Addition By Subtraction: Reversing Epikeratophakia And Stromal Scarring In A Patient With Myopia Magna

This case report presents the clinical journey of a 55-year-old woman who underwent epikeratophakia surgery in 1986 (right eye) and 1990 (left eye) to correct myopia magna. Decades after the procedure, the patient experienced a progressive decline in vision, not amenable to visual rehabilitation. A three-phase surgical approach was employed, involving the removal of the corneal lenticule, cataract extraction with intraocular lens placement, and transepithelial topography-guided-photorefractive keratectomy (trans-PRK). The case describes a potential strategy for consideration in phakic post-epikeratophakia patients.

Single Center Case report from IROC, Zürich, Switzerland.

A 55-year-old woman with previous epikeratophakia underwent evaluation for declining vision unimproved by spectacles or contacts. History: epikeratophakia in 1986 (OD) and 1990 (OS) for pathological myopia and CNV in both eyes, treated with Lucentis injections (OD). Presented with worsening vision in the right eye affecting daily tasks, attributed to corneal scarring, haze, irregularities (both eyes), and early cortical cataracts. Initial refraction: OD -16.25D/-1.50D @100°, OS -30D sphere. Proposed treatment: 1) Removal of epikeratophakia lenticule, 2) cataract extraction with IOL targeting -4.5D for both eyes, 3) transPTK/PRK for OD targeting -0.38D. Preoperative counseling emphasized refractive change post-lenticule removal. Post-lenticule removal, residual scar tissue affected vision, prompting cataract surgery. Axial length: 34.30mm (OD) and 33.47 mm (OS). IOL implanted targeting -4.5D. Refraction post-cataract surgery: OD -4.5 D/-3.00 D @ 25°, BSCVA 0.20 logMAR. Subsequently, transPTK/PRK targeted -0.38D for OD. Procedure performed with an OZ of 6.5mm, central ablation depth of 154.68 μm. Post-PRK, UDVA: 0.40 logMAR, BSCDVA: 0.15 logMAR, manifest refraction: -1.75D sphere. Left eye underwent cataract surgery targeting -4.50 diopters, achieving UDVA 1.0 logMAR, BSCDVA 0.3 logMAR. Trans-PRK targeted -1.70D/-0.40D @ 157°, achieving UDVA 0.45 logMAR, BSCDVA 0.3 logMAR. Refraction: +0.25D/-1.0 D @ 120°. Overall satisfaction with outcomes.

Our case highlights complications that can arise many years after Epikeratophakia. While epikeratophakia is essentially an abandoned procedure in modern times, anterior segment surgeons must nonetheless be aware of late-term complications and the unique surgical challenges these patients pose with as they may now increasingly present for cataract surgery due to advancing age.  Our described experiences may provide a helpful rubric for our colleagues in these infrequent cases. Though several non-surgical and surgical approaches may be taken in this patient population, we found success using our described three-step surgical approach, which resulted in a favorable visual outcome in this patient.