Single intrastromal corneal ring segment implantation using the femtosecond laser after radial keratotomy in a keratoconic patient.

A 33-year-old woman with irregular astigmatism 6 years after radial keratotomy (RK) for keratoconus was treated with implantation of a single intrastromal corneal ring segment (Keraring) using the femtosecond laser. The segment (0.150 mm thick with a 160-degree arc) was inserted in the steepest area (inferior) with no intraoperative or postoperative complications. Six months postoperatively, the uncorrected visual acuity had improved from 20/40 to 20/25 and the best spectacle-corrected visual acuity, from 20/32 to 20/20. The mean manifest astigmatic correction decreased from -2.50 diopters (D) to -0.75 D, and corneal topography showed improved inferior steepening and less irregular astigmatism. Although the results are encouraging, the long-term effect of this approach in post-RK patients is not known

Intrastromal corneal ring segment implantation with the femtosecond laser in a post-keratoplasty patient with recurrent keratoconus.

A 50-year-old woman had implantation of intrastromal corneal ring segments for recurrent keratoconus 15 years after penetrating keratoplasty. Two segments (0.15 mm and 0.25 mm) were inserted without any intraoperative or postoperative complications, using the femtosecond laser to create the tunnels (superior and inferior). Ten months after the procedure, the uncorrected visual acuity was 20/100, compared with counting fingers preoperatively, and the best spectacle-corrected visual acuity improved from 20/63 to 20/32. Although the results are encouraging, the long-term effect of this approach for the management of post-keratoplasty patients with recurrent keratoconus is not known

Topography-guided transepithelial PRK after intracorneal ring segments implantation and corneal collagen CXL in a three-step procedure for keratoconus.

To present the results of topography-guided transepithelial photorefractive keratectomy (PRK) after intracorneal ring segments implantation followed by corneal collagen cross-linking (CXL) for keratoconus. In this prospective case series, 10 patients (16 eyes) with progressive keratoconus were included. All patients underwent topography-guided transepithelial PRK after Keraring intracorneal ring segments (Mediphacos Ltda) implantation, followed by CXL treatment. The follow-up period was 6 months after the last procedure for all patients. Time interval between both intracorneal ring segments implantation and CXL and between CXL and topography-guided transepithelial PRK was 6 months. LogMAR mean uncorrected distance visual acuity and mean corrected distance visual acuity were significantly improved (P<.05) from 1.14±0.36 and 0.75±0.24 preoperatively to 0.25±0.13 and 0.13±0.06 after the completion of the three-step procedure, respectively. Mean spherical equivalent refraction was significantly reduced (P<.05) from -5.66±5.63 diopters (D) preoperatively to -0.98±2.21 D after the three-step procedure. Mean steep and flat keratometry values were significantly reduced (P<.05) from 54.65±5.80 D and 47.80±3.97 D preoperatively to 45.99±3.12 D and 44.69±3.19 D after the three-step procedure, respectively. Combined topography-guided transepithelial PRK with intracorneal ring segments implantation and CXL in a three-step procedure seems to be an effective, promising treatment sequence offering patients a functional visual acuity and ceasing progression of the ectatic disorder. A longer follow-up and larger case series are necessary to thoroughly evaluate safety, stability, and efficacy of this innovative procedure

INTACS followed by KeraRing intrastromal corneal ring segment implantation for keratoconus.

To describe the visual and refractive outcomes in three eyes (two keratoconic patients) with previous intrastromal corneal ring segments (INTACS, Addition Technology Inc) that underwent adjuvant single KeraRing (Mediphacos) intrastromal corneal ring segment implantation. Two keratoconic patients (three eyes) with implanted INTACS segments underwent an additional (without explanting previous INTACS) single KeraRing segment implantation. No intraoperative complications occurred. Six months postoperatively, uncorrected distance visual acuity improved from 20/100 and 20/200 to 20/32 and 20/40 in the right and left eyes, respectively, of patient 1, and from 20/400 to 20/50 in the treated right eye of patient 2. Corrected distance visual acuity improved from 20/50 and 20/100 to 20/30 and 20/32 in the right and left eyes, respectively, of patient 1 and from 20/200 to 20/40 in patient 2. Keratometric measurements improved from 51.00/45.70 to 47.00/44.60 diopters (D) and from 50.80/48.80 to 42.70/40.30 D in the right and left eyes, respectively, of patient 1, and from 49.30/45.70 to 45.60/44.10 D in patient 2. In keratoconic patients with INTACS in place, adjuvant single intrastromal corneal ring segment (KeraRing) implantation could improve visual and refractive outcome

Femtosecond LASIK retreatment using side cutting only.

To present visual and refractive outcomes in 11 eyes that underwent femtosecond LASIK and subsequent retreatment with flap lifting using only side cutting. Seven patients (11 eyes) with a mean age of 30.55±5.42 years (range: 24 to 39 years) underwent retreatment 18.18±5.41 months (range: 12 to 26 months) after primary LASIK treatment with side cutting only using a femtosecond laser for the correction of residual refractive error. Mean follow-up after retreatment was 7.72±1.48 months (range: 6 to 10 months). No intra- or postoperative complications were found after LASIK retreatment. Uncorrected distance visual acuity (UDVA) improved in all patients. Mean UDVA improved from 0.54±0.12 (decimal scale) (range: 0.4 to 0.7) preoperatively to 0.99±0.03 (range: 0.9 to 1.0) after retreatment. No patient lost lines of corrected distance visual acuity. Retreatment using a femtosecond laser to create only a side cut is an effective modality to treat residual refractive errors in postoperative LASIK patients

Four-stage procedure for keratoconus: ICRS implantation, corneal cross-linking, toric phakic intraocular lens implantation, and topography-guided Photorefractive Keratectomy

PURPOSE: To evaluate a four-stage combined treatment for keratoconus including intrastromal corneal ring segment (ICRS) implantation followed by corneal cross-linking (CXL), toric phakic intraocular lens (IOL) implantation, and topography-guided photorefractive keratectomy (TG-PRK). METHODS: In this retrospective interventional case series, 11 eyes of 7 patients with progressive keratoconus were treated with a four-stage procedure including the following: Keraring ICRS (Mediphacos Ltda, Belo Horizonte, Brazil) implantation followed by CXL, phakic IOL implantation, and TG-PRK (minimum 6 months between each stage). Minimum follow-up was 12 months after TG-PRK. RESULTS: Both mean uncorrected distance visual acuity and corrected distance visual acuity (CDVA) improved from 0.025 decimal (20/800 Snellen) and 0.093 decimal (20/215 Snellen) preoperatively to 0.68 decimal (20/30 Snellen) and 0.73 decimal (20/27 Snellen), respectively, after the combined treatment (P < .0001). Mean postoperative CDVA of 0.73 decimal (20/27 Snellen) was similar to preoperative contact lens CDVA of 0.72 decimal (20/28 Snellen). Mean manifest refraction spherical equivalent reduced from 16.78 ± 3.58 to 0.59 ± 0.89 diopters (P < .0001) and mean refractive astigmatism reduced from 5.16 ± 1.86 to 0.82 ± 0.28 diopters (P < .0001). CONCLUSIONS: This four-stage procedure appears to be an effective and safe approach for corneal stabilization and improvement of functional vision in patients with keratoconus. Larger case series with a longer follow-up are required to thoroughly evaluate the efficacy, safety, and stability of this combined approach

Four-Stage Procedure for Keratoconus: ICRS Implantation, Corneal Cross-linking, Toric Phakic Intraocular Lens Implantation, and Topography-Guided Photorefractive Keratectomy.

To evaluate a four-stage combined treatment for keratoconus including intrastromal corneal ring segment (ICRS) implantation followed by corneal cross-linking (CXL), toric phakic intraocular lens (IOL) implantation, and topography-guided photorefractive keratectomy (TG-PRK). In this retrospective interventional case series, 11 eyes of 7 patients with progressive keratoconus were treated with a four-stage procedure including the following: Keraring ICRS (Mediphacos Ltda, Belo Horizonte, Brazil) implantation followed by CXL, phakic IOL implantation, and TG-PRK (minimum 6 months between each stage). Minimum follow-up was 12 months after TG-PRK. Both mean uncorrected distance visual acuity and corrected distance visual acuity (CDVA) improved from 0.025 decimal (20/800 Snellen) and 0.093 decimal (20/215 Snellen) preoperatively to 0.68 decimal (20/30 Snellen) and 0.73 decimal (20/27 Snellen), respectively, after the combined treatment (P < .0001). Mean postoperative CDVA of 0.73 decimal (20/27 Snellen) was similar to preoperative contact lens CDVA of 0.72 decimal (20/28 Snellen). Mean manifest refraction spherical equivalent reduced from 16.78 ± 3.58 to 0.59 ± 0.89 diopters (P < .0001) and mean refractive astigmatism reduced from 5.16 ± 1.86 to 0.82 ± 0.28 diopters (P < .0001). This four-stage procedure appears to be an effective and safe approach for corneal stabilization and improvement of functional vision in patients with keratoconus. Larger case series with a longer follow-up are required to thoroughly evaluate the efficacy, safety, and stability of this combined approach. [J Refract Surg. 2017;33(10):683-689.]

Combined Intacs and posterior chamber toric implantable Collamer lens implantation for keratoconic patients with extreme myopia.

To evaluate the results of combined Intacs (Addition Technology, Fremont, California, USA) and posterior chamber toric implantable Collamer lens [ICLs] (Visian ICL; STAAR Surgical, Monrovia, California, USA) implantation in keratoconic patients with extreme myopia and irregular astigmatism. Prospective, single-center, noncomparative, interventional, consecutive case series. Three eyes of two consecutive highly myopic keratoconic patients who had undergone posterior chamber toric ICLs implantation after Intacs implantation. Implantation of posterior chamber toric ICLs was performed at intervals between six and 10 months after Intacs implantation. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refraction, topographic findings, adverse events, and postoperative complications were noted. No intraoperative or postoperative complications were observed. An improvement in UCVA and BSCVA was found after the Intacs and toric Visian ICL procedures in all eyes. All eyes were emmetropic within 1 diopter (D), whereas the mean manifest refractive spherical equivalent refraction reduced from -18.50 +/- 2.61 D (range, -16.75 to -21.50 D) to 0.42 D (range, plano to -0.75 D). The mean difference between preoperative and last follow-up UCVA and BSCA was a gain of 6.67 +/- 1.15 lines (range, gain of six to eight lines) and 4.33 +/- 2.52 lines (range, gain of two to seven lines), respectively. Combined Intacs and posterior chamber toric phakic Visian ICL implantation in a two-step procedure is an effective method for correcting keratoconic patients with extreme myopia

Management of post laser in situ keratomileusis ectasia with simultaneous topography guided photorefractive keratectomy and collagen cross-linking.

A thirty-nine year old man was referred to our institute due to progressive decreased visual acuity five years after bilateral Laser in situ Keratomileusis (LASIK). Topography revealed signs of post - LASIK ectasia. Patients' left eye was treated with simultaneous Topography Guided Photorefractive Keratectomy (PRK) followed by Corneal Collagen Cross Linking (CXL). Twelve months after the combined procedure both uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) showed significant improvement while topographic findings revealed an improvement of the astigmatic pattern. All higher order aberrations showed a significant decrease twelve months postoperatively. Combined topography guided PRK and corneal cross linking could represent an alternative treatment for post - LASIK ectasia