, intraretinal hyperreflective foci, loss of outer retinal integrity, choriocapillaris perfusion and thickness, and pigmentary changes. Eventually, the integration of multivariable risk calculators may provide composite progression estimates for patients, clinicians, and researchers. The modern parameters for dry AMD disease staging were first outlined by the Beckman classification in 2013.1 In 2017, the Classification of Atrophy Meeting provided an updated consensus on OCT-based classification of geographic atrophy (GA).2 Dry AMD disease staging relies on a combination of dilated fundus examination, color fundus photography (CFP), fundus autofluorescence (FAF), and OCT. Disease progression is gauged by these same modalities, with OCT being the most reliable for assessing interval anatomic changes. FAF is particularly well-suited for tracking GA lesion topography over time, with active expansion of GA lesion(s) on FAF representing the key indication for considering anticomplement therapy. Other structural and functional testing modalities are also under investigation as adjuncts for assessing the progression of dry AMD. For example, there is burgeoning interest in using OCT angiography to evaluate regional flow features of the choriocapillaris in different stages of dry AMD.3 In addition, functional measurements can be used to quantify sub-anatomic AMD progression in patients, with studies validating functional metrics such as microperimetry, dark adaptation, contrast sensitivity, and low-luminance visual acuity.4,5 In clinic, the most granular assessment of retinal anatomy is derived from OCT, which has generated most modern imaging biomarker candidates. A variety of tomographic disease features have been reported, providing us with broad insight into the diversity of anatomic changes that can occur during the natural history of dry AMD. The ability to leverage these imaging biomarkers into risk stratification algorithms will improve our ability to counsel patients and direct clinical trial design.