Combined Surgical Approach In Advanced Keratoconus

To describe the clinical outcomes in a male patient with advanced keratoconus and contact lens intolerance managed using a staged surgical approach. Initial treatment consisted of femtosecond laser–assisted intrastromal donor lamellar transplantation. After achieving corneal stability at one year postoperatively, the protocol was completed with topography-guided surface ablation. Keratoconus is a progressive corneal ectasia characterized by stromal thinning, often resulting in significant visual impairment. In advanced stages, surgical intervention is often necessary to restore corneal structure and improve visual function. This report highlights a potential stepwise strategy for managing advanced keratoconus cases.

All diagnostic evaluations, surgical procedures, and postoperative follow-up visits in this case were conducted at Gemini Eye Clinic, a private outpatient clinic in the Czech Republic. Both surgical interventions were performed by a single experienced surgeon, Dr. Pavel Stodůlka, the chief physician of the clinic. Preoperative diagnostic assessments and postoperative follow-up examinations were carried out by ophthalmologists and optometrists practicing at the same institution.

A 32-year-old male with keratoconus previously treated with CXL 5 years earlier presented with worsening hybrid contact lens intolerance and recurrent allergic conjunctivitis. UDVA was 0.6 logMAR and CDVA 0.2 logMAR (−1.0 D sphere, −5.0 D cylinder ×45°); Kmax 60.7 D, TCT 498 µm, TKC stage 2–3.

A 140 µm, 10 mm anterior donor lamella containing Bowman’s layer was prepared with femtosecond laser (FEMTO Z8, Ziemer), soaked in 0.25% riboflavin, UV-A crosslinked (9 mW, 10 min), and stored in Eusol. A 9.5 mm, 220 µm-deep stromal pocket with a 3-mm incision at 270° (Victus, Technolas) was created; the trypan blue–stained lamella was inserted. Postoperative treatment included subconjunctival methylprednisolone acetate and tobramycin/dexamethasone drops.

At 12 months, TCT increased, Kmax decreased, TKC regressed to stage 1. The graft remained clear and centered; mild edema resolved within 1 month. UDVA was 1.1 logMAR, CDVA 0.3 logMAR (−1.5 D sphere, −5.5 D cylinder ×75°). Hybrid lens wear resumed at 3 months but intolerance persisted.

After 12 months, topography-guided PRK (Amaris 1050S, Schwind) over 4.5 mm treated half the LOA cylinder and coma from HOAs. UDVA improved from 1.0 to 0.3 logMAR and CDVA from 0.3 to 0.2 logMAR at 3 years post-PRK. Post-PRK TCT remained ≥640 µm. Acute allergic conjunctivitis 3 months later resolved with fluorometholone. At 4 years post-transplant and 3 years post-PRK, UDVA was improved, topography stable, slit-lamp normal, contact lenses discontinued.

In keratoconus with contact lens intolerance, therapeutic options are limited and conventional correction often fails. A staged, minimally invasive strategy femtosecond laser–assisted intrastromal transplantation of a pre-crosslinked donor lamella followed by delayed topography-guided PRK—enabled structural reinforcement before safe refractive correction. The lamellar step provided biomechanical stabilization and corneal thickening, creating conditions for effective surface ablation. This case underscores the value of individualized, stepwise management combining tectonic support with customized refractive surgery to optimize long-term visual outcomes while avoiding higher-risk keratoplasty.