Total Visual Rehabilitation In Advanced Keratoconus: Sequential Topography-Guided Prk, Cxl, Phakic Iol, And Addon Iol Implantation

To describe a staged multimodal approach for complete visual rehabilitation in a patient with advanced keratoconus and extreme myopia (−18.00 D) with preoperative best-corrected visual acuity (CDVA) of 20/100.

Eye clinic Svjetlost, Zagreb, Croatia

A bilateral advanced keratoconus patient with −18.00 D spherical equivalent and CDVA 20/100 underwent a structured, stepwise treatment strategy. First, limited topography-guided photorefractive keratectomy (PRK) was performed to reduce irregular astigmatism and partially decrease refractive error, immediately followed by corneal cross-linking (CXL) for biomechanical stabilization. After corneal stabilization, residual high myopia was corrected with intraocular lens (IOL) implantation. A secondary AddOn IOL was subsequently implanted to refine residual refractive error and optimize spherical and astigmatic outcomes. Serial follow-up included tomography, pachymetry monitoring, and endothelial cell assessment.

Preoperatively, spherical equivalent was −18.00 D with CDVA of 20/100 in both eyes. Following completion of staged treatment and stabilization, the patient achieved bilateral uncorrected visual acuity (UCVA) of 20/25. Corneal tomography demonstrated structural stability without progression. Endothelial cell density remained within safe limits. No intraoperative or postoperative complications occurred. The patient reported significant functional improvement and independence from optical correction.

Advanced keratoconus with extreme myopia can be successfully rehabilitated using a structured corneal-to-lenticular strategy integrating PRK for corneal regularization, CXL for stabilization, and staged intraocular lens implantation for refractive correction. This case demonstrates that even severely myopic keratoconus patients with poor preoperative visual acuity may achieve high-quality uncorrected vision when biomechanical and optical components are sequentially addressed.