Sequential Topography-Guided Photorefractive Keratectomy and Iris-Claw Phakic IOL Implantation in the Management of Postkeratoplasty Astigmatism
DOI:
https://doi.org/10.48560/rspo.43664Keywords:
Astigmatism, Keratoconus, Lens Implantation, Intraocular, Phakic Intraocular Lenses, Keratoplasty, Penetrating, Photorefractive KeratectomyAbstract
INTRODUCTION: Keratoplasty is effective in treating corneal dysfunction. However, residual refractive error limits visual recovery. The aim was to demonstrate the benefit of sequential topography-guided photorefractive keratectomy (tgPRK) and iris-claw phakic intraocular lens (pIOL) implantation in the treatment of astigmatism after keratoplasty.
METHODS: Retrospective analysis of patients undergoing sequential tgPRK and pIOL after penetrating keratoplasty (PK) or deep anterior lamellar keratoplasty (DALK) between January 2013 and September 2023 at the Cornea Unit of a tertiary hospital. Patients undergoing other refractive procedures and without a minimum follow-up of 2 years were excluded. Demographic data, spherical equivalent (SEQ), uncorrected (UDVA) and corrected (CDVA) distance visual acuity were collected preoperatively, after tgPRK, and 2 years after pIOL implantation. Endothelial cell density was evaluated by the same specular microscope. Results are explained according to standard nomenclature.
RESULTS: Twenty eyes of 17 patients undergoing keratoplasty (65.0% DALK) were included. Ten (58.8%) patients are male, with a mean age of 31.7 ± 7.6 years. Preoperative SEQ was -5.0 ± 3.4 diopters (D), with a mean refractive astigmatism of -6.4 ± 3.3 D. At the last visit, 10 eyes (50%) had UDVA ≥ 20/32, and 3 (15%) had ≥ 20/20. The efficacy index was 1.2 ± 0.5. After sequential treatment, all eyes achieved refractive correction without loss of CDVA, and 18 (90.0%) eyes gained ≥ 1 line of vision. The safety index was 1.3 ± 0.7 at the last evaluation. Fourteen (70%) of the eyes obtained residual SEQ within ±0.50 D. There was a tendency for undercorrection (α<1), with final residual SEQ -0.13 ± 0.9 D. There was a mean annual endothelial cell loss of 26.7 ± 155.6 [-417.6 to 168] cells/mm² (4.0%) (p<0.001). No statistically significant differences were recorded between types of keratoplasty (3.9% vs 4.2% for DALK and PK, respectively, p=0.989).
CONCLUSION: Sequential tgPRK and pIOL treatment is effective in correcting astigmatism after keratoplasty. Nomogram adjustment may be beneficial to improve outcomes. Given the risk of endothelial loss, strict follow-up is mandatory.
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