Multimodal Corneal And Refractive Analysis With Tmr-Guided Astigmatic Modulation In Evo Icl Planning For Significant Anisometropia After Stable Post–Athens Protocol Keratoconus: Lens-Based Binocular Rehabilitation Within Commercial Power Limits.

To report refractive rehabilitation with EVO posterior chamber phakic ICL implantation in a structurally stable keratoconic eye previously treated with the Athens Protocol CXL, where the primary indication was significant anisometropia and contact lens intolerance, and where ICL selection required multimodal optical reconciliation and TMR-guided cylinder refinement within available EVO power limits. Spectacle correction failed to restore binocular balance and the patient was unable to tolerate contact lenses. This case highlights lens-based refractive equalization as a strategy-in clinical situations that subjective refraction is variable and challenging- for functional binocular rehabilitation after corneal stabilization.

A 36-year-old patient with progressive keratoconus previously underwent the Athens Protocol CXL (topography-guided PRK combined with higher fluence corneal cross-linking) and demonstrated 13 month structural and tomographic stability. UDVA was 20/400 and BCVA 20/50; however, the patient suffered from significant anisometropia, binocular imbalance, asthenopia, and functional visual limitation.

Intolerant to contact lens wear, while  spectacle correction failed to provide satisfactory binocular visual function due to aniseikonia/refractive disparity, made him a candidate for lens-based rrfractive intervention.

EVO posterior chamber phakic ICL selection was guided by a multimodal refractive workup (Scheimpflug tomography, Placido topography, AS-OCT, epithelial mapping, and ray-tracing/wavefront validation) to reconcile objective optics with subjective refraction. Cylinder planning incorporated our TMR refractive strategy to refine the treatable regular astigmatic component, while the spherical target was constrained by commercially available EVO ICL myopia ranges; anterior chamber depth, WTW, and vault prediction parameters were confirmed for safety. Postoperatively, UDVA was 20/60, CDVA 20/25 with restoration of binocular balance. Vault and rotational alignment were appropriate, endothelial cell density remained stable, and no ectatic progression was observed during 14-month follow-up from the ICL implantation and 27 months following the original Athens protocol CXL procedure.

In keratoconus eyes stabilized and central cornea shaped improvement  with the Athens Protocol CXL, persistent anisometropia may compromise binocular function despite satisfactory best-corrected acuity and structural corneal stability. EVO ICL implantation can safely restore refractive symmetry and binocular balance-even result in significant number of lines of vision gained-when careful multimodal evaluation confirms ectatic stability and adequate anterior segment anatomy. This case demonstrates that post-normalization keratoconic corneas manifest refraction challenges, while  with our technique establish expanding therapeutic options beyond corneal procedures and offering predictable long-term visual rehabilitation.