The combination of CXL and toric phakic IOL implantation may be used to correct myopic astigmatism in patients with progressive mild to moderate keratoconus.

A 21-year-old man presented with keratoconus. The referring ophthalmologist reported that the patient’s refraction and topography had been progressively changing during the past 3 years. CXL was performed in both eyes with application of riboflavin solution and ultraviolet-A light. Three months later, a Toric Artiflex (Ophtec BV) foldable iris-supported phakic IOL was implanted in the patient’s ambylopic (high anisometropia) right eye. At 14 months postoperative, in the right eye his UCVA was 0.6 and BCVA was 0.6 with a refraction of plano -0.25 X 30 and 0.6 with a rigid gas-permeable contact lens (RGPCL) overrefraction. In the left eye, UCVA was 0.8 and BCVA was 0.9+ with refraction of +0.50 -1.00 X 105 and 1.00 with RGPCL.

In this case, CXL stabilized the patient’s keratoconus, while the toric IOL corrected his ametropia. If the degree of irregular astigmatism is clinically nonsignificant, the ametropia is high, and the patient desires spectacle independence, the implantation of a phakic IOL (in the absence of standard contraindications) might be considered an option for patients with early keratoconus. If the degree of irregular astigmatism is clinically significant, we could have first considered the implantation of intracorneal ring segments.

Jose L. Güell, MD, PhD, is Director of the Cornea and Refractive Surgery Unit of the Instituto de Microcirugía Ocular, Barcelona, Spain, and an Associate Professor of Ophthalmology at the Universitat Autonoma de Barcelona. Dr. Güell may be reached at tel: +34 93 253 15 99; fax: +34 93 417 13 01; e-mail: guell@imo.es.