Two-stage procedure in the management of selected cases of keratoconus: clear lens extraction with aspherical IOL implantation followed by WFG-PRK

AIM: To assess the objective and subjective results of a two-stage procedure for management of keratoconus: clear lensectomy with aspherical intraocular lens (IOL) implantation followed by wave front-guided photorefractive keratotomy (WFG-PRK). METHODS: This prospective interventional non-randomized study included patients aged 35 years old or more with grade I and II stable keratoconus, a clear visual axis, minimal corneal thickness (MCT) 420 mu m or more and average keratometric reading (K) less than 54 diopter (D). Refraction of all selected eyes should be -8.00 D sphere or more with less than -6.00 D cylinder and could be corrected two lines or more with spectacles or contact lenses. All studied eyes underwent a two-stage approach treatment: first refractive lens exchange and aspherical IOL implantation followed, after at least 3mo, by WFGPRK. Pre and postoperative complete ophthalmological examination were performed. Topographical, visual and aberrometric results were recorded and evaluated during 6mo follow up period. Moreover, patient satisfaction and other subjective outcomes were also analyzed. RESULTS: The 13 eyes of 11 patients diagnosed with stable keratoconus and aged from 39 to 49y (42.4 +/- 6.2y) were enrolled in the study. At baseline, 8 eyes had grade I and 5 eyes had grade II keratoconus. The manifest sphere was -10.3 +/- 4.2 D (ranged from -8.0 to -14.0 D) and the manifest cylinder was -4.2 +/- 1.2 D (ranged from -1.75 to -5.50 D). After the two-stage procedure, sphere and cylinder reduced significantly to -0.43 +/- 0.22 D and -1.3 +/- 0.72 D respectively (P<0.001). There was also a highly significant improvement in the mean uncorrected distance visual acuity (UDVA) from logMAR 1.41 +/- 0.49 preoperatively to 0.51 +/- 0.16 postoperatively (P<0.001) and the mean corrected distance visual acuity (CDVA) from 0.76 +/- 0.24 preoperatively to 0.49 +/- 0.13 after the operation (P<0.001). All aberrometric and mesopic vision parameters and most of the topographical indices demonstrated highly significant improvement that remains stable until the end of follow up. All recorded subjective data revealed a high degree of patient satisfaction. CONCLUSION: Two-stage approach (clear lens exchange with monofocal IOL followed by WFG-PRK) in selected cases of keratoconus is a safe, effective and highly predictable procedure with satisfactory visual and refractive results.