Más contenido relacionado La actualidad más candente (20) Similar a INTACS Nomogram (13) INTACS Nomogram1. A D D I T I O N
T E C H N O L O G Y
I N C .
T h e
L ea d er
I n
C o rn ea l
S c i en ce
&
I m p l a nt
Tec h n o l o g y
!
C O M P R E H E N S I V E
N O M O G R A M
!
A N D
P R E -‐ S U R G I C A L
P L A N N I N G
G U I D E
UPDATED
February 1, 2011
w w w . A d d i t i o n T e c h n o l o g y . c o m
I n t e r n a t i o n a l
U s e
O n l y
9 5 0 L e e S t re e t , S u i t e 2 1 0 , D e s P l a i n e s , IL 60015 • t e l e p h o n e: (847) 297-8419 • fax : (847) 297-8678
2. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
AddiEon
Technology
in
collaboraEon
with
highly
experienced
Intacs
surgeons
have
analyzed
thousands
of
cases
over
a
mulE-‐year
period
to
provide
a
“best
pracEces”
approach
to
pre-‐
surgical
planning.
The goal of Intacs is to restore functional vision by re-
shaping the cornea from within the stromal layers thus Quick
Summary:
changing the optical properties of the cornea.
Step
1:
View
corneal
topogra-‐
The
following
nomogram,
pearls
and
pre-‐surgical
plan-‐ phy
and
manifest
refracEon.
ning
steps
have
been
created
to
assist
you
with
your
ini-‐ Step
2:
Verify
steep
meridian
Eal
cases.
AddiEonal
pearls
and
Eps
are
available
via
for
incision
locaEon.
your
on-‐line
account
at
www.addiEontechnology.com.
Contact
your
representaEve
for
further
assistance
with
Step
3:
Select
Intacs
segments
pre-‐surgical
planning
and
case
review. using
nomogram
on
this
page.
Keratoconus
Nomogram
-‐
Intacs
Choose
symmetric
or
asymmetric
segments
using
the
following
guidelines:
Use
the
symmetric
chart
when
the
cone
on
the
posterior
float
is
within
the
central
3-‐5
mm
opEcal
zone
and
the
sphere
power
is
greater
than
the
cylinder
power
on
the
manifest
re-‐
fracEon
notated
in
posiEve
cylinder.
Use
the
asymmetric
chart
when
the
cone
on
the
posterior
float
is
located
outside
the
3
mm
geometric
center
and
the
cylinder
power
is
greater
than
the
sphere
power
on
the
manifest
refracEon
notated
in
posiEve
cylinder.
When
the
sphere
power
is
equal
to
or
similar
to
the
cylinder
power
on
the
manifest
refrac-‐
Eon
notated
in
posiEve
cylinder,
use
the
symmetric
chart
however,
consider
asymmetric
chart
when
cone
is
de-‐centered
or
superior-‐nasal
periphery
shows
considerable
flaWening
compared
to
inferior-‐temporal
periphery.
See
Verifier
3.
SYMMETRIC
Sphere
Power Inferior
Intacs Superior
Intacs
-‐0.00
to
-‐1.00
D 0.210
mm 0.210
mm
-‐1.00
to
-‐1.75
D 0.250
mm 0.250
mm
-‐2.00
to
-‐2.75
D 0.300
mm 0.300
mm
-‐3.00
to
-‐3.75
D 0.350
mm 0.350
mm
-‐4.00
to
-‐4.75
D 0.400
mm 0.400
mm
Over
-‐5.00
D 0.450
mm 0.450
mm
ASYMMETRIC
Cylinder
Power Inferior
Intacs Superior
Intacs
2.00
to
3.00
.350mm
.210mm
3.00
to
4.00
.400mm
.210mm
4.00
and
higher
.450mm
.210mm
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
1
3. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
Myopia
Nomogram
-‐
Intacs
SYMMETRIC
Spherical
Power Inferior
Intacs Superior
Intacs
-‐0.00
to
-‐0.75
D 0.210
mm 0.210
mm
-‐0.75
to
-‐1.00
D 0.230
mm 0.230
mm
-‐1.00
to
-‐1.30
D 0.250
mm 0.250
mm
-‐1.30
to
-‐1.70
D 0.275
mm 0.275
mm
-‐1.70
to
-‐2.00
D 0.300
mm 0.300
mm
-‐2.00
to
-‐2.30
D 0.325
mm 0.325
mm
-‐2.30
to
-‐2.70
D 0.350
mm 0.350
mm
-‐2.70
to
-‐3.00
D 0.375
mm 0.375
mm
-‐3.00
to
-‐3.40
D 0.400
mm 0.400
mm
-‐3.40
to
-‐3.70
D 0.425
mm 0.425
mm
Over
-‐4.00
D 0.450
mm 0.450
mm
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
2
4. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
Intacs
Pre-‐Surgical
Planning
Guide
Step
1:
Measurements
&
Materials
Ideal
measurements
and
materials:
• Manifest
refracEon
• BCVA
/
UCVA
• Corneal
topography
• Axial
• Posterior
Float
• Keratometric
(Numeric
Overlay)
• Pachymetry
(at
least
4-‐6
locaEons)
• Min
K
&
Max
K
values
(on
topography)
Other
measurements
to
consider
notaEng
and
topography
views
include:
• Incision
locaEon
and
depth
(measured
and
actual)
• Contact
lens
tolerance
• Contact
lenses
prescribed
(pre
&
post
operaEve)
• Endothelial
cell
counts
are
not
necessary
but
may
be
helpful
• Numeric
Overlay
• RefracEve
Power
(Front)
• Mean
Power
Keratometric
Defini>ons:
Steep
Meridian:
IdenEfied
as
the
manifest
refracEon
axis
in
posiEve
cylinder
notaEon
or
the
topographical
Max
K
axis.
Flat
Meridian:
IdenEfied
as
the
manifest
refracEon
axis
in
minus
cylinder
notaEon
or
the
topographical
Min
K
axis.
Step
2:
Incision
Placement
&
Cone
Loca>on
Verify
steep
meridian
for
incision
placement.
The
manifest
refracEon
axis
notated
in
posiEve
cylinder
and
the
Max
K
axis
on
topography
should
match.
If
they
vary
by
±
15°,
see
Verifier
2
for
more
details.
The
“red”
line
in
image
below
idenEfies
the
steep
meridian.
Using
a
posterior
view,
idenEfy
if
the
cone
is
centered
or
de-‐centered
by
using
the
3
mm,
5
mm
and
7
mm
markings
on
topography.
Draw
a
line
across
the
cornea
in
the
direcEon
of
cone
displacement
(blue
line
in
image
on
lel).
In
most
cases,
the
incision
is
placed
superior-‐temporal
on
the
steep
meridian.
See
Verifier
1
below
for
more
details.
Step
3:
Segment
Selec>on
-‐
See
nomogram
on
page
1
The
keratoconic
cornea
has
unique
biomechanical
properEes
and
asymmetric
irregulariEes
whereby
a
number
of
measurements
may
require
verificaGon
prior
to
surgery.
The
supporEng
pages
outline
key
verifiers
helpful
in
enhancing
results.
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
3
5. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
Verifiers
For
Pre-‐Surgical
Planning
The
refracEve
power
of
the
cornea
is
based
on
the
curvature
and
symmetry
of
the
corneal
sur-‐
face.
In
keratoconus,
the
corneal
surface
is
irregular
resulEng
in
compound
/
irregular
asEgma-‐
Esm.
Each
keratoconus
case
is
unique
with
various
irregular
properEes
that
can
be
evaluated
using
diagnosEc
data
that
has
been
idenEfied:
• With
the
Manifest
RefracEon
• From
the
BCVA
/
UCVA
findings
• Across
the
anterior
surface
of
the
cornea
(keratometric
values)
• Within
the
stromal
layers
(pachymetry
values)
• From
the
corneal
back
surface
(posterior
float)
Verifier
1:
Posterior
Float
-‐
Centered
or
De-‐centered
Centered
cones
typically
call
for
symmetric
segments
whereas
de-‐centered
cones
call
for
asym-‐
metric
segments.
Using
the
posterior
view
showing
cone
displacement
helps
with
choosing
symmetric
or
asymmetric
segments.
EvaluaEng
cone
locaEon
and
displacement
also
aids
in
verifying
the
proposed
incision
locaEon
&
Intacs
placement.
To
idenEfy
the
proposed
incision
locaEon,
draw
a
“blue”
line
across
the
center
of
the
posterior
view
in
the
direcEon
the
cone
is
displaced.
Then,
draw
a
“red”
line
perpendicular
to
the
“blue”
line
making
a
plus
sign
or
“X”
over
the
posterior
view
(See
Figure
1).
The
blue
line
represents
the
flat
meridian
(where
the
Intacs
will
be
placed)
and
the
red
line
represents
the
steep
merid-‐
ian
(where
the
incision
will
be
placed).
NoEce
the
Max
K
axis
and
manifest
refracEon
axis
in
posiEve
cylinder
notaEon
should
match.
Match
Mis-‐Match
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
4
6. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
Verifier
2:
Manifest
Refrac>on
vs
Steep
K
(Max
K)
Axis
&
BCVA
Compare
the
axis
in
the
manifest
refracEon
notated
in
posiEve
cyl-‐
inder
to
the
Max
K
axis
on
topography.
Is
the
BCVA
20/50
or
beWer?
In
an
ideal
case,
the
Max
K
axis
and
manifest
refracEon
axis
in
posi-‐
20/50
Eve
cylinder
notaEon
should
match
within
15ᴼ
of
each
other
and
be
located
along
the
steep
meridian
idenEfied
in
Verifier
1.
Each
case
is
unique.
The
BCVA
provides
us
informaEon
on
how
well
the
paEent
“sees”
with
their
current
refracEon.
When
the
BCVA
is
worse
than
20/50,
and/or
there
is
more
than
a
15°
difference
between
the
BCVA
and
the
Max
K
axis,
re-‐take
the
manifest
refracEon
and/or
topog-‐
raphy
to
confirm
they
match
or
conEnue
to
look
at
the
verifiers
in
this
guide.
Verifier
3:
With-‐The-‐Rule
As>gma>sm
vs
Against-‐The-‐Rule
As>gma>sm
&
Corneal
Imbalance
Color
paWerns
and
K
values
on
the
keratometric
Figure
2
view
provide
important
informaEon
for
evaluat-‐
ing
corneal
refracEve
imbalance.
First,
idenEfy
the
steep
and
flat
areas
of
the
map
by
visual
ob-‐
servaEon
of
the
map
colors.
Is
there
a
clear
dis-‐
EncEon
of
blue
(superiorly)
and
red
(inferiorly)?
Is
the
map
mostly
red?
Does
the
overall
paWern
look
like
an
hourglass?
PMD
(Crab
claw)?
Is
the
cone
on
the
posterior
view
centered
or
de-‐
centered?
Next,
evaluate
the
K
values
on
the
keratometric
view
or
use
a
numeric
overlay
view
and
evaluate
K
values
across
all
areas
of
the
map.
If
the
map
clearly
shows
a
split
of
blue
and
red
color
in
the
6
-‐
7
mm
diameter,
idenEfy
the
steepest
K
values
(circle
them)
and
the
flaWest
K
values
(circle
Figure
3
them).
Then,
idenEfy
the
K
values
that
are
most
similar
on
opposite
sides
of
each
other
(See
fig-‐
ure
2).
In
these
cases,
asymmetric
segments
are
ideal
unless
the
cone
is
centered
on
the
posterior
float
(See
figures
2
and
3).
If
the
map
looks
like
a
crab
claw
(PMD),
noEce
how
the
flaWest
peripheral
K
readings
are
oppo-‐
site
the
steepest
peripheral
K
readings
along
the
the
flat
meridian
(See
figure’s
2
&
3).
In
PMD
to-‐
pographical
paWerns,
the
flaWest
peripheral
K
reading
is
usually
significantly
less
than
the
op-‐
posing
steep
peripheral
K
reading
(<41K).
Also,
noEce
the
two
similar
peripheral
K
readings
op-‐
posite
each
other
located
along
the
steep
merid-‐
ian
circled
in
white
in
figure’s
2
&
3.
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
5
7. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
OpEcally,
the
asEgmaEsm
in
highly
asym-‐ Figure
4
metric
PMD
cases
is
typically
against-‐the-‐
rule
and
requires
balancing
inferior
and
su-‐
perior
to
the
steep
meridian
and
can
some-‐
Emes
be
located
along
the
oblique
axis.
If
the
map
looks
like
an
incomplete
crab
claw
(PMD-‐Like)
or
a
highly
irregular
hour
glass
or
snowman
with
a
very
small
crooked
head
(see
figure
4),
noEce
how
the
flaWest
peripheral
K
readings
are
90°
away
from
the
steep
meridian.
The
asEgmaEsm
in
these
cases
is
mostly
oblique.
Symmetric
seg-‐
ments
are
commonly
recommended
how-‐
ever,
asymmetric
segments
may
be
used
depending
on
the
posterior
cone
displace-‐
ment,
the
amount
of
cylinder
and
how
flat
the
superior
side
of
the
steep
meridian
shows.
Figure
5
If
the
map
looks
like
an
hourglass
(see
figure
5),
noEce
how
the
peripheral
K
readings
are
fairly
similar
and
the
two
similar
peripheral
K
readings
opposite
each
other
are
located
along
the
flat
meridian.
The
asEgmaEsm
in
these
cases
is
typically
with-‐the-‐rule
and
requires
balancing
nasal
and
temporal
to
the
steep
meridian.
The
steep
meridian
axis
may
vary
±
15°
and
may
someEmes
be
lo-‐
cated
along
the
oblique
axis.
Symmetric
segments
are
commonly
used.
Verifier
4:
Pachymetry
IdenEfying
the
peripheral
pachymetry
can
be
an
indicator
for
corneal
health
and
can
be
a
characterisEc
in
detecEng
corneal
ecta-‐
sia
1.
Thin
peripheral
readings
can
help
verify
cone
displacement
in
some
cases
and
can
assist
in
verifying
incision
locaEon
and
placement.
1
R.
Ambrósio
Jr,
Poster
ASCRS
2006
Note:
Determining
segment
selecGon
is
dependent
upon
the
surgeons
decision
where
to
im-‐
prove
sphere
and/or
cylinder
correcGon
to
best
achieve
a
biomechanical
and
refracGve
corneal
balance.
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
6
8. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
Corneal
Topography
Views
&
Various
Cone
Examples
-‐9.75
+2.25
x
56 -‐3.25
+5.75
x
162
-‐5.75
+3.75
x
123 -‐11.25
+3.50
x
47
-‐8.75
+2.00
x
107 -‐3.75
+5.50
x
30
-‐5.25
+3.00
x
67 -‐4.50
+7.00
x
14
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
-‐
Plus
Cylinder
NotaEon
7
9. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
Intacs
Guidelines
&
Pearls
General
Guidelines
&
Pearls
• Incision
depth
should
be
a
minimum
of
70%.
• Snug
incision
closure
with
10.0
nylon
suture.
Maintain
for
up
to
2
months.
• Keep
cornea
hydrated
during
surgery.
• PaEents
with
pupils
greater
than
7
mm
may
be
predisposed
to
low
light
sensiEvity
such
as
glare
and
halos
and
should
be
appropriately
advised.
• Single
segments
are
not
recommended.
• It
may
take
3
–
6
months
for
visual
acuity
to
stabilize.
• When
creaEng
a
channel
where
the
cornea
is
thinnest,
slowly
advance
the
dissector
threading
into
stroma.
If
any
resistance
or
wave-‐like
appearance
is
seen
with
corneal
Essue,
slow
or
stop
dissecEon/
inserEon
unEl
Essue
adjusts.
• UElizing
a
disposable
contact
lens
to
manage
spherical
correcEon
during
the
first
1
-‐
6
months
may
aid
in
final
contact
lens
success.
Advise
paEent
of
visual
limitaEons
due
to
no
cylindrical
correcEon
with
disposables.
• Contact
lens
fixng
can
start
as
early
as
6
weeks
with
the
understanding
that
vision
may
fluctuate
for
up
to
3
–
6
months
before
stabilizing.
• Vision
conEnues
to
improve
over
Eme.
3,4
Pa>ent
Acceptance
Criteria
• PKP
a
consideraEon
• Diagnosis
indicates
ectaEc
condiEon
• Contact
lens
intolerant
(Clear
central
cornea)
• Pachymetry
at
least
450μ
at
incision
locaEon
Femtosecond
Guidelines
• Inner
diameter
sexng:
6.8
/
Outer
diameter
sexng:
7.8
• If
channels
too
Eght,
increase
outer
diameter
sexng
by
0.1
mm
unEl
desired
width
is
achieved.
Your
AddiEon
Technology
representaEve
is
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More
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sician
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3
Long-‐term
Follow-‐up
of
Intacs
in
Keratoconus,
George
D.
Kymionis,
MD,
PHD,
et
al,
Am
J
Ophthalmol.
2007
Feb;143(2):236-‐244.
Epub
2006
Nov
30.
4
My
First
Intacs
Case
–
10
Year
Stability,
Prof.
Joseph
Colin,
Presented
at
the
American
Academy
of
Ophthalmology,
2007.
Cover
image
courtesy
of
David
Schanzlin,
M.D.
AddiEon
Technology,
Inc.
-‐
©
2011
AddiEon
Technology,
Inc.
All
Rights
Reserved
-‐
Intacs®
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Plus
Cylinder
NotaEon
8
10. Intacs®
Pre-‐Surgical
Planning
Guide
&
Comprehensive
Nomogram
!
The
Worldwide
Leader
In
Corneal
Science
&
Implant
Technology
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Lee
Street,
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Nomogram
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-‐
the
only
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in
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world
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ReproducEon
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www.AddiEonTechnology.com
AddiEon
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©
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Inc.
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9