Corneal Instability With Delayed Corneal Opacification After Keratophakia: A Case Report

Keratophakia, a surgical procedure involving the implantation of corneal tissue -donor or synthetic- within the corneal layers to correct refractive errors, was introduced by Dr. José Ignacio Barraquer in the 1940s. While LASIK (laser-assisted in situ keratomileusis) gained popularity in the late 1990s for its less invasive and more predictable refractive correction, keratophakia increased its applicability in treating keratoconus cases. However, long-term complications can still arise.

This case report presents the experience of a single patient with corneal opacification following corneal keratophakia surgery in the left eye from another hospital. All the following treatment and final surgery was performed at the Barraquer Ophthalmology Center in Barcelona, Spain.

A 47-year-old male patient presented with a chief complaint of decreased visual acuity in his left eye for approximately 1 year. He reported a history of undergoing a previous keratoplasty 11 years before and 3 years after cataract surgery with IOL implantation in the same eye.

Corrected visual acuity was 20/25 in the right eye and 20/100 in the left eye with 10 diopters of oblique astigmatism and +14 diopters of hyperopia. Slit-lamp examination revealed mild-to-moderate keratoconus in the right eye and generalized corneal opacification in the left eye with abundant scar nodules and for our surprise, we observed an optically transparent zone between the mid and posterior stroma, resembling a round hydrogel lens, that has an approximate diameter of 9-10 mm. The endothelium was preserved, and topography showed very flat K values and irregular astigmatism.

A surgical solution was proposed, with DALK surgery planned if feasible. The patient agreed, and during the surgery, a hydrogel lens occupying most of the corneal diameter was removed as expected. It was observed that there was almost no remaining posterior stroma, so we decided to directly place the DALK graft on top. Eight months after the surgery, visual acuity was 20/40 with two diopters of astigmatism.

This case report emphasizes the possibility of late corneal opacification and destabilization after keratophakia. Although the procedure can provide short-term benefits, long-term monitoring is essential due to the significantly increased risk of complications.

It is clear that keratophakia with large-diameter hydrogel lenses, as presented here, should not be used as a treatment for keratoconus, given the advancements and alternatives available today.