Management Dilemma After Repeated Intrastromal Corneal Ring Segment Failure In Keratoconus: Reimplantation Versus Phacoemulsification With Toric Intraocular Lens Implantation

To present the management strategy of a keratoconus patient with two failed intrastromal corneal ring segment (ICRS) implantations and to analyze whether further corneal manipulation is justified or whether phacoemulsification with toric intraocular lens (IOL) implantation represents a safer and more predictable refractive rehabilitation approach.

University Hospital of 12 de Octubre, Madrid, Spain, a tertiary referral academic center for corneal surgery, managing cases of keratoconus unsuitable for spectacle correction and intolerant to contact lenses.

We report the case of a 53 years old patient with keratoconus in the right eye, that underwent femtosecond-assisted implantation of a 5-mm ICRS. Postoperative assessment showed improvement in corrected distance visual acuity (CDVA), corneal tomography, and refractive error and optimal depth of the ring within the corneal stroma was confirmed using anterior segment optical coherence tomography (AS-OCT). However, severe dysphotopsias led to explantation. One year later, 6-mm ICRS were implanted. The postoperative course was complicated by fungal keratitis requiring urgent explantation and antifungal therapy. Corneal integrity, refractive status, crystalline lens status and risk profile were reassessed to determine further management.

Although the first implantation achieved objective visual and tomographic improvement, intolerance due to dysphotopsias precluded long-term success. The second procedure resulted in infectious keratitis, leading to device removal and additional stromal compromise. After two failed corneal-based interventions, the risk of further stromal manipulation became a significant concern. The residual refractive error remained visually limiting, prompting evaluation of early phacoemulsification surgery with toric IOL implantation as a non-corneal refractive alternative.

In keratoconus cases with prior ICRS intolerance and infection, a third corneal implantation may represent diminishing returns with escalating risk. Phacoemulsification with toric IOL may provide a more predictable and biomechanically neutral alternative once corneal stability and mild crystalline lens disfunction is confirmed. This case highlights the importance of strategic escalation in keratoconus management and supports earlier consideration of intraocular solutions after repeated corneal surgical failure.