Visual rehabilitation in a patient with keratoconus

A 44-year-old man, head of human resources in an office setting and a dedicated recreational cyclist, presented seeking visual rehabilitation. He was diagnosed with keratoconus at the age of 16. The left eye underwent deep anterior lamellar keratoplasty (DALK) in 2012, followed by implantation of an anterior chamber phakic intraocular lens (pIOL) (Artisan) 3 years later to correct residual ametropia. The right eye was treated with intracorneal ring segments (ICRS) in 2019 to address irregular astigmatism. The patient reported an inability to tolerate rigid gas-permeable (RGP) contact lenses (CL) and described being functionally monocular because anisometropia prevented comfortable spectacle wear. More recently, he began experiencing increasing difficulty with near vision tasks. On examination, manifest refraction in the right eye was −5.75 −2.25 × 45, achieving a corrected distance visual acuity (CDVA) of 20/40. The left eye had a refraction of +1.25 −1.25 × 180, with 20/20 visual acuity. Slitlamp evaluation showed a clear cornea in the right eye with well-centered ICRS (Figure 1 JOURNAL/jcrsoc/04.03/02158035-202501000-00047/figure1/v/2025-10-28T185800Z/r/image-tiff ). The left eye had a clear lamellar graft, with a well-positioned pIOL and a patent peripheral iridectomy. Intraocular pressure was measured at 11 mm Hg in the right eye and 12 mm Hg in the left. Fundus examination was unremarkable in both eyes. Tomographic analysis revealed simulated keratometry values in the right eye of 47.21 diopters (D) at 56 degrees and 49.06 D at 146 degrees, with a thinnest corneal thickness of 426 μm (Figure 2 JOURNAL/jcrsoc/04.03/02158035-202501000-00047/figure2/v/2025-10-28T185800Z/r/image-tiff ). In the left eye, K1 was 42.44 D at 174 degrees and K2 was 44.49 D at 84 degrees, with the thinnest pachymetry measuring 540 μm. Specular microscopy showed endothelial cell density of 2245 cells/mm 2 in the right eye and 2167 cells/mm 2 in the left (Figure 3 JOURNAL/jcrsoc/04.03/02158035-202501000-00047/figure3/v/2025-10-28T185800Z/r/image-tiff ). The patient now seeks options to improve distance vision and reduce spectacle dependence in the right eye. In a keratoconic eye that has undergone ICRS implantation and presents with residual myopic astigmatism and a thinnest pachymetry of 426 μm, what is your preferred strategy to achieve spectacle-free distance vision? Would you consider a pIOL, customized topography-guided photorefractive keratectomy (PRK), or another approach? Do you believe there is potential to gain lines of corrected vision in this eye?