Deep Anterior Lamellar Keratoplasty After Intacs Implantation in Patients With Keratoconus

Purpose: To evaluate the clinical outcomes of deep anterior lamellar keratoplasty (DALK) in patients with unsatisfactory vision after intrastromal corneal ring segment (ICRS) implantation for keratoconus refractive correction. Methods: Prospective interventional case series. Five patients with consecutive keratoconus and poor visual outcome after ICRS implantation underwent DALK Big bubble technique. Three patients had ICRS explanted several months before lamellar graft surgery because of late postoperative complications; the other 2 had ring segments in place at the time of DALK. Results: Average preoperative logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity was 1.5 +/- 0.685 (20/800) and 0.74 +/- 0.427 (20/114) at the end of the follow-up. Mean preoperative logMAR best-corrected visual acuity was 0.56 +/- 0.089 (20/70) and 0.12 +/- 0.044 (20/25) at the last examination. Mean MRSE changed from -8.75 +/- 6.74 diopters (D) preoperatively to -3.35 +/- 2.302 D postoperatively. Mean topographic astigmatism and mean topographic keratometry (K) varied from 3.96 +/- 2.197 and 50.06 +/- 3.965 D preoperatively to 1.72 +/- 1.147 and 42.34 +/- 2.356 D postoperatively, respectively. No operative complications occurred. One patient developed stromal rejection that regressed after topical steroid therapy. Conclusions: DALK may be proposed in alternative to penetrating keratoplasty for the treatment of patients with keratoconus with poor visual result after ICRS implantation. DALK Big bubble technique may be carried out with ICRS in place. Visual and refractive outcomes are comparable with standard penetrating keratoplasty in patients with keratoconus.