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      Intracorneal Ring Segment Implantation in the Management of Keratoconus: An Evidence-Based Approach

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          Abstract

          Intracorneal ring segment (ICRS) implantation represents a modern, minimally invasive, surgical option for visual improvement in patients with keratoconus. ICRS modify the corneal geometry in a manner that enhances its refractive properties and thereby, they improve visual acuity. It is well-documented that implantation of ICRS decreases the keratometric readings, spherical equivalent and cylinder, reduces high-order aberrations and improves uncorrected distance visual acuity (UDVA) and best-corrected distance visual acuity (BCDVA) in patients with keratoconus. Success rate after ICRS implantation is high, depending on appropriate patient selection and adherence to suitable implantation nomograms, and most important, the overall complication rate is very low. This review is summarizing current indications/contra-indications for ICRS implantation, implantation techniques, clinical outcomes and potential complications, shedding light on myths and realities related to this innovative surgical option.

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          Intracorneal ring segments in ectatic corneal disease - a review.

          David Piñero, Jorge Alio (2010)
          The purpose of this review is to collect and summarize all the scientific literature regarding the use of intracorneal ring segments (ICRS) in corneal ectatic disease. These implants, initially designed to correct myopia in normal eyes, are implanted in the deep corneal stroma with the aim of achieving modifications to the corneal curvature and subsequently refractive adjustments. Colin et al. in 2000 were the first to report the efficacy of these implants in reducing the refractive error and corneal steepening in keratoconus eyes. Two main types of ICRS have been developed and used for the treatment of ectatic corneal disease, different in profile and diameter of implantation: Intacs and Ferrara rings. Successful outcomes have been reported by several authors with these implants in keratoconic eyes using different nomograms. Besides keratoconus, ICRS have been also used successfully for the management of pellucid marginal degeneration and post-laser in situ keratomileusis corneal ectasia. The implantation procedure may be performed today by two surgical techniques to create the corneal channels where implants are inserted: mechanical dissection using a manual semicircular dissector (mechanical-assisted) and photodisruption of lamellar tissue using the femtosecond laser technology (femtosecond-assisted). With both techniques, visual, refractive and topographic improvements have been observed, although higher incidence of intraoperative and postoperative complications have been reported with the mechanical procedure according to the evidence found in the peer-reviewed literature. ICRS technology is a promising therapeutic option in corneal ectatic disease, avoiding corneal graft and allowing a visual and refractive rehabilitation.
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            Collagen fibril orientation in the human corneal stroma and its implication in keratoconus.

            A Daxer, P Fratzl (1997)
            The kind and the degree of preferred collagen fibril orientation in normal human corneal stroma were investigated as important qualities of the cornea with respect to its mechanical properties and, hence, to refractive surgery. To determine whether this information is relevant to corneal disease, the authors investigated collagen fibril orientation in several corneas with keratoconus. By means of low-angle x-ray scattering, 17 normal human corneas and four corneas of eyes with keratoconus were investigated. Collagen fibrils in the normal human corneal stroma showed two preferred orientations orthogonal to each other. These were the horizontal and the vertical directions. The authors defined a degree of orientation gamma, determined to be gamma = 0.49 +/- 0.10 (mean +/- SD). This means that the excess of the preferentially oriented fibrils in relation to the total number of fibrils was approximately 49%. It follows from this value that approximately two thirds of the fibrils (66%) were within in a 45 degrees sector (+/-22.5 degrees) around the horizontal and vertical meridians, whereas approximately one third (34%) is oriented in the oblique sectors in between. No statistically significant variation of gamma within a central 7 mm zone could be detected in normal corneas. The orthogonal arrangement of the collagen fibrils was, however, profoundly altered in keratoconus, in which nonorthogonal orientations were found inside the apical scar. The normal human corneal stroma shows a considerable degree of structural anisotropy. It is characterized by two preferred collagen fibril orientations orthogonal to each other. Alteration of the regular orthogonal arrangement of the fibrils in keratoconus may be related to the biomechanical instability of the tissue.
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              Intracorneal ring segments for keratoconus correction: long-term follow-up.

              Magda Shabayek, L. Alio, A Artola (2006)
              To evaluate long-term results and stability of intracorneal ring segment (Intacs) implantation for keratoconus correction. Vissum, Instituto Oftalmológico de Alicante and University of Miguel Hernandez, Alicante, Spain. This retrospective study comprised 13 eyes operated on between April 2000 and December 2001 that had Intacs implantation for keratoconus correction. The outcomes were evaluated at 6, 12, 24, and 36 months in all eyes and at 48 months (6 eyes). Mean best spectacle-corrected visual acuity (BSCVA) increased from 0.46 (20/50) preoperatively to 0.66 (20/30) postoperatively (P< or =.001). Mean decrease of inferior-superior (I-S) asymmetry was 2.81 diopters (D) (P< or =.02), and the average K-value was 3.13 D (P< or =.001). Mean difference between 6 and 36 months (stability) showed no significant difference regarding BSCVA (P< or =.5) and I-S asymmetry (P< or =.6). Although a significant increase was noticed in the average K by 1.67 D (P< or =.002), at 36 months it did not reach the initial preoperative values. Intacs increased the BSCVA and decreased I-S asymmetry with stability up to 36 months. In spite of the decrease of the K-values at 6 months, a further significant increase was detected 36 months after surgery.
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                Author and article information

                Contributors
                Zisis Gatzioufas: zisisg@hotmail.com
                Journal
                Journal ID (nlm-ta): Ophthalmol Ther
                Journal ID (iso-abbrev): Ophthalmol Ther
                Title: Ophthalmology and Therapy
                Publisher: Springer Healthcare (Cheshire )
                ISSN (Print): 2193-8245
                ISSN (Electronic): 2193-6528
                Publication date (Electronic): 11 October 2019
                Publication date PMC-release: 11 October 2019
                Publication date (Print): October 2019
                Volume: 8
                Issue: Suppl 1
                Pages: 5-14
                Affiliations
                [1 ]Ophthalmica Institute, Thessaloniki, Greece
                [2 ]GRID grid.411937.9, Department of Ophthalmology, , University Clinic Saarland, ; Homburg, Saarland Germany
                [3 ]GRID grid.11804.3c, ISNI 0000 0001 0942 9821, Department of Ophthalmology, , Semmelweis University, ; Budapest, Hungary
                [4 ]GRID grid.410567.1, Department of Ophthalmology, , University Hospital Basel, ; Basel, Switzerland
                Article
                Publisher ID: 211
                DOI: 10.1007/s40123-019-00211-2
                PMC ID: 6789055
                PubMed ID: 31605316
                SO-VID: 40f04012-7f78-4e45-be8a-84433b649710
                Copyright © © The Author(s) 2019
                History
                Date received : 15 May 2019
                Categories
                Subject: Review
                Custom metadata
                issue-copyright-statement © The Author(s) 2019

                Keywords: implantation,intracorneal ring,keratoconus
                Data availability:
                Keywords: implantation, intracorneal ring, keratoconus

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