Sequential Intrastromal Corneal Ring Implantation and Cataract Surgery in a Severe Keratoconus Patient with Cataract

Abstract

A 49-year-old man with an uncorrected visual acuity (UCVA) of 20 / 1000, a best spectacle-corrected visual acuity (BSCVA) of 20 / 400, keratometric readings of K1 = 59.88 × 82° / K2 = 45.88 × 172°, and an inferior steepening that was consistent with keratoconus in his left eye was treated with clear-cornea phacoemulsification and an intraocular lens (IOL) implantation after insertion of keraring intrastromal corneal ring segments for severe keratoconus and cataract. An asymmetrical pair of kerarings was implanted with the assistance of a femtosecond laser in September 2008; the one segment was 250 µm and the other was 150 µm and both were placed at 70°. Three months after the kerarings were implanted, clear-cornea phacoemulsification and IOL implantation were performed on the left eye. After surgery, both the UCVA and the BSCVA of the left eye improved by eight lines. Postoperative central keratometry showed a decrease of 7.35 diopters in the left eye. Both the postoperative refraction (-0.75 -0.75 × 60°) and the keratometric reading (K1 = 50.05 × 93° / K2 = 48.83 × 3°) remained stable one month following the procedures. Thus, the sequential order of intrastromal corneal rings implantation and cataract surgery can be considered as a treatment option in patients with severe keratoconus and cataract.

Current concepts in the management of cataract with keratoconus

“…Lee et al . [ 46 ] performed a femtosecond-assisted asymmetric Kerarings implantation, followed by cataract surgery with PCIOL implantation 3 months later. Following the Kerarings implantation, the central K reduced from 60 D to 55 D, and after cataract surgery, the best corrected spectacle-aided visual acuity improved to 20/25.…”

Title: Cataract Surgery in Patients with Underlying Keratoconus: A Focused Review

“…There is some evidence that stabilization or improvement of the ectatic cornea shape by means of CXL and ICRS implantation before attempted cataract extraction may have the added benefit of improving the accuracy of IOL power calculation and refractive outcomes, with a small number of studies reporting favorable outcomes in patients undergoing cataract surgery with a history of prior CXL or ICRS. [59][60][61][62][63][67][68][69] Nevertheless, it is essential to remember that even in patients with prior CXL, there remains a risk for progression of corneal ectasia after phacoemulsification secondary to postsurgical inflammation and the mechanical stress induced by corneal incisions. 70 Of interest, Northey et al recently reported favorable outcomes using procedural approach in which phacoemulsification was performed before topographyguided photorefractive keratectomy and simultaneous CXL (Reference 71, Supplemental file 1, http://links.lww.com/JRS/A711).…”

Surgical Options for the Refractive Correction of Keratoconus: Myth or Reality

“…A sequential procedure has also been studied for the combined treatment of cataract and keratoconus [ 56 , 84 ]. Alfonso et al [ 56 ] reported the long-term results of sequential implantation of the Ferrara-type ICRS and IOL implantation in 70 eyes with keratoconus and cataract.…”