eMedicine Specialties > Ophthalmology > Refractive Disorders

Hyperopia and Presbyopia, Conductive Keratoplasty: Treatment

Author: Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic
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 II, MD,, Scholar, The Academy at Harvard Medical School; Director, Refractive Surgery Service, Massachusetts Eye and Ear Infirmary; Assistant Professor of Ophthalmology, Harvard Medical School
Contributor Information and Disclosures

Updated: Oct 24, 2008

Treatment

Medical Therapy

Medical therapy is limited to broad-spectrum topical antibiotics and corticosteroids for uncomplicated cases (see Postoperative details).

Surgical Therapy

See Intraoperative details for the surgical procedure.

Preoperative Details

The procedure for CK can be performed with a local (topical) anesthetic in the form of eye drops to numb the eye. Patients who are nervous and/or have a high level of anxiety may be given a mild sedative to assist them in relaxing for the procedure.

The operative field is prepared, and the patient is prepared in the usual sterile fashion for ophthalmic surgery. A lid speculum is used for globe exposure.

This procedure may be performed inside the clinic.

Intraoperative Details

After appropriately preparing the patient, a lid speculum is used to hold open the eye during the CK procedure; it also serves as a return path for the radiofrequency energy applied via the instrument. CK is performed using a pen-shaped instrument to apply controlled radiofrequency energy in a ring pattern on the cornea. In performing CK, the conductive tip should be placed perpendicularly to the corneal surface prior to activation. This placement of the conductive tip ensures appropriate application of the conduction marks. The procedure is considered painless and typically requires only a few minutes (approximately 5 min) to perform.

LightTouch technique

LightTouch is a corneal compression technique in which surgeons should apply minimal pressure to the cornea. The application of the tip is similar to the initial procedure identified above, except that after the tip is completely implanted into the cornea, it is retracted slightly until there is minimal to no indentation of the cornea, followed by application of the radiofrequency energy.

Postoperative Details

Following the procedure, the lid speculum is removed. Postoperatively, antibiotic-corticosteroid combination drops and/or ointment are used. Antibiotic-corticosteroid combination drops are used 4 times daily for 1 week. The eye may be covered overnight with a shield.

Follow-up

Certain precautions should be taken following the CK procedure and are similar to those that are required with any other type of vision procedure where the cornea is altered.

  • Patients should take the following precautions for at least 1 week after surgery:
    • Avoid getting contaminated water (eg, fountains, swimming pools, spas, lakes, ocean, rivers) in the eyes.
    • Keep the eyes closed while showering or taking baths to avoid getting soap and dirty water into them.
    • When exercising, keep sweat out of the eyes.
    • For females, avoid applying eye makeup.
  • Patients should avoid vigorously rubbing the eyes for 2 weeks after the surgical procedure.

Patients are seen postoperatively on day 1; week 1; and months 1, 3, 6, and 12. Vision begins to improve within a week's time. The surgeon should monitor patients for postoperative complications; an observation timeline is outlined in Complications.

For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Vision Correction Surgery and Contact Lenses.

Complications

  • Preservation of best spectacle corrected visual acuity (BSCVA)28,29,30
    • Loss of greater than 2 lines BSCVA in less than 5% of eyes
    • Decrease from 20/20 preoperative to worse than 20/40 postoperative in less than 1% of eyes
  • Induced cylinder31
    • Induced cylinder greater than 2.00 D in 5% of eyes (<1% of eyes per draft ANSI guidance)
    • Induced cylinder greater than 1.00 D reported in labeling for all comparable products for hyperopia treatment
    • Induced cylinder greater than or equal to 1.00 D reported at request of FDA
    • Effect of induced cylinder and axis shift on UCVA eyes treated with current nomogram
    • Approximately 1 line impact on mean UCVA at 12 months in the following:
      • Eyes with greater than 1.00 D and greater than or equal to 1.00 D induced cylinder
      • Eyes with greater than 1.00 D and greater than or equal to 1.00 D induced vector cylinder
      • Eyes with greater than 0.75 induced cylinder and 30° axis shift
    • Correcting for residual sphere using regression models, difference in UCVA not statistically significant (P=0.82)
  • Induced cylinder summary
    • Meets FDA safety guideline (<5%, <1% proposed)
    • Frequency and magnitude diminish over time.
    • No effect on BSCVA
    • When induced cylinder is present, UCVA is affected by approximately 1 line at 6 months and improves over time as induced cylinder resolves.
    • level of persistent induced cylinder is low (>1.00 D is 6.4% at 12 mo)
  • Endothelial cells
    • Endothelial cell loss is no more than 10%.
    • No change (within ±1%) in endothelial cell density over the course of follow-up in any region (central, midperipheral, and peripheral cornea)
    • No polymegathism or polymorphism
    • Radiofrequency energy can be safely delivered to the cornea with no effect on the endothelium.
  • Patient symptoms
    • Increase of greater than or equal to 5% in moderate-to-severe symptoms
    • Subjective questionnaire was administered at baseline and at 1, 3, 6, 9, and 12 months. Patients were asked to rate the following symptoms as none, mild, moderate, marked, or very severe: light sensitivity, headaches, pain, redness, dryness, excessive tearing, burning, foreign body sensation, glare, halos, blurred vision, double vision, fluctuation of vision, variations of vision with change in lighting, and night driving vision problems.
    • Symptoms with greater than or equal to 5% increase from baseline in moderate, marked, or very severe, at months 6, 9, and 12, included dryness, glare, halos, double vision, fluctuation of vision, and variations of vision with change in lighting.
  • Complications and adverse events28,32
    • Adverse events to occur in no more than 5% of eyes; any single adverse event to occur in less than 1% of eyes
    • Recurrent corneal erosions in both eyes of 1 patient (<1%), resolved by 3 months
    • Foreign body sensation in 1 eye of 1 patient (<1%), reported at 9 months and resolved by 12 months
    • Pain in both eyes of 1 patient (<1%), reported at 3 months and resolved by 6 months
    • Double/ghost images in 13 eyes of 9 patients (3%), complaint resolved in most eyes (10 out of 13 eyes)
    • Other complications occurring at a rate of less than 1% include blepharitis, external hordeolum, viral conjunctivitis, allergic conjunctivitis, bacterial conjunctivitis, meibomianitis, subconjunctival hemorrhage, central striae, central stromal defects, lash loss, ecchymosis, blurry vision, starbursts, headaches, film over eye, glare, halos, and light sensitivity.33
  • Adverse events related to device/procedure
    • Corneal perforation in 1 eye of 1 patient (<1%)34,35
      • Resulted from detachment of Teflon stop
      • Healed uneventfully; CK procedure successfully completed 2 weeks later
      • Preoperative - UCVA 20/40, mean refractive spherical equivalent (MRSE) +2.00 D
      • 12-month outcome - UCVA 20/16, MRSE 0.0 D
      • Corrective actions implemented
    • No radiofrequency energy delivered during treatment in 2 eyes of 2 patients (<1%)
      • Resulted from poor solder joint
      • 1 eye successfully treated 3 weeks later
      • Preoperative - UCVA 20/200, MRSE +2.00 D
      • 12-month outcome - UCVA 20/32, MRSE +0.50 D
      • Second eye determined to be ineligible because of previously undetected narrow angles
      • Corrective action validated, implemented, and reviewed by FDA
  • IOP greater than 25 mm Hg in 3 eyes of 2 patients (<1%)36
    • 1 eye of 1 patient had baseline IOP of 25 mm Hg and ineligible for enrollment
    • 2 eyes of 1 patient had increased IOP that resolved without treatment or sequelae
  • Mild iritis in 1 eye of 1 patient at 7 days (<1%), resolved without sequelae37
  • Decrease of BSCVA of greater than 2 lines, inferior altitudinal hemianopsia, and optic atrophy secondary to spinal surgery in 1 eye of 1 patient
  • Retinal break in 1 eye of 1 patient
    • Occurred 18 months after CK procedure
    • Successfully treated with argon laser
  • Nonophthalmic events included terminal cancer, heart attack, breast cancer, temporal arteritis, hospitalization for tonsillectomy, and nasal septum repair.
  • Maloney reported that out of 50 cases of CK, no single patient complained of dryness or haziness.32,28

More on Hyperopia and Presbyopia, Conductive Keratoplasty

Overview: Hyperopia and Presbyopia, Conductive Keratoplasty
Workup: Hyperopia and Presbyopia, Conductive Keratoplasty
Treatment: Hyperopia and Presbyopia, Conductive Keratoplasty
Follow-up: Hyperopia and Presbyopia, Conductive Keratoplasty
Multimedia: Hyperopia and Presbyopia, Conductive Keratoplasty
References
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Further Reading

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Keywords

radiofrequency keratoplasty, CK, Refractec, farsightedness, laser surgical procedures, refractive surgery, corneal reshaping, laser in situ keratomileusis, LASIK, hyperopic LASIK, excimer laser ablation, photorefractive keratoplasty, PRK, radial keratotomy, RK, hyperopic photorefractive keratectomy, HPRK, laser thermal keratoplasty, LTK, hyperopic correction via LTK, ViewPoint conductive keratoplasty system, vision correction, NearVision CK, Light Touch, LightTouch

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Contributor Information and Disclosures

Author

Manolette R Roque, MD, MBA, President and CEO, Service Chief of Ocular Immunology and Uveitis, Refractive Surgery, EYE REPUBLIC Ophthalmology Clinic; General Manager, Ophthalmic Consultants Philippines; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, Asian Hospital and Medical Center; Section Chief of Ocular Immunology and Uveitis, Department of Ophthalmology, St. Luke's Medical Center Global City; Senior Eye Surgeon, The LASIK Surgery Clinic
Manolette R Roque, MD, MBA 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 II, MD,, Scholar, The Academy at Harvard Medical School; Director, Refractive Surgery Service, Massachusetts Eye and Ear Infirmary; Assistant Professor of Ophthalmology, Harvard Medical School
Roberto Pineda II, 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: eMedicine Salary Employment

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
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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