Visian Toric ICL Implantation for Residual Refractive Errors After ICRS Implantation and Corneal Collagen Cross-linking in Keratoconus

Abstract

Some patients with keratoconus have poor corrected distance visual acuity (CDVA) associated with high refractive errors. According to our treatment protocol, 1 the best approach for these cases is intracorneal ring segments (ICRS) implantation (usually one segment) to improve CDVA followed by corneal collagen cross-linking (CXL) treatment 4 weeks later to stabilize the cornea and phakic toric implantable collamer lens (TICL) (Visian Toric V4b ICL; STAAR Surgical, Monrovia, CA) implantation 4 to 6 months after CXL to correct the residual refractive errors. We conducted a retrospective analysis of 11 eyes of 7 patients with moderate to severe keratoconus (according to the Amsler-Krumeich classifi cation 2 , 4 eyes had stage II keratoconus and 7 eyes had stage III) and poor CDVA who underwent three-step ICRS implantation-CXL-TICL implantation procedures at our eye hospital. The two procedures (ICRS implantation-CXL) were performed sequentially at an interval of 4 weeks and TICL implantation was performed at least 6 months after CXL. Data were collected preoperatively, at the 6-month follow-up visit after sequential ICRS implantation-CXL, and at the 6-month follow-up visit after TICL implantation.Mean age was 29.20 years (range: 22 to 46 years). Uncorrected distance visual acuity (UDVA) showed signifi cant improvement after three sequential procedures (mean UDVA improved from 1.47 ± 0.38 log-MAR at baseline to 1.13 ± 0.50 logMAR after ICRS implantation-CXL procedures and to 0.27 ± 0.20 logMAR after ICL implantation). Overall, 63.7% of eyes (7 of 11) had UDVA greater than 20/40 by 6 months after ICL insertion. CDVA also showed signifi cant change 6 months after ICRS implantation-CXL (CDVA improved from 0.50 ± 0.22 logMAR at baseline to 0.29 ± 0.23 log-MAR 6 months after ICRS implantation-CXL). However, CDVA did not show any signifi cant improvement after ICL insertion (0.19 ± 0.11 logMAR).Refraction signifi cantly improved after the three procedures. The spherical equivalent changed significantly from -9.70 ± 3.1 diopters (D) at baseline to -7.65 ± 3.23 D 6 months after ICRS implantation-CXL and to -0.58 ± 1.01 D 6 months after TICL implantation. The cylindrical component also changed signifi cantly from 3.81 ± 1.15 D at baseline to 1.84 ± 0.35 D 6 months after ICL insertion. However, no signifi cant change was noted in cylindrical component 6 months after ICRS implantation-CXL (3.81 ± 1.15 D at baseline vs 4.06 ± 1.58 D 6 months after ICRS implantation-CXL). Keratometric readings (central corneal power obtained by topography) decreased after ICRS implantation-CXL: mean K (fl at) decreased from 48.51 ± 4.26 D at baseline to 45.19 ± 3.98 D 6 months after ICRS implantation-CXL and mean K (steep) decreased from 54.24 ± 4.96 D at baseline to 50.41 ± 4.32 D 6 months after ICRS implantation-CXL. Mean K (max) decreased from 57.41 ± 6.32 D at baseline to 54.01 ± 4.75 D 6 months after ICRS implantation-CXL.In this retrospective study, all patients had poor CDVA and ICRS insertion (performed using femtosecond laser to create t...

Toric Implantable Phakic Contact Lens in the Correction of Stable Keratoconus after Corneal Collagen Crosslinking

“…Other choices for keratoconus therapy are the use of ICRS and CXL, but with less reduction in myopia and astigmatism than with toric phakic IOLs. Phakic IOL could be implanted after ICRS by Jarade et al, 2013 in a two-step procedure for treating progressive keratoconus [23].…”

Implantable Contact Lenses in Keratoconus

“…23 Implantation of toric ICL in keratoconus patients has been evaluated even for the residual refractive error after Intacs implantation and CXL, suggesting that ICL can serve as a good treatment option for the residual refractive error in such patients. 24,25 In another study conducted on 16 eyes with keratoconus ICL implantation after CXL, results were observed to be fairly stable even after long-term follow-up of 3 years, with no significant endothelial cell loss. The mean Snellen decimal CDVA improved from 0.56 ± (p < 0.0001).…”

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

“…The authors concluded that this combined 3-stage approach was effective in improving functional vision and reducing disease progression in keratoconic eyes. Jarade et al [ 134 ] retrospectively analysed 11 keratoconus who had 3-step ICRS implantation followed by CXL and then toric PC pIOL implantation. The time interval between ICRS implantation and CXL was 4 weeks and between CXL and toric PC pIOL implantation was at least 6 months.…”