Keratopigmentation And Refractive Surgery

Keratopigmentation is increasingly used for cosmetic and therapeutic indications, yet it creates unique anatomic and optical considerations for subsequent keratorefractive surgery. Evidence comparing technique selection after keratopigmentation—particularly the interaction between pigment depth/density and the intended surgical plane—remains limited. This case series reports 1-year outcomes of keratorefractive surgery performed 4 years after keratopigmentation in two sisters, comparing transepithelial photorefractive keratectomy (trans-PRK) and femtosecond small-incision lenticule extraction (femto-SMILE), with emphasis on feasibility, safety, efficacy, and refractive predictability while preserving pigment integrity.

Retrospective interventional case series performed at a refractive surgery service. Both patients had prior stable cosmetic/therapeutic keratopigmentation and sought keratorefractive correction after demonstrating refractive and tomographic stability.

Two sisters with a 4-year history of stable keratopigmentation underwent keratorefractive correction using either trans-PRK or femto-SMILE after confirmation of refractive and tomographic stability. Pre-op assessment included uncorrected and corrected distance visual acuity, manifest and cycloplegic refraction, slit-lamp examination, and corneal tomography, with targeted characterization of pigment architecture (depth, homogeneity, and proximity to the planned treatment plane). Surgical planning prioritized an anatomic separation between the refractive treatment plane and dense pigment whenever feasible. For trans-PRK, treatment parameters were selected to optimize surface regularity and minimize disruption of stromal pigment. For femto-SMILE, cap thickness, lenticule depth, and dissection strategy were tailored to avoid intersecting pigmented stromal layers and to preserve intraoperative visualization. Postoperative follow-up through 12 months evaluated visual acuity, refractive accuracy and stability, corneal clarity (surface or cap/interface), pigment stability (migration, fading, or color change), and patient-reported outcome. At 1 year, both techniques achieved clinically meaningful improvement in uncorrected visual acuity with stable refraction and preservation of corrected acuity. No vision-threatening adverse events, clinically significant haze, cap/interface opacity, pigment mobilization, or pigment-related dysphotopsia were observed under depth-appropriate planning.

In this two-patient comparison, trans-PRK and femto-SMILE performed 4 years after keratopigmentation demonstrated feasible surgery and acceptable 1-year visual and refractive outcomes without pigment destabilization when technique selection and depth planning were guided by careful mapping of pigment location and density. The anatomical relationship between pigment architecture and the intended refractive plane appears central to safety and optical quality. Larger studies are needed to validate long-term stability and refine candidate selection and surgical planning in keratopigmented corneas.