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    Keratoconus as refractive surgery: Thinking outside the ‘cone’

    Adapting a planned approach for taming keratoconus presentations to 20/20


    I also explain the use of corneal collagen crosslinking (CXL) as a staged part of any of these surgeries, because it can stabilize this new shape (following laser vision surgery). I teach surgeons that they should first correct the scoliotic spine (corneal shape = vision) before making the shape permanent with CXL unless the cornea is changing enough to justify CXL before any refractive correction.

    Now let’s look at the same case and consider that it has a thinner cornea with a best-corrected VA less than 20/40. Now I would choose Intacs surgery.

    The most common Intrastromal Corneal Ring Segments (ICRS) are Intacs, which are semicircular inserts made of polymethylmethacrylate.

    I tell patients that having this kind of keratoconus is like being 11 feet tall. People of normal height go to the mall and buy a suit based on their measurements. I say, I am going to put you in braces (Intacs) and make you 6’ 5” or 5’ 8”. I don’t know for sure because Intacs are not mathematically predictable, but I know that you will be moving in the right direction, and the chances are that you will be able to walk into a mall and find a suit that will fit, i.e., Intacs help get patients back into contact lenses and glasses. I perform Intacs in various forms, single, paired, steep axis, and varied various thicknesses and sizes to customize each shape effectively.

    I can also perform Laser ASA over the Intacs to treat residual astigmatism. Again, astigmatic laser procedures remove the least tissue, and I have achieved stability and safety with the braces (Intacs) in place. Crosslinking also provides a stability factor which can be timed accordingly.


    Arun C. Gulani, MD
    Dr. Gulani is director of refractive surgery and chief, cornea & external disease, as well as assistant professor, department of ...

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