eMedicine Specialties > Ophthalmology > Refractive Disorders

Myopia, Intracorneal Rings: Treatment

Author: Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Coauthor(s): Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic; Ruben Limbonsiong, MD, Chief of Service, Refractive Surgery Service and Vision Laser Center, St. Luke's Medical Center; Program Director, Clinical Assistant Professor, Department of Ophthalmology, University of the Philippines at Manila; Roberto Pineda, ll, MD, Scholar, The Academy at Harvard Medical School; Director, Refractive Surgery Service, Massachusetts Eye and Ear Infirmary
Contributor Information and Disclosures

Updated: Dec 19, 2008

Treatment

Medical Therapy

Medical therapy is limited to broad-spectrum topical antibiotics and corticosteroids for uncomplicated cases.

See Postoperative details and/or articles on ocular pharmacology for more information.

Surgical Therapy

See Intraoperative details for the surgical procedure.

Preoperative Details

The procedure for placement of the intrastromal ring and ring segments is similar, and both can be performed with topical anesthesia. The operative field is prepared, and the patient is prepared and draped in the usual sterile fashion for ophthalmic surgery. A lid speculum is used for globe exposure.

Intraoperative Details

  • The corneal center is identified and marked with a Sinskey hook.
  • A 2-mm long epithelial impression is created at the 12-o'clock position, where the ring segments are to be placed at an 8-mm diameter optical zone.
  • A diamond blade, set at 65% of the peripheral corneal depth, is used to perform a radial incision along this mark.
  • A vacuum-centering guide is positioned relative to the central corneal indentation.
  • The vacuum is increased, and the guide is circumferentially adhered onto the perilimbal conjunctiva, stabilizing the globe. This device provides a guide for the dissector. The dissector is inserted into the radial incision, and blunt dissection of the cornea at two-thirds depth is performed in the clockwise and counterclockwise directions to create 2 stromal channels.
  • The vacuum is released, and the vacuum-centering guide is removed.
  • Ring segments are inserted through the radial incisions using special forceps and are positioned using a Sinskey hook nasally and temporally, such that the superior ends are approximately 3 mm apart.
  • The incision is closed with 1 or 2 interrupted 11-0 nylon sutures.

Postoperative Details

Postoperatively, antibiotic-corticosteroid combination drops and/or ointment are used, and the speculum is removed. The eye may be covered overnight with a shield. Antibiotic-corticosteroid combination drops are used 4 times daily for 1 week. The sutures are removed 2 weeks postoperatively or longer if the incision is not healed adequately.

Follow-up

Patients are seen postoperatively on day 1, week 1, and months 1, 3, 6, and 12. The surgeon should watch for postoperative complications. An observations timeline has been outlined for potential complications. See Complications.

Complications

Complications include localized incision-related epithelial defects, epithelial plug formation, wound dehiscence, superficial neovascularization, surgically induced astigmatism, infiltrates in the channel, transient decreased corneal sensation, and delayed infectious keratitis. Other observations included haze and deposits around the intrastromal channel.

Observations timeline consists of the following:

  • Immediate (1-7 d)
  • Early (1-4 wk)
  • Intermediate (after 4 wk)
  • Immediate postoperative observations may include epithelial defects, lamellar channel haze, undercorrection and overcorrection, and incision-healing responses.
  • Early postoperative observations may include sterile infiltrates, epithelial cysts or plugs, and infectious keratitis.
  • Late postoperative observations may include positioning hole deposits, lamellar channel deposits, and infectious keratitis.
Exchange or explantation

In selected patients with undercorrection or overcorrection, an exchange procedure can be done. In selected patients who are dissatisfied, an explantation procedure can be done. The procedures can be done with the patient using only topical anesthesia. The surgical steps are listed below:
  • Early in the postoperative period, a Sinskey hook can be used to reopen the original incision, or, if the original incision is healed, a radial incision is made at the original site at the same depth as the original incision.
  • Fibrous tissue is gently loosened with blunt dissection.
  • A Suarez spreader is used to dissect the channel opening.
  • A Sinskey hook is then used to engage the positioning hole and to rotate the segment out of its channel.
  • In cases of exchange, a new ICR segment can then be placed into the previously made channel.
  • The incision is closed with a suture.
  • The same postoperative procedure is followed as with the original insertion.

More on Myopia, Intracorneal Rings

Overview: Myopia, Intracorneal Rings
Workup: Myopia, Intracorneal Rings
Treatment: Myopia, Intracorneal Rings
Follow-up: Myopia, Intracorneal Rings
Multimedia: Myopia, Intracorneal Rings
References
Further Reading
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References

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Further Reading

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Keywords

Intacs microthin prescription inserts, Intacs, Intacs inserts, intracorneal rings, intrastromal corneal rings, ICR, intrastromal corneal ring segments, ICRS, refractive keratotomy, RK, photorefractive keratectomy, PRK, laser-assisted in situ keratomileusis, LASIK, myopia, astigmatism, refractive surgery, keratoconus

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, DPBO, FPAO, President and CEO, Chief of Service, Ocular Immunology and Uveitis, Consulting Staff, Cornea and Refractive Surgery, Eye Republic Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines Co; Consulting Staff, CME Liaison, Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center
Manolette R Roque, MD, MBA, DPBO, FPAO is a member of the following medical societies: American Academy of Ophthalmic Executives, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, American Society of Ophthalmic Administrators, American Uveitis Society, International Ocular Inflammation Society, Philippine Medical Association, Philippine Ocular Inflammation Society, and Philippine Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Coauthor(s)

Barbara L Roque, MD, Full Partner, Ophthalmic Consultants Philippines Co, Chief of Service, Pediatric Ophthalmology and Strabismus, Consulting Staff, Orbit and Eye Plastics, Eye Republic Ophthalmology Clinic
Disclosure: Nothing to disclose.

Ruben Limbonsiong, MD, Chief of Service, Refractive Surgery Service and Vision Laser Center, St. Luke's Medical Center; Program Director, Clinical Assistant Professor, Department of Ophthalmology, University of the Philippines at Manila
Ruben Limbonsiong, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Roberto Pineda, ll, MD, Scholar, The Academy at Harvard Medical School; Director, Refractive Surgery Service, Massachusetts Eye and Ear Infirmary
Roberto Pineda, ll, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Daniel S Durrie, MD, Director, Department of Ophthalmology, Division of Refractive Surgery, University of Kansas Medical Center
Daniel S Durrie, MD is a member of the following medical societies: American Academy of Ophthalmology and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Louis E Probst, MD, Medical Director of Refractive Surgery, Chicago, Madison, Milwaukee, and Windsor Centers, TLC the Laser Eye Centers
Louis E Probst, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and International Society of Refractive Surgery
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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