Eyeworld

73 EW CORNEA September 2016 loss of vision. In my mind, there's no clear picture of which procedure provides better vision or stability." The combined use of ICRS and crosslinking "will continue to be a major treatment for keratoconus and ectasia," Dr. Hardten said. EW He prefers not to remove any epithelium and to use a suture "for a few days at the incision site." He implants the rings away from the incision site "so there is no mechan- ical stretching of the incision site or melting." Patient follow-up Post-implantation, patients "need to be seen a little bit more often in the early postop period because intrastromal corneal rings are made out of plastic, it's clearly a foreign body, and as with any implant, there's a higher risk of infection," Dr. Asbell said. She recommends close follow-up during the first 2 postop weeks to ensure the channel remains infection-free. If infection does develop and does not respond to topical antibiotics, the devices can be removed and an antibiotic course continued. Dr. Hardten uses a 10-0 vicryl suture in the incision and also in between the segments 180 degrees away from the incision. "This dissolves in 6 weeks. Usually the patient can go back into a contact lens at 4 to 6 weeks or after the suture dissolves," he said. "I do transepithelial crosslinking, so the epithelium is usually stable by then." Dr. Kanellopoulos recommend- ed "very careful follow-up at least every 6 months" because of the potential for late-occurring com- plications. Rings have been shown to "work best in corneas that are thicker than 400 microns, and their need is usually more necessary in corneas that have dropped under 400 microns, and there the options are very limited," he said. He "would use them today only for a patient who desires an immediate refractive result, but in the long-term I would advise patients to have the rings removed and to choose some type of crosslinking procedure that appears to be better tested and stable." Until crosslinking is covered by insurance in the U.S., Dr. Asbell thinks that may tip the scales in fa- vor of ICRS for now, but she expects combination treatments will become more prevalent in the future. "Rings are here to stay, and I think they have a role," she said. "They're minimally invasive. Crosslinking with epi-off techniques can result in infections, scarring, or permanent Editors' note: Dr. Asbell has financial interests with Addition Technology. Drs. Hardten and Kanellopoulos have no financial interests related to their comments. Contact information Asbell: penny.asbell@mssm.edu Hardten: drhardten@mneye.com Kanellopoulos: ajkmd@mac.com

• Cover