Rewriting The Surgical Fate: Therapeutical Multimodal Approach In Advanced Keratoconus With High Myopia

To describe a staged multimodal surgical approach for visual rehabilitation in a patient with advanced keratoconus associated with high myopia, traditionally considered a candidate for corneal transplantation.

Private Clinic - Para de Minas - Brazil

A 30-year-old female with high myopia and advanced keratoconus initially presented in 2019 seeking evaluation for visual rehabilitation but was lost to follow-up. She returned in 2024 reporting progressive visual decline. Examination revealed worsening visual acuity and documented progression of the ectatic disease. During the interval, the patient had been evaluated elsewhere and advised to undergo corneal transplantation. Reluctant to proceed with keratoplasty and concerned about the invasiveness of the procedure, she sought an alternative treatment.

A staged multimodal rehabilitation approach was performed, beginning with Donut-Shaped Intrastromal Keratoplasty (DSIK), a 360-degree variant of CAIRS, followed by implantation of a 320-degree intrastromal corneal ring segment (ICRS), and subsequent phakic intraocular lens implantation.

Postoperatively, uncorrected distance visual acuity improved from counting fingers to 20/40. The combined intervention resulted in substantial corneal regularization and meaningful functional recovery.

Even in advanced keratoconus traditionally considered candidates for keratoplasty, a staged multimodal approach may provide meaningful visual rehabilitation while preserving the native cornea.