Lens-assisted Pharmacological-induced Kerato-steepening
Dr. Jay McDonald, an ophthalmologist in Little Rock, Ark., developed the treatment Contact Lens Assisted Pharmacological Induced Kerato-Steepening (CLAPIKS). He wanted to be able to correct previous laser refractive surgical patients who developed hyperopia, had residual hyperopia or didn't have enough myopia at near for monovision. Dr. McDonald credits Tal Raviv, MD, for giving him the idea because Dr. Raviv presented a paper at the 1999 American Society of Cataract and Refractive Surgery meeting describing topical ketorolac treatment of hyperopia in overcorrected myopic patients.
The CLAPIKS treatment consists of a patient wearing a steep-fitting contact lens continuously while instilling NSAID drops q.i.d. for two weeks in the affected eye. After two weeks the practitioner removes the lens and performs a new manifest refraction to measure the results of the treatment. Practitioners should inform patients that this is an off-label use of the NSAID and of the lenses.
I've used the CLAPIKS treatment on eight patients (10 eyes) who had previously undergone laser refractive surgery. Seven patients had hyperopic overcorrection and one needed an increase in myopia. The required hyperopic correction ranged from +0.50D to +1.50D. The required myopic increase was -0.50D.
Treatment continued for two to three weeks. All patients used either Acular PF or Acular LS (both Allergan) except for one who used Voltaren (Novartis Ophthalmics). All patients wore the Night &Day lens (CIBA Vision) with the exception of one who used an O2Optix lens (CIBA). One patient underwent CLAPIKS two weeks after LASEK surgery. Some had the procedure within one year of surgery and others underwent CLAPIKS years after their laser treatment (Table 1).
We treated Patient ML in both eyes two weeks after her LASEK surgery because of a +1.25D spherical hyperopic overcorrection OU. Her best visual acuity with correction was 20/40 in each eye. After two weeks of CLAPIKS, her manifest refraction was plano with a best visual acuity of 20/30 in each eye. Four months later she had a correction of +0.50D OU and a best visual acuity of 20/20 in each eye. Two questions arise: Did she really need the CLAPIKS treatment and how long does the CLAPIKS last?
ML was experiencing subjective complaints at near, so the treatment may have alleviated her symptoms sooner than if she hadn't undergone the treatment. Because she became more hyperopic later, is this treatment really effective?
Patients DB and JB had their laser surgeries in 2000 and 2001, respectively. DB complained of blurred vision in the right eye. The manifest refraction OD was +1.50D sphere with 20/20 VA. After CLAPIKS for two weeks, the manifest refraction OD was plano with 20/20 VA.
JB's manifest refraction was OD -0.50 +2.50 x065 20/30, OS +0.50 sphere 20/25. After CLAPIKS for two weeks, the manifest refraction improved to OD plano +1.00 x60 20/30 and OS plano 20/20. We requested that he return in two to three months to check stability of the treatment.
One patient (CE) used Voltaren instead of Acular. Her manifest refraction was OS +0.75 sphere 20/25. Two weeks later after CLAPIKS treatment, the manifest refraction was variable from +0.25 to +0.75, but her VA was 20/20 and subjectively she felt that her vision was better. The question here is, does Voltaren not work as well as Acular or is this patient's eye resistant to CLAPIKS?
Discussion and Conclusions
The mechanism of how CLAPIKS works isn't clear. Dr. McDonald et al postulate that the CLAPIKS treatment molds and structures the corneal curvature to a steeper conformation by the NSAID affect on the epithelial cell arrangement and anterior stromal proteoglycan swelling. The contact lens serves as a mold and assists this process.
I varied from Dr. McDonald's protocol by using high-Dk/L lenses for all patients and once using Voltaren instead of Acular. Clinically, besides refraction and subjective improvement noted by the patients, you could assess corneal curvature and topography pre- and post-CLAPIKS treatment to see if corneal curvature changes can be documented.
Could CLAPIKS work for hyperopic patients who have not undergone laser refractive surgery? Dr. McDonald doesn't think so. Clearly, further study is needed.
Since submitting this article I've attempted the CLAPIKS treatment on a natural hyperope (has not had any refractive surgery) and on a hyperopic patient who underwent LASIK, but the refraction regressed. There was no affect on the manifest refraction after two weeks of treatment.
At present, clinically I can conclude that CLAPIKS seems to work well for myopic LASIK patients who present with some overcorrection. CLAPIKS worked in the one myopic LASEK patient I treated, but I'd need to treat more such patients before I could come to a conclusion.
I don't think CLAPIKS will be successful for naturally hyperopic patients or for LASIK patients who were hyperopic before undergoing surgery.
Dr. Scharff has practiced in Rhode Island since 1986. He currently has practiced at Koch Eye Associates, a multispecialty eyecare practice, for two-and-one-half years. You can reach him at EScharff@kocheye.com.