Efficacy of Different Procedures of Intra-Corneal Ring Segment Implantation in Keratoconus: a Systematic Review and Meta-Analysis

Purpose: To evaluate the efficacy of the functional, keratometric, and refractive postoperative parameters of intracorneal ring segment (ICRS) implantation in keratoconus and its association with collagen cross-linking (CXL), photorefractive keratectomy (PRK), and intraocular lenses (IOLs). Methods: We conducted a systematic review and meta-analysis on case series published between 2007 and 2017. Results: We included 95 case series with a total of 4560 patients. We included 64 studies of the ICRS procedure, 20 studies of ICRS+CXL, 9 studies of ICRS+CXL+PRK, and 5 studies of ICRS+IOL. We demonstrated an overall improvement of all parameters in all procedures. Cylinder was decreased with an overall effect size (ES) of -1.15 (-1.36 to -0.95; I-2 = 93.7%). Corrected distance visual acuity was improved with an overall ES of 0.89 (0.78 to 1.00; I-2 = 81.9%). Maximal keratometry was decreased with an overall ES of 0.98 (0.85 to 1.11; I-2 = 78.9%). ICRS+IOL is the best procedure to improve spherical equivalent and uncorrected distance visual acuity (P < 0.05) compared with other procedures. ICRSs versus ICRS+CXL are similar in all parameters except for corrected distance visual acuity. ICRS+CXL+PRK is better than ICRS alone in all parameters except for the correction of spherical equivalent. Conclusions: Although the quality and strength of the data are questionable, ICRS implantation is an effective strategy to preserve visual function in keratoconic patients. Particularly, ICRS+CXL+PRK could be a low invasive procedure to propose to young keratoconic patients. Translational Relevance: To propose an overview of postoperative parameters on each ICRS procedure on keratoconus.