Elective Treatments

[GarethB]

I think with the wide avriety of people within the group and that post we should perhaps encourage people to look at the literature and anything the do not understand should be posted here.

For example if someone wants to know more about protein purification and identification of which SDS page is one techneque there will be some one who can answer that and say if it is relevenat or not.

I am a microbiologits by training and a research chemist by trade so there is one link to the science community. We have optomotrists that post who will be able to help interpret other aspects of reports.

We have had in the past an optometrist in training that has KC and other medical proffesionals with KC that visit this site, so I think among us there are people who can help others through thje minefield of research into KC and make it more user friendly?

[Hari Navarro]

Hi Gareth,
I had no idea you were a research chemist... this should indeed give you a professional insight into all things technical. I know that you have already been in contact with prof. Lombardi and his clinic but I would be keen to see what you make of any input others in the medical field have of ARK and it's possibilities.
By the way, if you could correct my ignorance, are there any other moderators of this forum whom are also attached in some way to the medical world?

Also I have an off topic question: There is a friend of my wifes mother who also has keratoconus... she underwent PK on her bad eye about a year ago but has now presented with a post-graft cataract.
My question is to the frequency of this problem and what, if anything, are the treatment options?
Any help would be much appreciated,
Regards,
Hari

[jayuk]

Hari

Whilst Im not Gareth, Ill chime in with your question

Post Graft (PK) cataract is the effect of either too high a dose / prolong used of the corticosteroids given to reduce the swelling of the cornea and eye. Cataracts are a side effect of this medication, and I am under the understanding that prolong use means 6months + at around 3+ drops per day.

However, to have the cataracts after a year, would mean one of the following a) she had them before but they were mild and the corticosteroids have accelerated them b) her eye is extremely sensitive to the corticosteroids.

Treatment options are to have them removed when they get in the way of vision. This I am led to beleive is a simple process and will not affect the grafted tissue.

HTH

Jay

[GarethB]

Cateracts can be a side effect of steroidal eye drops, but firstly you have to be on a high dose for a long time. However this does not mean you will get cataracts. The reaso the risk is mentioned on the patient leaflet is because during clinical trilas the start of catarcts may have been observed so the manufacturers are duty bound to list it. If anyone died during the trilas and the only link was use of eye drops that would have to be noted too even if it is a single case.

The manufacturers are just covering themselves really.

Age is also a factor, as we get older chances of a cataract is more common. We have developed ways of lving longer faster than the rest of our body can evolve. There was a time where we would be eaten my prey animals before cataracts became a real problem. So in one respect long ago KC would not really exist as we would have been eaten before we knew wh had a real problem

Survival of the fitest.

Grafts at a real young age are not the most common but I could be wrong.

It is possible the cataract was always present to a lesser extent and the use of steroid drops caused the cataract to ripen a little quicker.

These are merly suggestions and initself would require further research.

[rosemary johnson]

As regards why no-one has produced an article with the counter-argument to ARK and published it:
- serious medical journals wouldn't print an article refuting something that itself hasn't been published. In some ways this is just etiquette - the proposers should have presented their case before others get the chance to try to shoot it down.
More practically, there is always great pressure from authors (or would-be authors_ trying to get papers published, and great pressure from funding bodies to produce long lists of publications to prove one is a scientist worth funding..... so a world where artciles can be published saying, in effect "X has been suggested as a treatment for disease Y, but it's a very silly idea dn here's why" would make it far too easy for people needing a longer publication list for their next grant application to come up with daft ideas with their mates inthe bar, just so they can write papers saying what a silly idea they are....
SOrry to sound cynical! - but in practice the reason that serious peer-reviewed medical journals (and all serious jscientific journals do have their papers peer-reviewed before accepting them for publication) haven't printed a counter-argument against ARK is that they haven't first printed a paper in favour of it.
Carch 22/ - maybe!

As regards less formal fora - I thought there was (once??) smething baout ARK written by ROger Buckley on the KC group site???? Is my memory playing tricks on me again?

As regards cataracts: maybe we should have a Post0Graft Cataract FAQ? ANyone like to offer to write one??
Rosemary

[GarethB]

Rosemary,

I think this is the link you are reffering to Ken Pullen regarding ARK

I have not clicked on the link at the top of the page this will divert you too, but having a quick read of the article on the KC site to me is dicsussng ARK.

Harri will correct me if I am wrong, but I think he had mini-ARK and that is what Prof Lombardi is doing now. To me the procedures used in RK, ARK and mini-ARK at first glance are similar but there are probably subtle differences which may make the differnce to KC.

[Hari Navarro]

Thanks everyone for your help and advice on all this. Does anyone know exactly what the process is for treating post graft cataracts? The Kcer friend of the family that I am talking about does not speak english so I would like to be able to give her as much info as possible.

As regards published ARK data there was... up untill the late 90's a concerted effort by prof Lombardi to have his work acknowledged. As he is based in Rome then of course the majority of his ideas that actually found print were in Italian, the following is a partial list:

1.
New Idea/Asymmetric radial keratotomy for the correction of keratoconus
Author: Massimo Lombardi, MD; Marco Abbondanza, MD
Source: Journal of refractive surgery - Vol. 13, no. 3
Date: May/June 1997

2.
Title: Update on keratoconus microsurgery
Author: Prof. Massimo Lombardi
Source: Leadership Medica
Date:
Link: http://www.cesil.com/

3.
Title: Aesthesiometry of the cornea after corneal surgery
Author: Kohlhaas M, Draeger J, Bohm A, Lombardi M, Abbondanza M, Zuppardo M, Gorne M.
Source: Pub Med
Date: Oct. 1992
Link: http://www.ncbi.nlm.nih.gov/

Additionally:

[1] Radial keratotomy in high myopia - Acta Medica Latina - year XI - no. 1 - 1986
[2] Radial keratotomy for high myopia - L'Uomo e la Medicina - Vol. 4 - no. 2 - 1988
[3] Keratocoagulation - La Stampa Medica Europea - Vol. 8 - no. 2 - 1988
[4] Surgical correction of keratoconus - EUR Medicina - Vol. 7 - no. 2 - 1988

[5] Surgical correction of keratoconus through Asymmetric Radial Keratotomy - Rivista di
oftalmologia sociale - year 15 - no. 2 - 1992
[6] A new method of computerized study of the corneal 'Haze' as a consequence of photo-
ablation with excimer laser - La Nuova Stampa Medica Italiana - Vol. 14 - no. 1 - 1994
[7] Mini Asymmetric Radial Keratotomy for the surgical correction of keratoconus in the initial
stage in the hypermetropic and myopic subject - Esperienze - year XII - no. 1 - 1997

So you see there is a body of published work out there that has not had the courtesy of a professional replie. Prof Lombardi and his clinic are not selling snake oil here... this procedure is being portrayed by its creator as a viable option for certain stages of KC, one that prof. Lombardi has had published and one that stretches back nearly 20 years.

Regards,
Hari

[Hari Navarro]

Further to the contention that incisional surgury should be reviewed as being viable for Keratoconus treatment we have this recent study.
Although it regards RK and not ARK there is still interest as both are generally considered contridictions (both defy the general 'stone wall' approuch of rejecting ANY incision into an already compromised Keratoconic cornea /note that in this case, as with ARK, very careful consideration is given to corneal thickness to access each patient on an individual basis).
If this is anything like ARK then it is not a standarized operation, it is no production line technique.:

Radial keratotomy for the optical rehabilitation of mild to moderate keratoconus: more than 5 years' experience.

Utine CA, Bayraktar S, Kaya V, Kucuksumer Y, Eren H, Perente I, Yilmaz OF.

Beyoglu Eye Education and Research Hospital, Istanbul--Turkey.

PURPOSE: To present the authors' long-term experience of radial keratotomy (RK) for the optical rehabilitation of patients with mild to moderate keratoconus--central corneal thickness of greater than 400 microm and without apical scarring.

METHODS: In this observational, noncomparative series of cases, all consecutive patients with mild or moderate keratoconus, treated by RK between 1990 and 2002, with at least 1 year follow-up were included. A total of 170 eyes of 96 patients were investigated. Mean follow-up was 42.08 +/- 28.14 months. Visual acuity, refraction, corneal curvature, central corneal thickness, and complications were evaluated.

RESULTS: In all of the control visits, mean uncorrected and best spectacle corrected visual acuities were better than preoperative values (p<0.0001). Preoperative myopic spherical refraction decreased significantly (p<0.0001), and remained relatively unchanged throughout the follow-up (p=0.43). A small but statistically significant decrease from baseline was ob-served in astigmatism (p=0.038), which almost disappeared 1 year after the surgery (p=0.47). The surgery produced a statistically significant flattening of the corneal curvature (p<0.0001). Central corneal thickness did not change significantly (p>0.05) in either control visit. In 33 eyes (19.4%), re-deepening of the incisions was required. In 3 eyes (1.8%) penetrating keratoplasty was performed, due to disease progression in 2 eyes (1.2%) and acute traumatic hydrops in 1 eye (0.6%). In 4 eyes (2.2%) microperforation, in 2 eyes (1.2%) macroperforation, in 1 eye (0.6%) infectious keratitis, and in 1 eye (0.6%) hyperopic shift occurred.

CONCLUSIONS: RK surgery was found to be a reasonable option for the rehabilitation of a selected group of keratoconus patients in the early or moderate stages.

PMID: 16761238 [PubMed - indexed for MEDLINE]

[jayuk]

Interesting study but alittle unclear

a) what was the VA changes, both aided and unaided......as to me "In all of the control visits, mean uncorrected and best spectacle corrected visual acuities were better than preoperative values" means nothing. BETTER is not informative or descriptive.

b) its obvious now that for Medium to Advanced KC this treatment simply isnt an option...as I am assuming that the 400 Micron is an average pre-qualification figure based on 6 or 9 point touch measurement?

On an off topic, and lets now assume this treatment would be for Mild KC; what is the recovery time?....I just still cant see this treatment being of high value at Mild KC.....when with the current level of lens technology and with C3R emerging, being taken seriously.....which then makes me wonder why sooo many of the optham community havent given this treatment the time of day?......something just doesnt add up here!

Again, im merely questioning this...not just rubbising it....I just cant help but wonder why soo many people have panned this treatment.............surely it must make you wonder?......one person can be wrong, two people can be wrong, but hundreds?......

J

[Hari Navarro]

I just cant help but wonder why soo many people have panned this treatment.............surely it must make you wonder?......one person can be wrong, two people can be wrong, but hundreds?

This is exactly my point... It's not a question of promoting ARK or RK, for me at least its a question of qualifying why I was told time and time again that ARK was a definite contridiction to KC and should be attempted at my peril.
When pushed as to why this was the case I was again more often than not told that this is a question of medicine and that I wouldn't understand the answer if I was givin it. This kind of response both angered me and also drove me to dig deeper... I had to see past this 'brush off' mentality.
As I have said...each case is individual and no one except the doctor using this technique can simply blanket dismiss ALL mid range and higher cases of KC.

The lens technology you speak of is another point of contention that is best decided on by the user... I for instance can not see how even the greatest lens technology does not hinder the daily function of the cornea in some way... and who's to say that even the slightest offset in natural activity will not have an adverse effect? Cross-linking is still in its infancy and we do not know what the future will hold... although in this case it does look bright.

I'm just saying that no treatment can be dismissed out of hand without stringent investigation.

Hari