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VA improves in astigmatic eyes after 2-step procedure
Both visual acuity and refractive results improved in patients undergoing deep intrastromal arcuate keratotomy with in situ keratomileusis for treatment of high astigmatism after keratoplasty, according to a study.
The two-step DIAKIK procedure was performed in 20 eyes of 20 patients in the prospective study. The femtosecond laser surgery involved two intrastromal arcuate keratotomies and development of a corneal flap, followed by excimer photoablation after reopening the flap at least 1 month later. At 24 months, both UDVA and CDVA were statistically significantly improved, from 1.12 logMAR before surgery to 0.58 logMAR (P < .001) and from 0.31 logMAR to 0.20 logMAR (P = .04), respectively. Mean spherical equivalent and refractive cylinder were also statistically significantly improved, from –5.01 D to –1.54 D (P = .001) and from –7.37 D to –2.63 D (P < .001), respectively.
Formation of a fibrosis ring after keratoplasty prevented development of a full flap in two eyes; these flaps were completed manually, with one flap requiring two sutures. – by Robert Linnehan
Disclosures: The researchers report no relevant financial disclosures.
Perspective
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Severe irregular astigmatism is one of the most challenging yet predictable complications after penetrating keratoplasty. For patients afflicted with this condition, a variety of refractive surgeries have been previously described, including both LASIK and arcuate keratotomy. The novelty of the study from Drouglazet-Moalic and colleagues lies, therefore, not in the nature but rather the sequencing of treatment. What they propose is a two-staged procedure, featuring an initial operation to create the LASIK flap and arcuate incisions with the femtosecond laser, followed by a second operation later in which the LASIK flap is re-lifted and excimer laser is applied to the anterior stromal bed. By splitting the surgery into two operations, the hope is that a more precise excimer correction can be applied, which would account for the new and settled shape of the cornea after it stabilizes from the femtosecond cuts. The complexity of the astigmatic problem in this cohort of patients is significant, and the authors are certainly to be commended for their ingenuity and dedication in seeking a solution. Their study also serves as a useful reminder of the refractive pitfalls of penetrating keratoplasty, which — although well known — continue to bedevil us all.