BAMDAD SH MD ASSISTANT PROFESSOR OF...
Transcript of BAMDAD SH MD ASSISTANT PROFESSOR OF...
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B A M D A D S H M D
A S S I S T A N T P R O F E S S O R O F O P H T H A L M O L O G Y
S U M S
Corneal Topography 1
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Placido-based Topography 2
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Topographic pattern 3
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Corneal topographic pattern (Rabinowitz et al)
Round: 21% Oval: 25% Sup steepening: 4% Inf steepening: 11%
Symmetric bowtie: 22% Symmetric with orthogonal axes : 20% Symmetric with skewed axes : 2%
Asymmetric bowtie:11% Asymmetric with sup steepening : 3% Asymmetric with inf steepening :7% Asymmetric with skewed axes :1%
Irregular: 6%
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Clinical applications of topography
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Pre-keratorefractive surgery evaluation Post-keratorefractive surgery evaluation
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Pre-keratorefractive surgery evaluation
Rule out subclinical / suspected KCN Detect / differentiate normal inferior steepining and FFKCN Detect / differentiate of contact lens induced corneal changes with KCN Tear film problems / corneal aberration in dry eye
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•Rule out subclinical / suspected KCN
Pre-keratorefractive surgery evaluation
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Topography scale 8
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Topography scale keratoconus
inferior steepening 9
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Topography scale 10
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Early keratoconus inferior steepening
absolute scale display 11
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Topographic scale upper: absolute scale (1.5D steps)
lower: normalized scale (0.2D steps) 12
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spherical central cornea & much steeper than surrounding cornea
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Topographic pattern findings
Keratoconus detection 20
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Hallmarks of KCN in topography
� Localized steepness � Overall steepness � Inferior steepening � Irregularity of surface (irregular astigmatism) � Asymmetric Bow –tie � Decentered , bended ,broken
� Rapid change of power in a specific area
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Topographic pattern of keratoconus
Inferior steepening, more prominent temporally
Astigmatic type: Central steepening, with asymmetrical bowtie pattern
Asymmetic bow tie (AB) &
skewed radial axes (SRAX)
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Localized steepness asymmetrical bow tie (AB) with inferior
steepening(IS) 23
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Localized steepness asymmetrical bow tie (AB) with superior
steepening(SS) 24
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Localized steepness sup keratoconus
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inferior steepening 26
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inferior steepening
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inferior steepening
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p Central steepening
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Overall steepness Central steepening with symmetrical bowtie
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Overall steepness Central steepening with asymmetrical bowtie 31
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asymmetrical bow tie & skewed radial axes (AB/SRAX) 32
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asymmetric bow tie (AB) & skewed radial axes (SRAX) 33
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Decentered , bended
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Quantitative indices Statistical indices
In order to complement the information provided by the color map several quantitative indices
have proposed
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Statistical indices (1)
Surface asymmetry index (SAI) Inferior-superior index (IS-value) Keratoconus predication index (KPI) Surface regularity index (SRI) Corneal uniformity index (CUI) Analyzed area (AA) Coefficient of variation of corneal power (CVP)
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Potential VA (PVA) Predicated corneal acuity (PCA) Difference in central power between fellow eyes Irregular Astigmatism index (IAI) Highest rate of steepening (HRS) Asphericity
Statistical indices (2) 37
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Average corneal power (ACP) Simulated KR (Simk) Effective refractive power (eff RP) or SEP Apical curvature or keratometry (AK) Apical gradient curvature (ACG) Coefficient of variation of corneal power (CVP)
Statistical indices (3) 38
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Skewed radial axes (SRAX)
If lines dissecting two lobes appear skewed by more than 30 degree from vertical meridian it is called skewed
Statistical corneal indices (SRAX) 39
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Non-orthogonal astigmatism (skewed radial axes)
Skewed radial axes (SRAX): angle between axes of two halves of
bowtie >20º
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SRAX
SRAX measurement 41
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Surface Regularity Index (SRI)
Approach zero for normally smooth corneal surface (<1.0 ) Increases with increasing irregular astig High correlation with BSCVA (PVA) Can predict the optical performance of a normal given corneal
topography
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Surface asymmetry Index (SAI)
SAI increases in asymmetry of a specific meridian like keratoconus and decentered
ablation
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Surface Asymmetry Index (SAI)
Normal SAI <0.5 Indicator of progression of KCN Mild KCN SAI: 1.5 to 2.5 Advanced KCN SAI>5
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Surface Asymmetry Index (SAI)
SAI is zero : A perfect sphere A surface with perfect spherocyl/ Regular astig
Normal cornea is fairly symmetrical (SAI <0.50) Is sensitive to paracentral K.C Part of basis for KCN detection program
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K value: Below 47.2D : normal 47.2 to 48.7D :KCN suspect Higher than 48.7D: clinical KCN
I-S value: Below 1.4: Normal 1.4 to 1.9: suspect KCN More than 1.9: clinical KCN
Keratoconus screening indices (modified Rabinowitz values ) 46
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Keratoconus screening indices Rabinowitz indices
Central corneal power >47.2D I-S value>1.2 Sim-K astigmatism >1.5D Skewed radial exes (SRAX) >21 degrees
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Keratoconus screening indices Klyce-
Maeda indices
Keratoconus predication index (KPI)
Multiple regression analysis of indices
Simk, SAI, five other indices Ranges from 0% to 100%
0% means no keratoconus
100% means severe keratoconus
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Advanced keratoconus KPI=95%
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Moderate Keratoconus KPI=50% 50
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Suspected Keratoconus KPI<5%
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Keratoconus screening indices 52
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Keratoconus screening indices 53
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Newer KCN detection subprograms
Neural network approach (Smolek and Klyce)
KISA % index (Rabinowitz and Rasheed)
To detect keratoconus suspects and
grade severity of keratoconus
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This index is product of 4 indices: K value I-S value SRAX value Regular astigmatism by KR reading
KISA% = (K) x (I-S) x (AST) x (SRAX) x 100
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Keratoconus screening indices (KISA% index) 55
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K value < 47.2D=1 , if>47.2D same number I-S value <1D=1 , if>1D same number SRAX value Regular astigmatism by KR reading , if <1D=1 ,
if>1D same number
KISA% = (K) x (I-S) x (AST) x (SRAX) x 100 300
Keratoconus screening indices (KISA% index)
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Useful longitudinal analysis of suspected keratoconus over time
Clinically obvious KCN: Cut off point of 100%
Keratoconus suspect: 60-100%
Keratoconus screening indices (KISA% index) 57
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Neural network
Based on an artificial intelligence mesh that enable making logic – based decisions , and
modification of information in a process simulating human learning , improves its recognition skills as it gains “experience”
Accuracy 96%
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Pre-keratorefractive surgery evaluation
Detect / differentiate of contact lens induced corneal changes with KCN
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Differential diagnosis of KCN in topography
Artifact: If there is any doubt for subclinical KCN re-exam with good fixation and alignment
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Pseudokeratoconus in topography
Ocular misalignment:Sup or inf eye rotation Inferior eyeball compression
Dry spot formation , tear film accumulation
Contact lens wear (rigid-soft) Displaced apex syndrome
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Normal inferior steepening
1. Elevated I-S value: Inferior corneal axial power>1.5D steeper than
comparable superior region
2. No other clinical or topographic aspects of KCN
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3. Normal topography pattern on elevation based system (Orbscan-Pentacam)
4. No KCN criteria of some of newer KCN detection subprograms
5. Normal pachymetry
Normal inferior steepening 63
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6. Orthogonal astigmatism 7. Stable refraction 8. BSCVA of 20/20 or better 9. Good outcome for myopic surgery 10. Variable outcome for hyperopic surgery
Normal inferior steepening 64
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Topographic pattern of KCN-like inferior steepening alone:
In a patient: More than 30 years of age With stable refraction for 1 year No clinical signs of KCN in either eye No other risks for KCN
Not necessarily a contraindication for PRK
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Normal inferior steepening 66
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Normal inferior steepening 67
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keratoconus Inferior steepening
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Pellucid Marginal Degeneration arching bow tie
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Pellucid Marginal Degeneration arching bow tie
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Pellucid marginal degeneration inferior steepening & against the rule astigmatism PMD -mild
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Pellucid marginal degeneration arching bow tie PMD -moderate
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Pellucid marginal degeneration generalized steepening of central or inferior PMD
-Severe 73
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Pellucid Marginal Degeneration versus keratoconus
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SRAX
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Post-keratorefractive surgery evaluation
Assessment of cornea after refractive surgery (visual problems)
Planning for possible future surgical strategy
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Topographic patterns after PRK irregular - semicircular
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Topographic patterns after PRK irregular - keyhole
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Topographic patterns after PRK irregular – central island
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Topographic patterns after PRK irregular – central island
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Topographic patterns after PRK regular –homogenous
PRK overcorrection 83
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Topographic patterns after PRK
PRK regression & haze
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Topographic patterns after PRK 85
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Topographic patterns after PRK 86
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Topographic patterns after PRK 87
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Topographic patterns after PRK 88
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Topographic patterns after PRK 89
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Topographic patterns after PRK Well –centered ablation 90
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Topographic patterns after PRK M-PRK decentration
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Topographic patterns after PRK H-PRK decentration
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Topographic patterns after PRK ablation decentration
mild gross 93
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Topographic patterns after Lasik myopia hyperopia
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Topographic patterns after Lasik hyperopic astigmatism
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Topographic patterns after Lasik myopic astigmatism
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Topographic patterns after Lasik planning for retreatment
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Tabbara KF, Kotb AA Ophthalmology 2006
Retrospective, comparative analysis of 37 patients who developed post lasik ectasia out of 148 myopic patients
(SE -4 to -8 D) (111 no ectasia age/gender matched controls) 6 parameters, each given a grade 1 to 3 Total grade ≤ 7: no ectasia 8-12: 16/27 (59%) ectasia > 12: 21/21 (100%) ectasia
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Tabbara KF, Kotb AA Ophthalmology 2006 Grade 1 Grade 2 Grade 3
Keratometry < 45 45-47 >47 Oblique Cylinder <0.5 0.5-1.5 >1.5 Pachymetry >520 500-520 <500 Posterior surface <30 30-40 >40 elevation I-S difference <1.0 1.0-1.4 >1.4 Post /Ant BFS <1.20 1.20-1.27 >1.27
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Randleman Ectasia Risk Factor Score System
Ophthalmology 2008 100
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Randleman Ectasia Risk Factor Score System
Ophthalmology 2008 101
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Thanks for your
attention