CASE REPORT

OFTALMOLOGI : Jurnal Kesehatan Mata Indonesia, 30 Dec 2020 | 1
Year : 2021 | Volume: 3 | Issue: 1 | Pages : 1

PENGARUH KECANDUAN PENGGUNAAN SMARTPHONE TERHADAP HASIL SCHIRMER TEST PADA MAHASISWA FK UPH TAHUN 2019

IntroductionKeratoconus is a vision disorder that occurs when the cornea becomes thin and irregular (cone) shaped. This abnormal shape causes the light entering the eye from being focused correctly on the retina and causes distortion of vision. Invasive therapy in keratoconus can be done by Refractive Lens Exchange.Case Description Male, 25 years old with complained blurry vision since 10 years ago. Every 6 months or 1 year, size of the glasses changes. Since 2 years ago, the patient used glasses with the right size S -11.00 and left S -16.00, but patient  feels his vision still blurry and uncomfortable. Ophthalmology examination found visual acuity in the right eye 2/60 PH 6/60 and if using S-9.00 visual acuity became 6/30; visual acuity in the left eye 1/60 PH 6/60 and if using S – 11.75 visual acuity becomes 6/48. Corneal examination of both eyes found keratoconus, the other anterior segments of both eyes within normal limits. A result of corneal topography, the patient with keratoconus. Patient was diagnosed with Right Left Eye High Myopia + keratoconus. Management for this patient Refractive Lens Exchange  with Intraocular Lens implantation + Capsular Tension Ring. Discussion Management for keratoconus glasses, contact lens, scleral lens, Intrastromal Corneal Ring Segments, RLE, Penetrating Keratoplasty (PK) or Deep Anterior Lamellar Keratoplasty (DALK), Corneal Cross-Linking, CXL Plus, Accelerated Cross-Linking. Keratoconus is contraindicated for LASIK action and corneal surface ablation.ConclussionRefractive Lens Exchange (RLE) + Intraocular Lens implantation is effective and safe procedures that can be chosen to treat high myopia patients with keratoconus to improve visual acuity. For therapy, a scleral lens can be added to correct irregular astigmatism so optimal vision can be achieved.

Introduction

Keratoconus is a common disorder in which the central or paracentral cornea undergoes progressive thinning and protrusion, resulting in a cone shaped cornea and leading to irregular astigmatism and visual deterioration. Keratoconus is a progressive, bilateral, but asymmetric 1,2

Keratoconus is a common disorder (incidence of about 1 per 2000). Onset occurs during puberty, and the progression rate is greatest in young people. Progression typically slows in the fourth decade of life and is unusual after age 40 years but can occur1. Keratoconus occurs in both genders. No gender predominance has been reported in several studies, whereas recent reports have suggested a higher prevalence among male patients2 

The etiology of keratoconus is multifactorial. Keratoconus can be associated with family history, ethnicity (Asian and Arabian), mechanical factors (eye rubbing, floppy eyelid), ocular allergy. It can also be associated with systemic diseases, including atopic disease, Down syndrome, Ehlers- Danlos syndrome, osteogenesis imperfecta, sleep apnea, and mitral valve prolapse1,2

               Disease progression is manifested by a significant loss of visual acuity which cannot be compensated for with spectacles, a visual acuity of 6/6 or better is difficult to achieve with increasing against-the-rule astigmatism. Keratometry readings are commonly abnormal,3

               Early detection for keratoconus with corneal topography and Scheimpflug imaging atau anterior segment Optical Coherence Tomography. Advanced keratoconus can be diagnosed using only slit-lamp and manual keratometry, but for more sensitive analysis corneal topography and corneal pachymetry should still be used4,5

Keratoconus is considered contraindicated for LASIK and corneal surface ablation, so it is imperative that a complete examination of the eye is made to establish a correct diagnosis. Inappropriate therapy on keratoconus can actually cause more severe and permanent visual disturbances, so a proper diagnosis is needed to provide satisfactory therapeutic results 1,5,6

Complication of keratoconus is vision loss which occurs mainly due to corneal protrusions, and secondly due to corneal scarring. Corneal thinning usually occurs in the center of the cornea as well as in the inferotemporal cornea. Advanced keratoconus can develop corneal hydrops, which can cause corneal scars5

This case report aims to increase knowledge in making a diagnosis, examining, and considering management of keratoconus cases in order to produce good and optimal visual acuity resolution

Results

Case Description

A male patient, 25 years old, came to the Eye Polyclinic February with complaints of blurred vision in both eyes since 10 years ago, at that time he went to an ophthalmologist and received glasses size S -2.50. Every 6 months or 1 year, size of the glasses changes. Since 2 years ago, the patient used glasses with the right size S -11.00 and left S -16.00, but patient  feels that his vision still blurry and uncomfortable, so the patient asks to do LASIK. Patients use computers for about 8-10 hours every day for work. The patient admitted that he often rubbed his eyes, was allergic to dust and often sneezed. History of Family history of wearing glasses, trauma, contact lens use, systemic disease is denied.

Ophthalmology examination found visual acuity (VA) right eye 2/60 Pin Hole (PH) 6/60 and if using S-9.00 VA became 6/30; VA left eye 1/60 PH 6/60 and if using S -11.75 VA becomes 6/48. Corneal examination of both eyes found keratoconus, the other anterior segments of both eyes within normal limits. Fundus examination of both eyes revealed rounded N.II papillae, well defined, cup disc ratio 0.3; retinal lattice degeneration, macular reflex (+).

Figure 1. Preoperative lateral eye view (Courtesy of Ivane, 2019)

The corneal topography of the right eye was obtained from steep K 56.38 D @ 92, Flat K 52.95 D @ 2, Astigmatism 3.43 D, Q - 0.82, Shape factor 0.82, pupil diameter 7.1 mm, Axial I - S 2.98 D; on the left eye, the results are steep K 60.89 D @ 76, Flat K 55.65 D @ 166, Astigmatism 5.24 D, Q - 0.77, Shape factor 0.77, pupil diameter 6.9 mm, Axial I - S 6.65D . The specular results in the right eye showed a mean CCT of 499, while the mean CCT of the left eye was 424. Anterior segment OCT of the right eye obtained an angle formed between the cornea and the iris at temporal 460 and nasal 430; while in the left eye the temporal is 360 and the nasal is 390

Figure 2. Corneal topography both eyes

Patient was diagnosed with Right Left Eye High Myopia + keratoconus. Patient was planned to undergo Refractive Lens Exchange RLE + Intraocular Lens (IOL) + Capsular Tension Ring (CTR) . Then the patient was measured the IOL which would be fitted with the barret formula, axial length right eye was 23.23, K1 53.25 D, K2 54.25 D, IOL + 7.00 D; axial length left eye was 23.59, K1 53.75 D, K2 55.25 D, IOL + 4.00 D.

Post RLE + IOL + CTR day 1 got VA right eye 6/9 and VA left eye 6/45 PH 6/18, conjungtiva both eye showed subconjuntival bleeding, cornea showed corneal edema and descemet fold, IOL (+). One week and one month after surgery visual acuity in the right eye 6/6 and visual acuity left eye 6/45 PH 6/18, anterior segment of both eye within normal limits, IOL (+).

Eight months after surgery, patient complained blurry vision in both eyes. On ophthalmology examination showed VA right eye 6/12 PH 6/9; VA left eye is 6/60 and no improvement with pin hole. Anterior segment examination on both eye found IOL and Posterior Capsular Opacification (PCO). Patient was planned for ND – Yag capsulotomy. Patient also underwent corneal topography, specular examination and anterior OCT on both eyes. The corneal topography of the right eye showed steep K 57.61 D @ 83; Flat K 52.82 D @ 173; ?K: 4.79 D; IS index 0.81 D; SAI 1.99; SRI 1.39. The topography of the left eye is steep K 64.87 D @ 80; Flat K 55.43 D @ 170; ?K: 9.44 D; IS index 5.05 D; SAI 4.10; SRI 1.81 The average CCT in the right eye showed a mean CCT of 444, while the mean CCT of the left eye was 387.

Figure 3. Cornea topography both eye

Post ND yag capsulotomy VA right eye 6/10 PH 6/7,5, with C - 4.00 x 1800 VA became 6/7,5. VA in the left eye was 6/15 PH 6/10, with C - 4.00 x 1700 VA became 6/7,5. One month post ND yag capsulotomy VA right eye 6/15 PH 6/6, with C - 4.00 x 1800 VA became 6/6.  VA left eye 6/18 dengan pinhole menjadi 6/9, with C - 4,00 x 17001800 VA became 6/9. Binocular vision was 6/6, comfortable adaptation. For near vision, +3.00 is added for both eyes.

Discussion

Keratoconus is a common disorder in which the central or paracentral cornea undergoes progressive thinning and protrusion, resulting in a cone shaped cornea and leading to irregular astigmatism and visual deterioration 1,2

The reported prevalence of keratoconus is highly variable, range from 0.0003% in Russia to 2.3% in India, 0.054% USA2. A hereditary pattern is not prominent or predictable, but positive family histories have been reported in 6%–8% of cases. Genetic predisposition and environmental risk factors such as eye rubbing, inflammation, atopy, hard contact lens wear, and oxidative stress all play a role in the onset and progression of keratoconus 1,2

               Keratoconus can be classified into four stages (Amsler – Krumeich classification system)5. Characteristic sign of keratoconus is Rizzutti sign, a focusing of the light within the nasal limbus when a penlight is shone from the temporal side, is another early but nonspecific finding. Munson sign, an inferior deviation of the lower eyelid contour on downgaze, is also nonspecific and is a late sign. Iron deposition within the basal epithelium at the base of the cone forms a Fleischer ring best seen with the slitlamp using a broad, oblique beam and the cobalt- blue filter1

               Corneal topography and tomographic have been accepted as sensitive methods for early diagnosis, monitoring progression, and treatment of KC, illustration of irregular astigmatism, detection other corneal ectatic disorders, corneal degenerative, perfection of contact lens fitting, trauma, scarring, corneal surgery, corneal thickness, angle elevation cornea, epithelial imaging dan analysis anterior segment4,5,7. The topographic pattern of eyes with keratoconus usually shows steepening in the inferonasal or inferotemporal area, or steepening in the central and superior areas. Typically, a variation greater than 10.00 diopters between the steepest and flatest curvatures is an indication of keratoconus5

Management for keratoconus glasses, contact lens, scleral lens, Intrastromal Corneal Ring Segments, RLE, Penetrating Keratoplasty (PK) or Deep Anterior Lamellar Keratoplasty (DALK), Corneal Cross-Linking, CXL Plus, Accelerated Cross-Linking. Keratoconus is contraindicated for LASIK action and corneal surface ablation. The weakening of the cornea when LASIK flap creation in action, and the removal of tissue significantly increases the risk of progressive ectasia1,5,8

RLE is the removal of the non-cataract eye lens with or without IOL implantation. RLE surgical technique is like the standard cataract surgery technique. The main element that distinguishes between RLE and standard cataract surgery is that in RLE, the crystalline lens still does not contain cataracts and abnormal anatomical conditions. The patient has high myopia is an indication for RLE 9, 10. Advantage of the RLE procedure is that it can maintain the normal contour of the cornea, thus improving the quality of vision, improving vision quickly, no need for cataract surgery in the future. For cases of high myopia and astigmatism, it can also be accompanied by Limbal Relaxing Incission (LRI) or implantation toric IOL 9, 11. Disadvantage of RLE is that the patient's expectation for visual acuity is higher than that of patients with cataract surgery, so it is important to provide thorough preoperative informed consent; uncorrected residual refractive errors during intraoperative IOL insertion; and postoperative care 11,12

The complication of keratoconus is vision loss which occurs mainly due to irregular astigmatism and myopia due to corneal protrusions, and secondly due to corneal scarring. Corneal thinning usually occurs in the center of the cornea as well as in the inferotemporal cornea. Advanced keratoconus can develop corneal hydrops, which is called acute keratoconus, where the Descemet layer breaks, and is associated with the stromal rlefts which can cause the aqueous to enter the stroma, causing corneal scars. Patients usually report sudden vision loss and discomfort in the eyes accompanied by pain and conjunctival injection5

Conclusion

Keratoconus is a visual disturbance that occurs when the central or paracentral shape of the cornea progressive thinning and protrusion, so that the cornea resembles a cone shape.

Keratoconus is a contraindication for LASIK and corneal surface ablation, so that a complete examination of the eye is important for proper diagnosis. Inappropriate therapy on keratoconus can actually cause more severe and permanent visual disturbances, so that a proper diagnosis is needed to provide satisfactory therapeutic results. An important test to determine the presence or absence of keratoconus is a conventional topography to see the curvature and characteristics of the cornea. RLE + IOL implantation is one of the most effective and safe procedures that can be chosen to treat high myopia patients with keratoconus to improve visual acuity. For therapy, a scleral lens can be added to correct irregular astigmatism so optimal vision can be achieved.

References

  1. American Academy Of Ophtalmology. 2019 – 2020. Corneal Dystrophies and Ectasias In: External Disease and Cornea Section 8. San Francisco : AAO; p.161 – 8.
  2. Andreanos K.D, Hashemi K, Petrelli M. 2017. Keratoconus Treatment Algorthm. Ophalmor Ther. Vol 6. P. 245 – 62.
  3. Jimenez R, Rubido S, Woffsohn JS. 2010. Keratoconus: A Review. Cont Lens Anterior Eye. 2010 Aug;33(4):157-66.
  4. American Academy Of Ophtalmology. 2019 – 2020. The Science of Refractive Surgery. In: Refractive Surgery. Section 13. San Francisco : AAO; p.29 – 36.
  5. Anderson D. 2017. Understanding Corneal Topography. Viewed Januari 26th 2020. Available on : <https://www.aoa.org/Documents/optometric-staff/Artirles/Understanding-Corneal-Topography.pdf >
  6. Martin R. Cornea And Anterior Eye Assessment With Placido-Disc Keratoscopy, Slit Scanning Evaluation Topography And Scheimpflug Imaging Tomography. 2018. Indian J Ophthalmol. 2018; 66 (3) : 360-366.
  7. Naderan M, Jahanrad A, Farjadnia M. 2017. Clinical Biomicroscopy And Retinoscopy Findings Of Keratoconus In A Middle Eastern Population. Clinical and Experimental Optometry.
  8. Denny P. 2015. Keratoconus : New Consensus, New Goals. Viewed Januari 26th 2020. Available on: <https://www.aao.org/Assets/45e72d35389d49278d690adc91fda8ef/635734282163130000/august-2015-clinical-update-cornea-pdf >
  9. Alio J.L, Grzybowski A, Romaniuk D. 2014. Refractive Lens Exchange In Modern Practice: When And When Not To Do It? Eye and Vision Vol 1. No. 10.
  10. Bashour M. 2019. Refractive Lens Exchange for Myopia Correction. Viewed Januari 26th 2020. Available on: < https://emedicine.medscape.com/artirle/1221340-overview>.
  11. Srinivasan B, Leung H.Y, Cao H. 2016. Modern Phacoemulsification and Intraocular Lens Implantation (Refractive Lens Exchange) Is Safe and Effective in Treating High Myopia. Asia-Pacific Journal Of Ophthalmology. Voli 5. No. 6. p. 438 – 444.
  12. Horgan N, Condan P.I, Beatty S. 2005. Refractive Lens Exchange In High Myopia: Long Term Follow Up. J Ophthalmology 89. P 670 – 2.

Keywords: Keratoconus, High Myopia, Refractive Lens Exchange

Citation: *, ( 2021), PENGARUH KECANDUAN PENGGUNAAN SMARTPHONE TERHADAP HASIL SCHIRMER TEST PADA MAHASISWA FK UPH TAHUN 2019. OFTALMOLOGI : Jurnal Kesehatan Mata Indonesia, 3(1): 1

Received: 03/04/2021; Accepted: 03/04/2021;
Published: 30/12/2020

Edited by:

Reviewed by:

*Correspondence: