Stromal lenticule addition keratoplasty as part of a three-stage procedure for advanced keratoconus: A case report

PurposePurpose: To report a case of success of a multimodal therapeutic approach in treating advanced keratoconus using Stromal Lenticule Addition Keratoplasty (SLAK), intrastromal corneal ring segments (ICRS), and phakic posterior chamber intraocular lens (pIOL) implantation.Case ReportA 31-year-old female with advanced keratoconus presented with a history of penetrating keratoplasty (PK) rejection in the right eye and severe visual impairment in the left. The left eye exhibited only hand motion of corrected visual acuity and 220 µm of corneal thickness in the thinnest point, suggesting a complex case for surgical intervention. The initial treatment involved SLAK, utilizing a donor corneal lenticule crafted and implanted using femtosecond laser technology. Subsequent interventions included sequential ICRS for correcting high corneal astigmatism and pIOL implantation to correct high myopia. Only 4 days after the last surgery, the patient had already attained a corrected distance visual acuity of 20/60, improving to 20/30 at day 15 postoperatively.DiscussionThis case highlights the integration of SLAK with other surgical modalities to address multiple aspects of advanced keratoconus. The SLAK procedure provided necessary corneal stabilization and thickness, which facilitated further corrective surgeries. While the literature has discussed SLAK and triple procedures for advanced keratoconus separately, this case uniquely combines these approaches, offering insights into their sequential application and potential synergistic effects.ConclusionsThe combined use of SLAK, ICRS, and pIOL is a promising strategy for managing advanced keratoconus, and provided significant improvements in corneal structure and visual acuity in this case. Further studies are recommended to assess the safety and efficacy of this strategy.