A new treatment algorithm for keratoconus and cataract: small aperture intraocular lens insertion with sequential topography guided photorefractive keratectomy and simultaneous accelerated corneal collagen crosslinking

PURPOSE To describe a new treatment algorithm aimed at optimizing refractive outcomes for patients with keratoconus and cataract. SETTING Private practice in Sydney, Australia. DESIGN Retrospective case series. METHODS This procedural approach involves cataract extraction with small-aperture intraocular lens (IOL) insertion, IC-8 IOL (AcuFocus, Inc.), followed by topography-guided photorefractive keratectomy (T-PRK) with simultaneous corneal crosslinking (CXL). Cataract surgery was performed with an initial 2.4 mm clear corneal incision enlarged to 3.5 mm to accommodate IC-8 IOL insertion. Once eyes demonstrated stable corneal tomography and refraction, T-PRK was performed using Schwind excimer laser (500 Hz) with the Vancouver custom topographical neutralization technique, aiming to achieve low myopia. CXL was performed immediately after T-PRK using Optolink hypotonic riboflavin with LIGHTLink-CXL (Lightmed) with 5.4 J total energy delivered at an 18 mw/cm2 irradiance. RESULTS Outcomes of 4 eyes are reported with all achieving rigid gas-permeable (RGP) contact lens independence, improved corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA), and regularization of corneal curvature with cone reduction. The mean CDVA improved from 0.43 preoperatively to 0.07 postoperatively (P = .00), and the mean UDVA improved from 0.81 preoperatively to 0.29 postoperatively (P = .04). Postoperative UNVA ranged from N.8 to N.12. CONCLUSIONS This treatment algorithm demonstrates unique combination of existing corneal and cataract surgical procedures to achieve satisfactory refractive outcomes and RGP contact lens independence in patients with keratoconus and cataract.