ESCRS - PO120 - VISUAL REHABILITATION IN KERATOCONUS FOLLOWING 2ND GENERATION CUSTOMIZED CORNEAL CROSS-LINKING (PACE) AND TORIC INTRAOCULAR LENS (IOL) IMPLANTATION.

VISUAL REHABILITATION IN KERATOCONUS FOLLOWING 2ND GENERATION CUSTOMIZED CORNEAL CROSS-LINKING (PACE) AND TORIC INTRAOCULAR LENS (IOL) IMPLANTATION.

Published 2025 - 29th ESCRS Winter Meeting

Reference: PO120 | Type: Case Report (Cornea Day) | DOI: 10.82333/zpzw-k925

Authors: Emilio A. Torres-Netto* 1 , Shady Awwad 2 , Francesco Versaci 3 , M. Enes Aydemir 1 , Mark Hillen 4 , Léonard Kollros 5 , Nikki Hafezi 5 , Farhad Hafezi 1

1ELZA Institute,Zurich ,Switzerland, 2American University of Beirut,Beirut,Lebanon, 3CSO Italia,Firenze,Italy, 4ELZA Institute,Zurich,Switzerland, 5ELZA Institute ,Zurich ,Switzerland

Purpose

Here we present a case of severe corneal irregularity due to corneal ectasia and coexisting cataract in a patient with stable keratoconus who was seeking visual rehabilitation. PTK-assisted customized epi-on (PACE) corneal cross-linking (CXL) is the second generation of customized CXL that is shifting paradigms by being able to improve large corneal irregularities without removing any corneal tissue. The aim of this case report is to highlight how PACE combined with toric intraocular lens implantation can provide remarkable visual rehabilitation in a patient with corneal irregularity and cataract.

Setting

ELZA Institute, Zurich, Switzerland.

Report of case

Prior to cataract surgery, corneal asymmetry was substantially improved using PACE-CXL. PTK-assisted customized epi-on corneal cross-linking involves a PTK (phototherapeutic keratotomy) over the cone while avoiding any stromal tissue removal. First, the PTK area is an epi-off CXL area as opposed to the rest of the cornea, which is treated in an epi-on fashion. Second, once riboflavin was applied, this generates a riboflavin gradient, with highest concentrations in the epithelium-denuded (cone) region. A differential UV gradient is also applied, where the highest fluences are delivered over the cone. After the primary procedure, corneal irregularity can be massively improved, as well as corneal stabilization. In a second step, femtosecond laser-assisted cataract surgery (Ziemer Z8, Ziemer Ophthalmic Systems) was performed using a toric intraocular lens (IOL) implant.

Conclusion / Take home message

This case exemplifies a paradigm shift in which cross-linking is utilized in a refractive manner to enhance corneal regularity, thereby improving corneal surface topography and reducing both low- and high-order aberrations. Subsequently, this approach facilitates a more effective refractive correction, particularly in the context of cataract surgery. In other words, PACE-CXL successfully reduces corneal topographical asymmetry allowing a regular corneal topographical pattern and consequently allowing the use of toric intraocular lenses and visual rehabilitation. PACE-CXL challenges paradigms by delivering a significant improvement of the corneal surface in a stable keratoconus with cataract. This may open avenues for new indications for CXL prior to other intraocular surgeries.