Woman presents with progressive keratectasia after LASIK

LASEK was performed with wavefront CustomCornea with expanded software for myopic astigmatism and mitomycin-C 0.02%.

Issue: April 15, 2005

ByColin C.K. Chan, MD

ByBrian S. Wachler, MD

History: Our patient is a 43-year-old woman who presented with progressive keratectasia in the right eye after LASIK. The ectasia was nasally displaced due to a horizontal LASIK flap keratectomy, which went progressively deeper into the nasal stroma during microkeratome translation. Slit-lamp exam showed the nasal aspect of the keratectomy was located just anterior to Descemet’s membrane in this region. The ectasia in the right eye was initially stabilized with a single C3-R (corneal collagen crosslinking with riboflavin) treatment. Six months after C3-R, the patient consented to wavefront-guided CustomCornea laser epithelial keratomileusis (LASEK) with mitomycin-C 0.02%.

		Figure 1. Progressive ectasia with an increase in nasal keratometric values of over 2.5 D (per difference map) over a 6-month period before C3-R. The ectasia is nasally based.
		Figure 2. Topography immediately before and 6 months after C3-R demonstrates minimal change in ectasia.
		Figure 3. Postoperative topography (upper left map) after LASEK shows markedly more regular topography compared to before LASEK (lower left map). The central optical zone was expanded, which reduced spherical aberration, and customized nasal flattening is evident, which reduced coma.
	Images: Chan CCK, Boxer Wachler BS

6 months before C3-R:

UCVA: 20/150+1
Manifest refraction: –1.00 –1.50 ×178
BCVA: 20/20-2

Immediately before C3-R:

UCVA: 20/100
Manifest refraction: –1.75 –3.50 × 180
BCVA: 20/30
Procedure: C3-R

Before LASEK examination, 6 month after C3-R:

UCVA: 20/60
Manifest refraction: –1.25 –3.50 × 5
BCVA: 20/25 Central pachymetry: 428 µm
Procedure: Wavefront CustomCornea LASEK (Alcon) with expanded software for myopic astigmatism and mitomycin-C 0.02%

3 months after LASEK:

UCVA: 20/50
Refraction: +1.25 –1.25 × 150
BCVA: 20/30
Lower-order aberrations (sphere and cylinder): reduced by 80%
Vertical and horizontal coma: reduced by 71%
Spherical aberration: reduced by 39%

Discussion: This woman had progressive eccentric keratoectasia resulting from a deep flap keratectomy down to the level of Descemet’s membrane. C3-R can be used to stabilize cases of progressive ectasia before considering subsequent keratorefractive surgery for correction of residual refractive error and higher-order aberrations.

In considering surface ablation for stable ectasia, it is important to understand the etiology of the ectasia. It may not be prudent to perform surface ablation on ectasia due to forme fruste keratoconus that existed prior to LASIK or for advanced ectasia with significant corneal thinning.

This case also demonstrates that the expanded CustomCornea software for myopic astigmatism is effective in reducing both lower- and higher-order aberrations in stable keratectasia, which led to a high level of satisfaction in this patient.

For Your Information:

Brian S. Boxer Wachler, MD, can be reached at Boxer Wachler Vision Institute, 465 N. Roxbury Drive, Suite 902, Beverly Hills, CA 90210; 310-860-1900; fax: 310-860-1902; e-mail bbw@boxerwachler.com. Dr. Boxer Wachler is a paid consultant for Alcon.