KERATOCONUS

Treating cataracts in keratoconus patients can be a long process involving many twists and turns, as shown in a case study presented by Soraya Jonker MD, University Eye Clinic Maastricht, The Netherlands, at a Cornea Day session of the 19th ESCRS Winter Meeting in Istanbul.

Corneal Topography at final visit

The case involved a 77-year-old woman with keratoconus in both eyes. From the time that she was first referred for INTACS implantation and cataract surgery in her right eye, she was hospitalised four times, underwent surgery eight times and visited the Maastricht clinic 42 times.

At first presentation she had a visual acuity of 0.50 and 0.05 in her right and left eye, respectively. On 29 November 2009, she underwent femtosecond laser-assisted INTACS implantation in her left eye. The surgeon noted that applanation was unsuccessful and suspected a possible vertical gas breakthrough.

THINNING

At a follow-up of one week there were signs of minor irritation and a slight thinning of the corneal layer covering the inferior INTACS segment. On 16 December 2009, the corneal thinning led to the extrusion of the inferior INTACS segment, which was therefore explanted.

On 17 March 2011, the patient underwent a deep anterior lamellar keratoplasty. A small perforation at 12 o’clock occurred during the dissection, which the surgeon attempted to remedy with air tamponade in the anterior chamber. However, by 4 April a double anterior chamber was detected.

The patient was immediately hospitalised and scheduled for surgery. But later that day the double anterior chamber progressed until there was iridocorneal touch from three to seven o’clock, combined with acute glaucoma with an intraocular pressure (IOP)
of 62mmHg.

The Maastricht team extracted air from the double anterior chamber with a dissection needle and again placed an air tamponade in the anterior chamber. They also performed a peripheral iridotomy.

The patient responded well to the interventions: the graft was clear and the IOP was 17mmHg. On 20 September 2012, the patient underwent femtosecond laser-assisted cataract extraction with arcuate keratotomy. However, the keratotomy flipped the astigmatism and had to be closed with sutures. When the sutures were removed the eye was amenable to refractive correction.

On 2 October 2014, the patient underwent a FLACS procedure with implantation of a toric intraocular lens (IOL) in her right eye. At her most recent visit in February 2015, the patient’s best corrected visual acuity was 1.0 in her right eye and 0.6 in her left eye.

Soraya Jonker: soraya.jonker@mumc.nl

Isabelle Saelens: isabelle.saelens@mumc.nl

Rudy Nuijts: rudy.nuijts@mumc.nl