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Nicholson M, Singh VM, Murthy S, Gatinel D, Pereira S, Pradhan A, Vasavada S, Dandekar P, Naik M, Sharma S. Current concepts in the management of cataract with keratoconus. Indian J Ophthalmol 2024; 72:508-519. [PMID: 38389251 PMCID: PMC11149527 DOI: 10.4103/ijo.ijo_1241_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 11/22/2023] [Indexed: 02/24/2024] Open
Abstract
This review analyzed all pertinent articles on keratoconus (KCN) and cataract surgery. It covers preoperative planning, intraoperative considerations, and postoperative management, with the aim of providing a simplified overview of treating such patients. Preoperatively, the use of corneal cross-linking, intrastromal corneal ring segments, and topo-guided corneal treatments can help stabilize the cornea and improve the accuracy of biometric measurements. It is important to consider the advantages and disadvantages of traditional techniques such as penetrating keratoplasty and deep anterior lamellar keratoplasty, as well as newer stromal augmentation techniques, to choose the most appropriate surgical approach. Obtaining reliable measurements can be difficult, especially in the advanced stages of the disease. The choice between toric and monofocal intraocular lenses (IOLs) should be carefully evaluated. Monofocal IOLs are a better choice in patients with advanced disease, and toric lenses can be used in mild and stable KCN. Intraoperatively, the use of a rigid gas permeable (RGP) lens can overcome the challenge of image distortion and loss of visual perspective. Postoperatively, patients may need updated RGP or scleral lenses to correct the corneal irregular astigmatism. A thorough preoperative planning is crucial for good surgical outcomes, and patients need to be informed regarding potential postoperative surprises. In conclusion, managing cataracts in KCN patients presents a range of challenges, and a comprehensive approach is essential to achieve favorable surgical outcomes.
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Affiliation(s)
- Maneck Nicholson
- Department of Cataract and Refractive Surgery, Shantilal Shanghvi Eye Institute, Mumbai, India
| | - Vivek M Singh
- Department of Cataract and Refractive Surgery, LV Prasad Eye Institute, Kallam Anji Reddy Campus, Telangana, India
| | - Somasheila Murthy
- Department of Cataract and Refractive Surgery, Shantilal Shanghvi Eye Institute, Mumbai, India
- Department of Cataract and Refractive Surgery, LV Prasad Eye Institute, Kallam Anji Reddy Campus, Telangana, India
| | - Damien Gatinel
- Department of Cataract and Refractive Surgery, Rothschild Foundation, Paris, France
| | - Savio Pereira
- Department of Cataract and Refractive Surgery, Nethradhama Super Speciality Eye Hospital, Bangalore, India
| | | | - Shail Vasavada
- Department of Cataract and Refractive Surgery, Raghudeep Eye Clinic, Ahmedabad, India
| | - Prajakta Dandekar
- Department of Cataract and Refractive Surgery, Shantilal Shanghvi Eye Institute, Mumbai, India
| | - Mekhla Naik
- Department of Cataract and Refractive Surgery, Shantilal Shanghvi Eye Institute, Mumbai, India
| | - Supriya Sharma
- Department of Cataract and Refractive Surgery, Shantilal Shanghvi Eye Institute, Mumbai, India
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2
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Fard AM, Patel SP, Nader ND. The efficacy of 2 different phakic intraocular lens implant in keratoconus as an isolated procedure or combined with collagen crosslinking and intra-stromal corneal ring segments: a systematic review and meta-analysis. Int Ophthalmol 2023; 43:4383-4393. [PMID: 37470861 DOI: 10.1007/s10792-023-02813-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE To compare the efficacy of phakic intra-ocular lenses in isolation or in combination with corneal crosslinking (CXL) and/or intra-stromal corneal ring segments (ICRS) in keratoconus. METHODS Data extracted from the publications meeting the selection. The outcome parameters included mean pre- and post-operative uncorrected distance visual acuity, corrected distance visual acuity (CDVA), sphere and cylinder of refraction and complications. Available data analyzed with Cochrane Review Manager. RESULTS A total of 23 studies including 464 eyes were included. All the parameters showed significant improvement in all subgroups other than CDVA in ACPIOL + CXL subgroup and cylinder in PIOL + CXL subgroups. There was not a significant difference between PCPIOL and ACPIOL in the outcomes, exception was more improvement of CDVA in "ACPIOL only" than" PCPIOL only" subgroup. CONCLUSION Both PCPIOLs and ACPIOLs are comparably safe and efficient options in management of KCN and their efficacy significantly improves when combined with CXL/ICRS.
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Affiliation(s)
- Ali Mahdavi Fard
- Department of Ophthalmology, Ross Eye Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, Doheny Eye Center of UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sangita P Patel
- Department of Ophthalmology, Ross Eye Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
- Research and Ophthalmology Services, Veterans Administration of Western New York Healthcare System, Buffalo, NY, USA
| | - Nader D Nader
- Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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3
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Singh C, Joshi VP. Cataract surgery in Keratoconus revisited - An update on preoperative and intraoperative considerations and postoperative outcomes. Semin Ophthalmol 2023; 38:57-64. [PMID: 35996343 DOI: 10.1080/08820538.2022.2112702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE This review aims to evaluate and simplify the recent literature on preoperative surgical planning, intraoperative considerations, postoperative surprises, and their management in patients with keratoconus undergoing cataract surgery. METHODS A review of the literature was done to analyze all the pertinent articles on Keratoconus and cataract surgery. RESULTS The surgical planning of cataracts in eyes with keratoconus needs a multifaceted approach. Preoperatively, techniques such as cross-linking or the use of intra-corneal rings help stabilize the progression. Unreliable biometric measurements are a significant problem in keratoconus patients, especially in an advanced stage of the disease. It is better to consider actual K readings if the K value is less than 55D but for a K value, more than 55D using standard K values will prevent postoperative refractive surprises. For calculation of K values, an elevation-based device like pentacam gives better repeatability in mild to moderate cases whereas for advanced keratoconus none of the keratometers is reliable. Recently, the Kane keratoconus formula performed better in all stages of disease whereas previous studies showed good results with SRK/T formula is a mild and moderate disease. Monofocal intraocular lenses are a better choice in these patients. Toric lenses can be used in mild and stable keratoconus. Intraoperatively, the use of a customized RGP lens can overcome the challenge of image distortion and loss of visual perspective. Despite taking necessary measures, postoperative refractive surprise can occur and can be managed with IOL exchange or Secondary IOLs. CONCLUSION There is a spectrum of challenges in managing cataracts in keratoconus which makes thorough preoperative planning important for good surgical outcomes. Despite the measures, there might be post-operative surprises and the patients need to be informed regarding the same.
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Affiliation(s)
- Charul Singh
- Academy of Eye Care Education, L V Prasad Eye Institute, Hyderabad, India.,The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Vineet P Joshi
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.,Centre for Innovation, L V Prasad Eye Institute, Hyderabad, India
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Gonzalez-Salinas R, Franco JJ, Reyes-Luis JL, Sánchez-Huerta V, de Wit-Carter G, Hernández-Quintela E, Pineda R. Cataract surgery in patients with underlying keratoconus: focused review. J Cataract Refract Surg 2023; 49:97-102. [PMID: 36194107 DOI: 10.1097/j.jcrs.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/24/2022] [Indexed: 11/07/2022]
Abstract
An underlying diagnosis of keratoconus (KC) can complicate cataract surgery. In this study, the results of a focused review of the literature pertaining to cataract surgery in patients with KC are detailed. Topics essential for the appropriate management of this patient population are discussed. First, the individual and shared epidemiology and pathophysiology of cataract and KC are reviewed. Then, the theory and approach to intraocular lens power calculation are discussed, highlighting particularities and pitfalls of this exercise when performed in patients with KC. Finally, several special-although not uncommon-management scenarios and questions are addressed, such as surgical planning in cases where corneal stabilization or tissue replacement interventions are also necessitated.
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Affiliation(s)
- Roberto Gonzalez-Salinas
- From the Anterior Segment Surgery Department, Asociación para Evitar la Ceguera I.A.P., Mexico City, Mexico (Gonzalez-Salinas); Harvard Medical School, Boston, Massachusetts (Franco, Pineda); Cornea and Refractive Surgery Service, Massachusetts Eye and Ear, Boston, Massachusetts (Reyes-Luis, Pineda); Cornea Department, Asociación para Evitar la Ceguera I.A.P., Mexico City, Mexico (Sánchez-Huerta, de Wit-Carter); Division of Comprehensive Ophthalmology, Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, Maryland (Hernández-Quintela)
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Alfonso-Bartolozzi B, Lisa C, Fernández-Vega-Cueto L, Baamonde B, Madrid-Costa D, Alfonso JF. Three-year follow-up of posterior chamber phakic intraocular lens with a central port design after deep anterior lamellar keratoplasty. EYE AND VISION 2022; 9:34. [PMID: 36068603 PMCID: PMC9450313 DOI: 10.1186/s40662-022-00306-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/17/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
To evaluate clinical outcomes of the Visian implantable collamer lens (ICL) with a central port to correct myopia and astigmatism after deep anterior lamellar keratoplasty (DALK) for keratoconus throughout 3 years of follow-up.
Methods
This study included 20 eyes of 20 patients that underwent V4c ICL (13 eyes with a spherical ICL and 7 eyes with a toric ICL) implantation after DALK. Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction, intraocular pressure (IOP), endothelial cell density (ECD), and vault were analyzed.
Results
The mean UDVA improved from the preoperative 1.18 ± 0.33 logMAR to 0.25 ± 0.14 logMAR at 6 months after surgery (P < 0.0001) and remained unchanged throughout the whole follow-up (P = 0.4). All eyes gained lines of CDVA compared to preoperative values. At the last follow-up visit, all eyes achieved CDVA of 0.2 logMAR or better and 13 eyes (65%) 0.1 logMAR or better. At 6 months post-surgery, all eyes (100%) had a spherical equivalent within ± 1.50 D, and 19 (95%) within ± 1.00 D. The mean manifest spherical equivalent was stable over the postoperative follow-up (P = 0.25). No significant increase in IOP occurred in any case throughout the 3 years of follow-up. The loss in ECD from the preoperative baseline at the last follow-up visit was 2.27%.
Conclusions
The clinical outcomes suggest that the V4c ICL implantation for correction of myopia and regular astigmatism in post-DALK eyes was satisfactory in terms of effectiveness, safety, and stability during 3 years of follow-up.
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Five-year long-term outcomes of intrastromal corneal ring segment implantation using the manual technique for keratoconus management. J Cataract Refract Surg 2021; 47:713-721. [PMID: 33196572 DOI: 10.1097/j.jcrs.0000000000000500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the long-term effectiveness, safety, and stability of Ferrara-type intrastromal corneal ring segments (ICRS) by manual surgery implantation in patients with keratoconus. SETTING Ophthalmology Department, Hospital de Braga, Braga, Portugal. DESIGN Retrospective cohort study. METHODS This study included 124 eyes that had ICRS implantation using the manual technique with a follow-up of 5 years. Uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), subjective refraction, keratometry, aberrometry, and pachymetry maps were evaluated preoperatively and at 6 months, 1 year, and 5 years postoperatively. A secondary analysis of all variables was performed comparing 2 subgroups of patients: a group younger than 30 years and a group of 30 years or older. RESULTS At 5 years, both mean UDVA and CDVA improved significantly (P < .0001) from a preoperative value of 0.91 ± 0.36 to 0.46 ± 0.32 logMAR and 0.40 ± 0.27 to 0.22 ± 0.20 logMAR, respectively. Spherical equivalent, refractive cylinder, and all topography values significantly decreased postoperatively (P < .0001). No regression was observed in any visual or topographic parameter during the entire follow-up. Regarding the subgroup analysis, both younger and older patients demonstrated similar and stable results from the preoperative to the 5-year visit, except for minimum pachymetry value change over time. CONCLUSIONS Ferrara-type ICRS implantation significantly improved visual acuity, refractive error, and topographic values; the improvement was stable throughout a 5-year follow-up period. This study confirms that ICRS implantation surgery for keratoconus is a stable procedure in a long-term follow-up, regardless of the preoperative patient's age.
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Case Report: Double Intrastromal Corneal Ring Segment and Posterior Chamber Phakic Intraocular Lens Implantation. Optom Vis Sci 2021; 98:404-408. [PMID: 33852555 DOI: 10.1097/opx.0000000000001669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Keratoconus can manifest asymmetrically, affecting binocularity and becoming a refractive problem that is sometimes complex to solve. We propose a therapeutic approach for correction of keratoconus based on parallel implantation of a second intrastromal corneal ring segment (ICRS). PURPOSE This study aimed to improve the refractive status of a patient affected with advanced bilateral keratoconus using implantation of a second ICRS and a phakic intraocular lens. CASE REPORT A 44-year-old man came to our clinic requesting a refractive solution for his visual impairment. He had been diagnosed with bilateral severe keratoconus categorized by the Amsler-Krumeich classification scale as grade III (right eye) and grade II (left eye). He had previously undergone corneal cross-linking and implantation of ICRS (Intacs) in both eyes. Significant anisometropia was present between the eyes, and the patient also complained of poor quality of vision. We decided to implant a posterior chamber phakic collamer lens in his right eye and to insert a new ICRS (Keraring) deep and parallel to the previous one in his left eye. We aimed to prevent anisometropia in his right eye and to further regularize the affected cornea in his left eye. Refractive symmetry was achieved, and vision was optimized after surgery. CONCLUSIONS In a patient with keratoconus, refractive surgery should be performed from a bilateral perspective. Specific cases of keratoconus can be managed by parallel implantation of a second ICRS.
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8
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Barros L, Sena N, Motta C, Criado G, Ambrósio R. Lentes intraoculares fácicas para miopia e astigmatismo: revisão prospectiva. REVISTA BRASILEIRA DE OFTALMOLOGIA 2021. [DOI: 10.37039/1982.8551.20210012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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9
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Kalra N, Asif MI, Bafna RK, Sharma N, Sinha R. Posterior Chamber Phakic Intraocular Lens Implantation for Refractive Correction in Corneal Ectatic Disorders: A Review. J Refract Surg 2021; 37:351-359. [PMID: 34044697 DOI: 10.3928/1081597x-20210115-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To summarize the indications and outcomes of posterior chamber phakic intraocular lens (PIOL) implantation in corneal ectasias including keratoconus, pellucid marginal degeneration (PMD), post-refractive surgery, and post-keratoplasty ectasias. METHODS A review of the literature was conducted using the relevant keywords from various databases up to August 15, 2020. All pertinent studies were reviewed, and the relevant articles were studied in detail for efficacy, stability, predictability, and safety outcomes. In addition, visual quality, corneal biomechanical outcomes, complications, the role of posterior chamber PIOL in combination treatment, and comparison of posterior chamber PIOL with other PIOLs for ectasias were also evaluated. RESULTS A total of 30 relevant studies (13 prospective, 13 retrospective, 4 case reports) on the subject were studied and summarized. All studies showed a favorable refractive outcome. Quality of vision remained unaffected and no significant complications were reported in any of the studies. CONCLUSIONS Posterior chamber PIOLs represent a viable option in the treatment of mild to moderate and stable corneal ectasia in patients with contact lens intolerance who have low irregular astigmatism, a clear central cornea, and good preoperative corrected distance visual acuity. [J Refract Surg. 2021;37(5):351-359.].
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10
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Ormonde S. Refractive surgery for keratoconus. Clin Exp Optom 2021; 96:173-82. [DOI: 10.1111/cxo.12051] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/31/2013] [Accepted: 02/03/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sue Ormonde
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand,
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11
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Hashemian SJ, Saiepoor N, Ghiasian L, Aghai H, Jafari ME, Alemzadeh SP, Hashemian MS, Hashemian SM. Long‐term outcomes of posterior chamber phakic intraocular lens implantation in keratoconus. Clin Exp Optom 2021; 101:652-658. [DOI: 10.1111/cxo.12671] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/29/2017] [Accepted: 12/20/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- Seyed Javad Hashemian
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Nahid Saiepoor
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Leila Ghiasian
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Hossein Aghai
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Mohammad Ebrahim Jafari
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Sayyed Pooya Alemzadeh
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Mahsa Sadat Hashemian
- Department of Ophthalmology, School of Pharmacy, International Campus, Tehran University of Medical Sciences, Tehran, Iran,
| | - Seyed Mahyar Hashemian
- Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran,
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Alfonso JF, Torquetti L, Fernández-Vega-Cueto L, Allan B, Poo-López A, Alfonso-Bartolozzi B, de la Cruz J, Monteiro T, Madrid-Costa D. Visual and Tomographic Outcomes of a 300° Arc-length ICRS Implantation in Moderate to Advanced Central Keratoconus. J Refract Surg 2021; 37:249-255. [PMID: 34038659 DOI: 10.3928/1081597x-20210115-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To assess the outcomes of implanting a new 300° arc-length intrastromal corneal ring segment (ICRS) in moderate to advanced central hyperprolate keratoconus. METHODS Forty-two eyes with moderate to advanced central hyperprolate keratoconus were evaluated before and after implanting an inferior 300° ICRS (AJL Ophthalmic). The clinical measurements taken included manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity (logMAR scale), and corneal tomographic analysis (Sirius; Costruzioni Strumenti Oftalmici). Changes in the anterior and posterior corneal surfaces and the root mean square (RMS) for coma-like aberrations for a pupil size of 4.5 mm were evaluated. All examinations were performed before surgery and 6 months after surgery. RESULTS The mean UDVA improved from 1.12 ± 0.48 logMAR preoperatively to 0.73 ± 0.37 logMAR postoperatively (P < .0001). The mean CDVA changed from 0.33 ± 0.20 to 0.20 ± 0.11 logMAR (P < .0001). Postoperatively, the CDVA improved by two or more lines in 45.2% of the eyes and increased by one line in 19.04%, and none of the patients lost lines of CDVA. All of the anterior and posterior corneal tomographic parameters analyzed were significantly improved after surgery, except posterior flat keratometry, which remained unchanged. In 80.95% of the eyes, the postoperative mean keratometry was 50.00 diopters or less. The 6-month RMS for coma-like aberrations also declined significantly from 1.57 ± 0.68 to 1.06 ± 0.42 µm after surgery (P < .0001). CONCLUSIONS These results suggest that implanting a 300° arc-length ICRS is a safe and effective procedure for treating patients with moderate to advanced central hyperprolate keratoconus and clear cornea. [J Refract Surg. 2021;37(4):249-255.].
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13
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[Excimer laser in keratoconus management]. J Fr Ophtalmol 2021; 44:564-581. [PMID: 33573798 DOI: 10.1016/j.jfo.2020.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 11/21/2022]
Abstract
Visual rehabilitation in keratoconus is a challenge, notably because of the significant irregular astigmatism and optical aberrations that it induces. Many surgical techniques have been developed in addition to, or in the case of failure of, spectacles and rigid gas permeable contact lenses: intracorneal ring segments, intraocular lenses, excimer laser and, as a last resort, keratoplasty. Excimer laser photoablates the cornea, allowing remodeling of its surface. There are various treatment modes (wavefront-optimized, wavefront-guided and topography-guided), allowing performance of a customized treatment if needed. Its use in keratoconus has been described since the 2000s, alone or in combination with other procedures. For example, the combination of photoablation and corneal cross linking, a technique that increases corneal rigidity and in so doing can slow or even stop the progression of keratoconus, proved its efficacy and safety in many studies, and various protocols have been described. A triple procedure, including intracorneal ring segments, excimer laser and cross linking, has also given some very promising results in progressive keratoconus, providing a significative improvement in visual acuity and topographic data. The combination of excimer laser and intraocular lenses remains a poorly explored lead that might provide some satisfactory results. The objective of this review is to summarize the recent data on excimer laser in keratoconus management.
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14
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McLintock CA, McKelvie J, Miraflores Gomez S, Gatzioufas Z, Elalfy M, Hamada S. Outcomes of sequential intracorneal ring segment and phakic intraocular lens insertion for visual rehabilitation in keratoconus. Eur J Ophthalmol 2020; 31:2219-2226. [PMID: 33135490 DOI: 10.1177/1120672120969600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report the visual and refractive outcomes of sequential intracorneal ring segment (ICRS) and toric phakic intraocular lens (IOL) insertion for visual rehabilitation in keratoconus. METHODS A retrospective interventional cohort study was performed through the Corneoplastics unit and Eye Bank, Queen Victoria Hospital, East Grinstead, United Kingdom. RESULTS 14 eyes of 12 patients had sequential ICRS and phakic IOL implantation for visual rehabilitation of keratoconus between June 2014 and February 2018. After at least 6 months follow-up, the number of eyes with an uncorrected distance visual acuity (UDVA) of 20/40 UDVA or better increased from zero (0%) to 10 (71%). 12 (85.7%) eyes achieved a post-operative UDVA equal to or better than the pre-operative corrected distance visual acuity (CDVA). The number percentage of eyes with a CDVA of 20/40 or better increased from 3 (31%) to 14 (100%). The mean final spherical equivalent improved from -4.07 to -0.17 (p ⩽ 0.001). The mean refractive astigmatism magnitude improved from 4.76D to 1.23D (p = 0.002). Seven (50%) eyes had 1.0D or less of refractive astigmatism post-operatively. CONCLUSION In this cohort of eyes with keratoconus, sequential ICRS and phakic IOL implantation resulted in excellent visual and refractive outcomes after at least 6 months.
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Affiliation(s)
- Cameron A McLintock
- Corneoplastic unit and Eye Bank, Queen Victoria Hospital, NHS Trust, East Grinstead, West Sussex, UK.,Department of Ophthalmology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - James McKelvie
- Corneoplastic unit and Eye Bank, Queen Victoria Hospital, NHS Trust, East Grinstead, West Sussex, UK.,Department of Ophthalmology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - Zisis Gatzioufas
- Corneoplastic unit and Eye Bank, Queen Victoria Hospital, NHS Trust, East Grinstead, West Sussex, UK.,Department of Ophthalmology, University Hospital Basel, Basel, BS, Switzerland
| | - Mohamed Elalfy
- Corneoplastic unit and Eye Bank, Queen Victoria Hospital, NHS Trust, East Grinstead, West Sussex, UK.,Cornea Unit, The Research Institute of Ophthalmology, Giza, Egypt
| | - Samer Hamada
- Corneoplastic unit and Eye Bank, Queen Victoria Hospital, NHS Trust, East Grinstead, West Sussex, UK
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15
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Visual outcomes and corneal biomechanics after V4c implantable collamer lens implantation in subclinical keratoconus. J Cataract Refract Surg 2020; 46:1339-1345. [DOI: 10.1097/j.jcrs.0000000000000262] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Alfonso JF. September consultation #5. J Cataract Refract Surg 2019; 45:1355-1356. [DOI: 10.1016/j.jcrs.2019.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Ghiasian L, Abolfathzadeh N, Manafi N, Hadavandkhani A. Intraocular lens power calculation in keratoconus; A review of literature. J Curr Ophthalmol 2019; 31:127-134. [PMID: 31317089 PMCID: PMC6611933 DOI: 10.1016/j.joco.2019.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 01/11/2019] [Accepted: 01/24/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose To review the published literature regarding cataract surgery in keratoconus (KCN) patients with emphasis on challenges encountered during intraocular lens (IOL) power calculation and their solutions. Methods A literature review was performed to investigate all the relevant articles on the advancements of IOL calculations in KCN patients. Results Cataract surgery in keratoconic eyes can improve patients' refraction, and proper patient selection and IOL calculation methods are necessary to get the best results. The main problem in KCN patients is unreliable biometric measurements. It is more difficult to make conclusions in more advanced keratoconic corneas, as the steep keratometric values in these eyes will result in the selection of a low-power IOL. Presence of a low-power IOL will yield in extreme postoperative hyperopia, and IOL exchange might be mandatory. In cases in which keratoplasty may be needed in the future, contact lens fitting can help surgeons make a better decision preoperatively. Axial length (AL) measurements may have better repeatability and reproducibility than keratometry (K) readings in keratoconic eyes. SRK II formula may provide the most accurate IOL power in mild KCN. There is still not a comprehensive consensus of which formula is the best one in moderate and severe KCN, as the literature is limited in this subject. Conclusions Various methods of IOL power calculation optimization and recommendations may hold the key to improve surgical outcomes in keratoconic eyes. There are multiple sources of biometric error in KCN patients, hence IOL calculation methods may not be as efficient as expected in these eyes.
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Affiliation(s)
- Leila Ghiasian
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Navid Manafi
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Hadavandkhani
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Torquetti L, Cunha P, Luz A, Kwitko S, Carrion M, Rocha G, Signorelli A, Coscarelli S, Ferrara G, Bicalho F, Neves R, Ferrara P. Clinical Outcomes After Implantation of 320°-Arc Length Intrastromal Corneal Ring Segments in Keratoconus. Cornea 2018; 37:1299-1305. [DOI: 10.1097/ico.0000000000001709] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Visian Toric ICL Implantation after Intracorneal Ring Segments Implantation and Corneal Collagen Crosslinking in Keratoconus. Eur J Ophthalmol 2018; 24:338-44. [DOI: 10.5301/ejo.5000384] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2013] [Indexed: 11/20/2022]
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20
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Surgical Options for the Refractive Correction of Keratoconus: Myth or Reality. J Ophthalmol 2017; 2017:7589816. [PMID: 29403662 PMCID: PMC5748308 DOI: 10.1155/2017/7589816] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/28/2017] [Indexed: 01/14/2023] Open
Abstract
Keratoconus provides a decrease of quality of life to the patients who suffer from it. The treatment used as well as the method to correct the refractive error of these patients may influence on the impact of the disease on their quality of life. The purpose of this review is to describe the evidence about the conservative surgical treatment for keratoconus aiming to therapeutic and refractive effect. The visual rehabilitation for keratoconic corneas requires addressing three concerns: halting the ectatic process, improving corneal shape, and minimizing the residual refractive error. Cross-linking can halt the disease progression, intrastromal corneal ring segments can improve the corneal shape and hence the visual quality and reduce the refractive error, PRK can correct mild-moderate refractive error, and intraocular lenses can correct from low to high refractive error associated with keratoconus. Any of these surgical options can be performed alone or combined with the other techniques depending on what the case requires. Although it could be considered that the surgical option for the refracto-therapeutic treatment of the keratoconus is a reality, controlled, randomized studies with larger cohorts and longer follow-up periods are needed to determine which refractive procedure and/or sequence are most suitable for each case.
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Doroodgar F, Niazi F, Sanginabadi A, Niazi S, Baradaran-Rafii A, Alinia C, Azargashb E, Ghoreishi M. Comparative analysis of the visual performance after implantation of the toric implantable collamer lens in stable keratoconus: a 4-year follow-up after sequential procedure (CXL+TICL implantation). BMJ Open Ophthalmol 2017; 2:e000090. [PMID: 29354720 PMCID: PMC5721648 DOI: 10.1136/bmjophth-2017-000090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/28/2017] [Accepted: 08/24/2017] [Indexed: 11/23/2022] Open
Abstract
Aims To report on 4-year postoperative visual performance with the toric implantable collamer lens (TICL) for stable keratoconus after sequential procedure (corneal collagen crosslinking plus TICL implantation). Methods Forty eyes of 24 patients with stable keratoconus with myopia between 0.00 and −18.00 dioptres (D) and astigmatism between 1.25 and 8.00 D were evaluated in this prospective interventional study (https://clinicaltrials.gov/ct2/show/NCT02833649). We evaluated refraction, visual outcomes, astigmatic changes analysed by Alpins vector, contrast sensitivity, aberrometry, modulation transfer functions (MTFs), defocus curve, and operative and postoperative complications. Results At 4-year follow-up, 45% had 20/20 vision or better and 100% had 20/40 or better uncorrected visual acuity (UCVA). Vector analysis of refractive astigmatism shows that the surgically induced astigmatism (SIA) (3.20±1.46 D) was not significantly different from the target induced astigmatism (TIA) (3.14±1.42 D) (p=0.620). At 4 years postoperatively, none of the eyes showed a decrease in UCVA, in contrast to 24 eyes in which UCVA was increased by ≥1 lines, with contrast sensitivity and improvement in total aberrations and MTF value at 5 per degree (*p=0.004) after TICL implantation. The cumulative 4-year corneal endothelial cell loss was ≤5%. No patients reported dissatisfaction. At the end of follow-up, the vault was 658±54.33m (range, 500–711) and the intraocular pressure was 11.7±2.08 mm Hg. Occurrences of glare and night-driving troubles diminished after TICL surgery. Conclusion The results from this standardised clinical investigation support TICL implantation from clinical and optical viewpoints in patients with stable keratoconus. Trial registration number NCT02833649, Pre-results
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Affiliation(s)
- Farideh Doroodgar
- Ophthalmology Department, Eye Research Center Tehran University of Medical Sciences, Tehran, Tehran, Iran
| | - Feazollah Niazi
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Thran, Tehran, Iran
| | - Azad Sanginabadi
- Ophthalmology Department, Eye Research Center Tehran University of Medical Sciences, Tehran, Tehran, Iran
| | - Sana Niazi
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Tehran, Tehran, Iran
| | - Alireza Baradaran-Rafii
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Tehran, Tehran, Iran
| | - Cyrus Alinia
- Department of Public Health, Urmia University of Medical Sciences, Urmia, West Azerbaijan, Iran
| | - Eznollah Azargashb
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Tehran, Tehran, Iran
| | - Mohammad Ghoreishi
- Ophthalmology Department, Isfahan University of Medical Sciences, Isfahan, Isfahan, Iran
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Abdelmassih Y, el-Khoury S, Chelala E, Slim E, Cherfan CG, Jarade E. Toric ICL Implantation After Sequential Intracorneal Ring Segments Implantation and Corneal Cross-linking in Keratoconus: 2-Year Follow-up. J Refract Surg 2017; 33:610-616. [DOI: 10.3928/1081597x-20170621-02] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 05/24/2017] [Indexed: 11/20/2022]
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23
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Outcome of Keratoconus Management: Review of the Past 20 Years' Contemporary Treatment Modalities. Eye Contact Lens 2017; 43:141-154. [DOI: 10.1097/icl.0000000000000270] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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24
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Sequential intrastromal corneal ring segment and monofocal intraocular lens implantation for keratoconus and cataract: Long-term follow-up. J Cataract Refract Surg 2017; 43:246-254. [DOI: 10.1016/j.jcrs.2016.11.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/08/2016] [Accepted: 11/09/2016] [Indexed: 11/24/2022]
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Esteve-Taboada JJ, Domínguez-Vicent A, Ferrer-Blasco T, Alfonso JF, Montés-Micó R. Posterior chamber phakic intraocular lenses to improve visual outcomes in keratoconus patients. J Cataract Refract Surg 2017; 43:115-130. [DOI: 10.1016/j.jcrs.2016.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/06/2016] [Accepted: 05/25/2016] [Indexed: 12/01/2022]
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26
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Feasibility of custom-made hydrogel contact lenses in keratoconus with previous implantation of intracorneal ring segments. Cont Lens Anterior Eye 2015; 38:351-6. [DOI: 10.1016/j.clae.2015.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 02/11/2015] [Accepted: 03/31/2015] [Indexed: 11/21/2022]
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Safety and Visual Outcome of Visian Toric ICL Implantation after Corneal Collagen Cross-Linking in Keratoconus: Up to 2 Years of Follow-Up. J Ophthalmol 2015; 2015:514834. [PMID: 25874116 PMCID: PMC4383407 DOI: 10.1155/2015/514834] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 10/14/2014] [Accepted: 10/27/2014] [Indexed: 11/17/2022] Open
Abstract
Purpose. To evaluate the long-term safety and clinical outcome of phakic Visian toric implantable collamer lens (ICL) insertion after corneal collagen cross-linking (CXL) in progressive keratoconus. Methods. This was a retrospective study of 30 eyes (19 patients), with progressive keratoconus, who underwent sequential CXL followed by Visian toric ICL implantation after 6 months. Results. At baseline, 6 eyes had stage I, 14 eyes stage II, and 10 eyes stage III keratoconus graded by Amsler-Krumeich classification. At 6 months after CXL, only K (steep) and K (max) decreased significantly from baseline, with no change in visual acuity or refraction. Flattening in keratometric readings was stable thereafter. There was significant improvement in mean uncorrected distance visual acuity (1.57 ± 0.56 to 0.17 ± 0.06 logMAR, P < 0.001) and mean corrected distance visual acuity (0.17 ± 0.08 to 0.11 ± 0.05 logMAR, P < 0.001) at 12 months after ICL implantation that was maintained at the 2-year follow-up. Mean cylinder power and mean spherical equivalent (SE) also decreased significantly after ICL implantation. A small hyperopic shift in SE (+0.25 D) was observed at 2 years that did not alter visual outcomes. Conclusions. Visian toric ICL implantation following CXL is an effective option for improving visual acuity in patients with keratoconus up to 2 years.
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Bozorg S, Pineda R. Cataract and Keratoconus: Minimizing Complications in Intraocular Lens Calculations. Semin Ophthalmol 2014; 29:376-9. [DOI: 10.3109/08820538.2014.959193] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kummelil MK, Hemamalini MS, Bhagali R, Sargod K, Nagappa S, Shetty R, Shetty BK. Toric implantable collamer lens for keratoconus. Indian J Ophthalmol 2014; 61:456-60. [PMID: 23925337 PMCID: PMC3775087 DOI: 10.4103/0301-4738.116064] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Keratoconus is a progressive non-inflammatory thinning of the cornea that induces myopia and irregular astigmatism and decreases the quality of vision due to monocular diplopia, halos, or ghost images. Keratoconus patients unfit for corneal procedures and intolerant to refractive correction by spectacles or contact lenses have been implanted toric posterior chamber phakic intraocular lenses (PC pIOLs) alone or combined with other surgical procedures to correct the refractive errors associated with keratoconus as an off label procedure with special informed consent from the patients. Several reports attest to the safety and efficacy of the procedure, though the associated corneal higher order aberrations would have an impact on the final visual quality.
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Affiliation(s)
- Mathew Kurian Kummelil
- Cataract and Refractive Lens Surgery Services, Narayana Nethralaya, Post-Graduate Institute of Ophthalmology, Bangalore, Karnataka, India
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Comparison of iris-claw and posterior chamber collagen copolymer phakic intraocular lenses in keratoconus. J Cataract Refract Surg 2014; 40:383-94. [DOI: 10.1016/j.jcrs.2013.07.052] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 07/25/2013] [Accepted: 07/30/2013] [Indexed: 02/07/2023]
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Femtosecond laser–assisted intrastromal corneal ring segment implantation for high astigmatism correction after penetrating keratoplasty. J Cataract Refract Surg 2013; 39:1660-7. [DOI: 10.1016/j.jcrs.2013.04.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 04/01/2013] [Accepted: 04/17/2013] [Indexed: 11/23/2022]
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Jaimes M, Ramirez-Miranda A, Graue-Hernández EO, Navas A. Keratoconus therapeutics advances. World J Ophthalmol 2013; 3:20-31. [DOI: 10.5318/wjo.v3.i3.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 09/04/2013] [Indexed: 02/06/2023] Open
Abstract
Keratoconus is a progressive, usually bilateral disease of the cornea that significantly diminishes visual acuity, secondary to a progressive corneal deformity which is characterized by corneal thinning, variable degrees of irregular astigmatism and specific abnormal topographic patterns. Normally it initiates during puberty and is progressive until the third or fourth decade of life, when normally the progression rate is diminished or waned. There are multiple scales to clinically classify keratoconus. One of the most commonly used is Amsler-Krumeich and recently with the development of morphometric and aberrometric techniques, additional scales have been created that allow keratoconus to be classified according to its severity. Despite certain etiology of keratoconus remains unknown, current treatment options are available in patients with ectatic corneas and they vary depending on the severity of the disease and they include spectacles, contact lenses, intrastromal rings, keratoplasty both penetrant or lamellar, cross-linking, refractive lens exchange with intraocular lens implant, phakic intraocular lenses and the combination of these alternatives. Some authors have been using excimer laser in patients with keratoconus but the safety of the procedure is controversial. Currently, the techniques for the management of keratoconus can be classified in 3 types: corneal strengthening techniques, optical optimization techniques and combined techniques.
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Abstract
Pre-2000, the clinical management of keratoconus centred on rigid contact lens fitting when spectacle corrected acuity was no longer adequate, and transplantation where contact lens wear failed. Over the last decade, outcome data have accumulated for new interventions including corneal collagen crosslinking, intracorneal ring implantation, topographic phototherapeutic keratectomy, and phakic intraocular lens implantation. We review the current evidence base for these interventions and their place in new management pathways for keratoconus under two key headings: corneal shape stabilisation and visual rehabilitation.
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Affiliation(s)
- D M Gore
- Moorfields Eye Hospital, London, UK.
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Navas A, Tapia-Herrera G, Jaimes M, Graue-Hernández EO, Gomez-Bastar A, Ramirez-Luquín T, Ramirez-Miranda A. Implantable collamer lenses after intracorneal ring segments for keratoconus. Int Ophthalmol 2012; 32:423-9. [DOI: 10.1007/s10792-012-9582-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 04/21/2012] [Indexed: 11/27/2022]
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Alfonso JF, Lisa C, Fernández-Vega L, Madrid-Costa D, Montés-Micó R. Intrastromal corneal ring segment implantation in 219 keratoconic eyes at different stages. Graefes Arch Clin Exp Ophthalmol 2011; 249:1705-12. [DOI: 10.1007/s00417-011-1759-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 05/19/2011] [Accepted: 07/28/2011] [Indexed: 11/29/2022] Open
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Ramirez-Miranda A, Gomez-Bastar A, Navas A. Keratoconus correction using intrastromal corneal ring segments and posterior chamber phakic intraocular lens implantation. J Cataract Refract Surg 2011; 37:1373-4; author reply 1374-5. [PMID: 21700125 DOI: 10.1016/j.jcrs.2011.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Indexed: 10/18/2022]
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