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In this review, we presented the principles of radial keratotomy (RK), its evolution, enhancement, and complications, and strategies to manage the consequences of RK in the present day. It is essential to understand the RK procedure f, the theoretical background that supported this surgery, the current effect on the cornea, and how to approach patients needing vision improvement. These patients are developing cataracts that need to be handled well, from the IOL calculation to the surgical procedure. Guided keratorefractive surgery is the most accurate procedure to improve these patient's vision and life. Nevertheless, some patients may need other approaches, such as sutures, penetrating keratoplasty, corneal rings, and pinhole implants, depending on the degree of irregularity of the cornea, ablation depth for guided surgery or if the sutures are open., (© 2023. The Author(s).)

An adult male in his 50s presented with complaints of glare and gradual, painless, progressive diminution of vision in the right eye (RE). Visual acuity in RE was noted to be 2/60, and slit lamp biomicroscopy revealed a pearly grey-white elevated corneal opacity measuring 4 mm × 3 mm, obscuring the visual axis. There was no history of ocular trauma or infection. The patient had undergone bilateral radial keratotomy for myopia correction 25 years ago. Anterior segment optical coherence tomography imaging demonstrated increased corneal thickness of 1080 µm at the site of lesion and the height of the epicorneal mass was noted to be 493 µm. The patient underwent fibrin glue-aided anterior lamellar keratoplasty. Histopathological examination of the excised host tissue confirmed the diagnosis of corneal keloid., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To report a case of post radial keratotomy (RK) cataract in a 55-year-old lady wherein biometry was done by ray-tracing method incorporated in scheimpflug topographer (Sirius + Scheimpflug Analyzer, CSO, Italy)., Method: In our case, we performed intraocular lens (IOL) power calculation using a recent concept of ray tracing with scheimpflug topographer and compared with traditional methods available at American Society of Cataract and Refractive Surgery(ASCRS) website (www.ascrs.org) for eyes with prior RK. Phacoemulsification was performed and a monofocal + 24.5D IOL implanted in the capsular bag., Result: Manifest refraction at six weeks postoperative period was + 1.0DS/-2.0DC × 75° with spherical equivalence of 0. On comparison of all the methods used to calculate IOL power, the absolute errors of ray tracing and Barrett true K were found to be the least, 0.14 and 0.18 respectively., Conclusion: Ray tracing biometry with scheimpflug topographer seems to provide accurate IOL power in post RK eyes.

A 51-year-old man was referred for refractive surgery evaluation. Spectacle dependence and poor visual quality in both eyes was his chief complaint. He cannot tolerate contact lenses. Corrected distance visual acuity (CDVA) was 20/40 in both eyes. Manifest refraction was +5.25 -2.25 @ 90 (20/40) in the right eye and +6.25 -2.25 @ 105 (20/40) in the left eye. The patient had a history of radial keratotomy (RK) almost 30 years ago in both eyes and at the slitlamp presented 8 RK incisions, proportionally spaced between one another. All incisions were closed, and there were no relevant signs of scarring. The patient denied any history of ocular trauma, systemic disease, or medications. Corneal topography with different technologies revealed an irregular pattern with marked central flattening in both eyes, with some points below 30 diopters (D) (Supplemental Figures 1 and 2, available at http://links.lww.com/JRS/A862 and http://links.lww.com/JRS/A863, respectively). There were no signs of cataract, and fundus examination was normal. Optical coherence tomography (OCT) of the right eye revealed a more homogeneous thickness pattern, little variation between the thinnest and thickest areas, and adequate transparency (Figure 1JOURNAL/jcrs/04.03/02158034-202306000-00018/figure1/v/2023-05-31T172126Z/r/image-tiff). In the left eye, there is wide variability between the thinnest and thickest stromal points, with annular thinning and central thickening (Figure 2JOURNAL/jcrs/04.03/02158034-202306000-00018/figure2/v/2023-05-31T172126Z/r/image-tiff). Both eyes show marked epithelial irregularity. Considering this patient's current ocular status, how would you reach visual rehabilitation? Because he is contact lens intolerant, would you consider surface ablation, for example, photorefractive keratectomy (PRK) with mitomycin-C (MMC)? If that were the case, would you think of an optimized or a topography-guided (TG) treatment? Would you immediately consider a corneal transplant option? Would you instead consider a more conservative approach? Which one and why?, (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To describe a case of late spontaneous postradial keratotomy corneal perforation after scleral contact lens (SCL) wear for optic correction., Setting: Tertiary referral center for corneal pathology., Design: Case report., Results: A 64-year-old man presented the consequences of a late radial keratotomy (RK) surgery performed for myopia correction 26 years ago. His ophthalmologic history was a RK in both eyes (BE), previous Lasik surgery in BE and Lasik enhancement in the right eye (RE), and pterygium excision with conjunctival transplantation in RE. To improve visual acuity, SCL were fitted in both eyes. After 8 months of use, on a certain day, when removing the lens from the RE, the patient reported experiencing intense eye pain and reduced visual acuity. On ophthalmologic examination, the RE cornea was perforated in one of the previous RK incisions. An urgent corneal transplant was performed in the RE, followed by cataract surgery in the same eye., Conclusion: Corneal instability caused by RK scars and daily manipulation with the SCL use may have led to ocular perforation., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Contact Lens Association of Ophthalmologists.)

Purpose: To evaluate the outcomes of tuck-in deep anterior lamellar keratoplasty (DALK) for the management of post-radial keratotomy (RK) keratectasia., Setting: Institution., Design: Retrospective., Methods: Medical records of all cases presenting with post-RK keratectasia from January 2012 to December 2019 were included. Data on corrected distance visual acuity (CDVA), refraction, keratometry, ultrasonic pachymetry, corneal topography, endothelial cell count, applanation tonometry, and dilated fundus examination recorded at all follow-up visits were included. Details of surgical steps, including intraoperative and postoperative complications and any secondary procedures performed subsequently, were also recorded., Results: 7 eyes of 5 patients that developed corneal ectasia after a previous RK procedure underwent DALK with peripheral tuck-in. All eyes had CDVA ≤6/24, preoperatively. The surgical procedure was successfully performed in all eyes without any intraoperative complications. CDVA at the final follow-up ranged between 6/9 and 6/60, with 6 eyes achieving CDVA of 6/18 or better. The median keratometric cylinder reduced from a preoperative value of 7.2 ± 9.27 diopters (D) to 2 ± 1.83 D at the final follow-up. The median central corneal thickness at the final follow-up was 598 ± 40.01 μm, and spherical equivalent ranged between -1.75 D and -3.5 D (median -2 ± 0.57). The percentage of endothelial cell loss ranged between 2.1% and 8.4%. All eyes retained graft clarity, and none showed any evidence of significant interface haze or corneal vascularization., Conclusions: Tuck-in DALK could successfully address corneal ectasia developing after RK, achieving visual gains. Moreover, it was able to restore the peripheral corneal thickness with a minimal risk for dehiscence of RK incisions., (Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Abstract: This case series examines the magnitude and regional variation in scleral lens-induced corneal edema in postradial keratotomy (RK) eyes. Scheimpflug imaging was used to measure corneal thickness across the central 6 mm before and after scleral lens wear in nine post-RK eyes (median age 64 years). Variations in corneal edema were examined as a function of distance from the corneal center (six 0.5-mm annuli) and from 0° to 360°. The median central corneal edema was 2.19% (interquartile range 1.03%-3.18%; P=0.02) and increased in magnitude and variability further from the central cornea (from 1.30% in the central 0-0.5 mm to 3.12% in the 2.5-3.0 mm midperiphery) (P=0.02). Scleral lens-induced corneal edema in post-RK eyes was greater in magnitude further from the corneal center and at the approximate location of corneal incisions., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Contact Lens Association of Ophthalmologists.)

Background: Anterior segment surgeries such as cataract surgery, intraocular lens (IOL) repositioning, and radial keratotomy (RK) may hasten endothelial dysfunction, particularly in the context of pre-existing Fuchs dystrophy, necessitating future corneal transplantation., Case Presentation: A 68-year-old woman with a history of RK with associated irregular astigmatism in both eyes and iris-fixated intraocular lens (IF-IOL) in the left eye presented with six months of decreased vision in the left eye. She was found to have Fuchs dystrophy and underwent DMEK surgery. She had an uncomplicated postoperative course, with uncorrected visual acuity improving to 20/20 three months after surgery., Conclusion: To our knowledge, this is the first reported case of a highly successful DMEK surgery in a patient with prior RK and IF-IOL., (© 2021. The Author(s).)

Results of clinical use of the radial keratotomy (RK) surgery are presented in the format of a lecture and a summary. The analysis encompasses the mechanism of changes in corneal refraction, immediate intra- and postoperative complications, so-called secondary symptoms and long-term effects (addition of various pathological processes, influence of corneal changes on the results of diagnostic tests and treatment methods) of the surgery.

Purpose: To describe the clinical outcome of a first patient undergoing Bowman layer (BL) transplantation with an onlay graft to reduce fluctuation in visual acuity and refractive error after previous radial keratotomy (RK) surgery., Methods: In 2018, a 66-year-old woman presented with complaints of long-standing diurnal fluctuation in best-spectacle corrected visual acuity (BSCVA) after RK in 1983. After the removal of host epithelium, a BL graft was positioned onto the host cornea. BSCVA, Scheimpflug-based corneal tomography, and anterior segment optical coherence tomography were evaluated up to 12 months postoperatively., Results: The surgery and postoperative course were uneventful. After surgery, the subjective complaints of visual fluctuation were reduced from 10 to 3 on a scale from 1 to 10. BSCVA (20/40; 0.5) did not change from preoperative to postoperative. Corneal tomography showed an overall central corneal steepening of 5.9 diopters. Biomicroscopy, Scheimpflug imaging, and anterior segment optical coherence tomography showed a completely epithelialized and well-integrated graft, with some minor epithelial remnants located in the preexisting keratotomy incisions., Conclusions: BL onlay grafting may have the potential to manage patients with subjective complaints of diurnal fluctuation in visual acuity after previous RK.

Competing Interests: Das IVCRC erhält Forschungsgelder von der Fa. Rayner, der Fa. Johnson & Johnson und der Fa. Alcon Pharma GmbH. G. Auffarth und R. Khoramnia erhalten Vortragshonorare sowie Reisekostenerstattungen von der Fa. Alcon Pharma GmbH und der Fa. Johnson & Johnson. T. Yildirim erhält Reisekostenerstattungen von der Fa. Alcon Pharma GmbH. S. Son, A. Xia und C. Mayer geben an, dass kein Interessenkonflikt besteht.

A 55-year-old male presented with an infectious keratitis in his left eye, affecting one of the incisions of the radial keratotomy he had undergone thirty-four years ago. Suturing the incision with two simple interrupted stitches was key to the resolution of the infection. Floppy eyelid syndrome was also found in this patient. Could this act as a risk factor for infectious keratitis in radial keratotomy? To our knowledge, this is the first reported case describing the association between both conditions, and the second reported case where sutures have been used as an adjuvant treatment in these types of cases., (Copyright © 2019. Publicado por Elsevier España, S.L.U.)

Objective: To evaluate the factors affecting clinical outcomes of correcting cumulative refractive errors or irregular astigmatism after radial keratotomy (RK) using mini-scleral lenses., Methods: We retrospectively analyzed 36 eyes receiving mini-scleral lenses after RK from July 2011 to June 2016. Analyses included age, refractive errors, best spectacle-corrected visual acuity (BSCVA), best contact lens-corrected visual acuity (BCLCVA), topographic indices, RK treatment zone diameter (TZD), power difference (PrD) within the RK treatment zone, and decentration distance (DD) of the RK treatment zone center. An increase of three lines or more of Snellen visual acuity was considered a successful fitting., Results: Of the eyes fitted with mini-scleral lenses, the BCLCVA (logarithm of the minimum angle of resolution [logMAR] 0.19±0.22) was significantly better than the BSCVA (logMAR 0.47±0.30). Twenty-three patients (64%) had a successful fitting. There was no statistically significant difference between successful and unsuccessful fittings with regard to age, prefitting refractive error, BSCVA, corneal astigmatism, simulated steep/flat K values, surface regularity index, TZD, or PrD. However, successful fittings had better centration of treatment zones with an average DD of 0.54±0.44 mm compared with a DD of 0.92±0.53 mm in the unsuccessfully fitted eyes. In addition, our case series showed that there was a negative impact on fitting outcomes in the presence of small central clear zones resulting from central incisions or scars., Conclusions: Although decentration of the RK treatment zone and small central clear zones were related to less optimal fitting results, mini-scleral lenses are a feasible option to correct cumulative refractive errors and irregular astigmatism in post-RK patients.

Purpose: To report the refractive correction in a case of hyperopia and astigmatism following radial keratotomy., Methods: A case report., Results: A 47-year-old woman, who had undergone refractive surgery for radial keratotomy in both eyes 22 years before the present study, presented to our clinic with blurred vision. Her best corrected visual acuity, with spectacle correction of +3.50 DS/-1.50 DCX130° in the right eye and +3.75 DS/-1.50 DCX80° in the left eye, was 0.2 logMAR and 0.3 logMAR, respectively. Her keratometric readings were 35.75 D/36.75 D at 74° and 35.25 D/36.25 D at 61°, respectively. Prompted by intolerance to glasses, the patient requested for contact lenses. First, we applied a rigid, gas-permeable contact lens. However, we noted poor fitting due to central corneal flattening. Subsequently, we applied a conventional plus spherical soft contact lens (PSSCL), which is thick in the center and can therefore correct hyperopia and low-grade astigmatism simultaneously. The conventional PSSCL showed slightly inferior decentration, with good movement, and the patient was satisfied with it. After ascertaining the patient's living habits, we decided that a daily disposable soft contact lens would most meet her needs. The final prescription was a daily disposable PSSCL; the patient was satisfied with her corrected visual acuity of 0.0 logMAR in the right eye and 0.0 logMAR in left eye. Her daily disposable PSSCL-corrected visual acuity was stable during the 10-month follow-up., Conclusion: For patients displaying hyperopia with astigmatism following radial keratotomy, the PSSCL may confer better corrected visual acuity and acceptability.

Purpose: To describe a case of spontaneous wound dehiscence 29 years after radial keratotomy (RK) and to illustrate how specialty contact lenses were used for tectonic support and optic correction., Setting: Tertiary referral center for corneal pathology., Design: Case report., Results: In November 2014, a 62-year-old woman presented to the emergency department with a spontaneous corneal perforation in her left eye. Her ocular history was significant only for uncomplicated RK surgery performed in 1985 to correct myopia (-5.50 D) in both eyes. At the slit-lamp pronounced, bullous edema was seen in the inferotemporal quadrant of the left cornea with internal opening of the 3.30- and 5-o'clock positions incisions and severe localized thinning and aqueous leakage at the 5-o'clock position incision. There was no history of trauma. A conservative approach was adopted: application of a standard bandage lens was effective in tamponading the leakage, allowing the anterior chamber to reform; a custom-made soft lens was worn for tectonic support over a period of 4 months. Finally, visual acuity was restored to 20/20-by fitting a scleral lens., Conclusion: Spontaneous corneal perforation is a rare but more dramatic long-term complication after RK. The pivotal role of appropriately fitted soft bandage lenses in the conservative management of this type of complex perforation is highlighted. For optical correction, a scleral lens was fitted with excellent visual result, illustrating the added value of specialty contact lenses as an alternative to surgery in the management of postrefractive corneas.

Purpose: To evaluate the efficacy and safety of topography-guided transepithelial photorefractive keratectomy (PRK) in a group of patients with post-radial keratotomy (RK) showing irregular corneas., Setting: Feiz University Hospital, Isfahan, Iran., Design: Prospective case series., Methods: Consecutive patients who had irregular astigmatism after RK with stable refraction and topography for at least 1 year were recruited. All eyes had excimer laser topography-guided single-step transepithelial PRK. The efficacy, safety, predictability, and corneal wavefront aberration changes were assessed 6 months after the surgery. Vector analysis was performed using the Alpins method to evaluate the astigmatic treatment., Results: Twenty-two patients (22 eyes) were enrolled. The patients' ages ranged from 37 to 61 years (45.77 years ± 4.9 [SD]); there were 12 men (54.54%) and 10 women (45.46%). Uncorrected distance visual acuity significantly improved after 6 months of treatment (0.45 ± 0.19 logarithm of the minimum angle of resolution [logMAR] preoperatively and 0.25 ± 0.19 logMAR after 6 months) (P < .001). Moreover, the corrected distance visual acuity significantly improved at the end of the study (0.14 ± 0.13 logMAR preoperatively and 0.09 ± 0.11 logMAR after 6 months) (P = .01). Furthermore, the aberrometric values were significantly reduced at the 6-month visit (P < .001). The mean of the surgically induced astigmatism was 2.15 ± 1.44 diopters. No significant complication was observed., Conclusion: Topography-guided single-step transepithelial PRK is a safe and effective method for treating the irregular refractive errors in post-RK patients., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Significance: As patients with previous radial keratotomy (RK) are still occasionally encountered, recognition of the anatomy of post-RK corneas and management of their complications remain relevant. High-definition anterior segment optical coherence tomography (AS-OCT) is a very useful tool to assess these postsurgical corneas., Purpose: To describe a case of acute corneal hydrops with Descemet membrane schisis after RK with observation by AS-OCT., Case Report: A 43-year-old woman presented with a 9-day history of sudden vision loss, foreign body sensation, and photophobia in her left eye. She had undergone bilateral RK 25 years ago at her local hospital. Slit-lamp examination revealed marked corneal edema and stromal clefts in the central cornea along with radial surgical scars in her left eye. Pentacam imaging showed the typical pattern of a post-RK cornea with ectasia in her right eye. Multiple dilacerations of collagen lamellae and fluid-filled intrastromal cysts together with epithelial edema were observed in her left eye using AS-OCT. A Descemet membrane detachment with schisis was also shown by AS-OCT. After 5 months of medication with topical 0.1% fluorometholone eye drops four times daily together with 3% ofloxacin eye ointment once daily, the corneal edema, Descemet membrane detachment, and Descemet membrane schisis had completely resolved resulting in pan-stromal scarring., Conclusions: This report describes acute corneal hydrops with Descemet membrane schisis after RK imaged using high-definition AS-OCT. The acute hydrops was possibly caused by corneal ectasia or underlying keratoconus, which was aggravated by RK. High-definition AS-OCT is a useful tool to demonstrate the details of different corneal layers and to observe the resolving process of acute hydrops. Topical medications consisting of antibiotic, lubrication, and corticosteroid can be used to treat the acute event effectively.

Purpose: This study aimed to evaluate the long-term stability of minimally invasive radial keratotomy (mini-RK) for eyes with mild to moderate keratoconus., Design: Retrospective observational case series., Methods: Eleven eyes from 6 patients with hard contact lens (HCL)-intolerant keratoconus underwent mini-RK and were followed up for more than 5 years. The mini-RK consisted of 8 radial incisions with depths of 90% of the thinnest corneal thickness, based on the Lindstrom nomogram. Best-corrected visual acuity (BCVA), keratometry, and corneal endothelial cell density (ECD) were examined preoperatively and for 5 to 10 years postoperatively. Changes in keratometric astigmatism were evaluated using power vector analysis. Severities of keratoconus preoperatively and 1 year postoperatively were graded using the Amsler-Krumeich classification., Results: The postoperative observation periods were from 6 to 10 years (mean, 7.9 years). There were no changes in the BCVA, ECD, and keratometric astigmatism. The mean keratometric refraction significantly decreased from 47.5 diopters (D) preoperatively to 44.0 D at 1 month after mini-RK (P = 0.037) and was stable over 5 years, whereas keratometric astigmatism did not change from preoperatively through the postoperative period (P > 0.59). Keratoconus of grade 2 or higher improved to lower grades., Conclusions: The mini-RK treatment was safe and effective for HCL-intolerant eyes with mild to moderate keratoconus., (Copyright 2017 Asia-Pacific Academy of Ophthalmology.)

We present a new method for treating complicated corneal gaps among patients who have previously undergone radial keratotomy (RK).After complete healing of a fungal keratitis in a patient who has undergone RK, we removed the oedematous corneal sector and put anterior tailored segment of a corneal button previously used for Descemet stripping endothelial keratoplasty. The patient's best-corrected visual acuity reached to 20/20 6 months later. This technique will compensate for oedematous parts without putting a significant effect on other parts such as purse string sutures., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: To evaluate femtosecond-assisted laser in situ keratomileusis (LASIK) for the treatment of hyperopic shift after radial keratotomy (RK)., Setting: Private practice, Siena, Italy., Design: Prospective case series., Methods: Eyes with a spherical equivalent (SE) of +1.0 diopters (D) to +4.0 D after RK with 6 or 8 incisions had LASIK. The flap (nominal thickness 130 μm) was created with a femtosecond laser (LDV Z2); the refractive ablation was performed with an excimer laser (217P). The flap was dissected in a centrifugal fashion along previous RK cuts., Results: Eighteen eyes of 10 patients were treated. Preoperatively, the mean defocus equivalent was 3.13 diopters (D) ± 0.71 (SD); the corrected distance visual acuity (CDVA) was 0.09 ± 0.06 logMAR. At 9 months, the mean defocus equivalent was 0.51 ± 0.47 D (P < .05), with 13 eyes (72%) having 0.50 D or less of defocus equivalent and 16 eyes (89%) having 1.0 D or less of defocus equivalent. The mean CDVA was 0.04 ± 0.06 logMAR (P < .05). No lines of logMAR CDVA were lost. The mean uncorrected distance visual acuity was 0.11 ± 0.10 logMAR. The safety index was 1.11; the efficacy index was 0.97. No retreatments were performed. Flap complications were limited to an RK incision opening larger than 2 mm in 3 eyes and 1 case of a small, self-limiting epithelial ingrowth., Conclusion: Laser in situ keratomileusis with a low-energy femtosecond laser was a safe and effective approach to treat post-RK hyperopia, causing no relevant inflammation., Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Aim: To describe possible causes of progressive hyperopia in patients who underwent radial keratotomy., Material and Methods: The study enrolled 33 subjects who underwent radial keratotomy earlier in their lives, of them 15 controls (29 eyes, group 1) with no refractive error and 18 patients (35 eyes, group II) with progressive hyperopia. The number and type of keratotomy scars was determined during biomicroscopy. Biomechanical properties of the cornea were assessed by means of bidirectional applanation (Ocular Response Analyzer). Dynamic contour tonometry (Pascal) was also used for intraocular pressure (IOP) measurement. Evaluation of the optic nerve head and retina included standard automated perimetry (Humphrey Field Analyzer) and confocal scanning laser ophthalmoscopy with Heidelberg Retinal Tomograph (HRT III)., Results: Group II showed reliable signs of low corneal rigidity, namely reduction of CH and CRF values (by 2.4 and 1.6 mmHg respectively) and central corneal thickness (by 56 microns) as compared to the controls. Tonometry results differed inconsiderably showing a tendency toward hypertension in both groups. The interquartile range of IOP was 17.8 ÷ 22.4 mmHg in group II and 16.3 ÷ 20.6 mmHg in group I. Changes in retinal light sensitivity and optic nerve head parameters were more pronounced in the controls., Conclusion: Several reasons for lowering of corneal rigidity can be suggested: initial biomechanical parameters of the cornea, surgical interference, and age-related changes. We think that hyperopic shift results from the combination of low corneal rigidity and increased IOP, i.e. not the lamina cribrosa but the cornea becomes the target of ocular hypertension. Thus, patients with weakened corneal refraction after radial keratotomy are at risk for developing glaucoma in the late postoperative period.

A 24-year-old male patient with bilateral high myopia presented to our outpatient department with sudden onset of pain and diminution of vision in his right eye. He had sequentially undergone bilateral trabeculectomy and photorefractive keratectomy at the age of 6 years in both eyes. This was followed by radial keratotomy in right eye at the age of 8 years. The slit lamp examination demonstrated the presence of infiltrates in central cornea with an underlying fluid cleft, along with 14 radial keratotomy scars. Anterior segment optical coherence tomography confirmed the presence of intrastromal cleft in communication with anterior chamber. Bacterial culture revealed coagulase-negative Staphylococcus. The patient was successfully treated with fortified antibiotics in conjunction with the sensitivity report. This case underlines the need for a cautious approach towards refractive surgery in paediatric age group and highlights the long-term sequelae of retreatments in these cases.

Unlabelled: We present a case of corneal perforation secondary to an intrastromal astigmatic keratotomy performed with an optical coherence tomography-guided femtosecond laser. The keratotomy was concomitant with cataract surgery and resulted in a flat anterior chamber prior to the start of lens extraction. Interrupted nylon sutures were placed to seal the keratotomy prior to phacoemulsification. Escape of cavitation bubbles into the anterior chamber or the liquid interface can alert the surgeon to the possibility of unintended perforation of the endothelium or the epithelium, respectively., Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

We describe a case of corneal ectasia in a patient with previous radial keratotomy (RK). The uncorrected distance visual acuity (UDVA) was 20/400, the corrected visual acuity (CDVA) 20/50, and the spherical equivalent (SE) -5.125 diopters (D). Corneal topography revealed inferior corneal ectasia with corneal astigmatism of 9.2 D. Six months after corneal collagen crosslinking (CXL), the UDVA improved to 20/200, the CDVA to 20/40, and the SE to -4.625 D. Corneal astigmatism was reduced to 8.7 D. An add-on IOL was implanted to correct the residual cylindrical refractive error (-9.25 × 60; Torica-sPB IOL, Humanoptics), after which the UDVA improved to 20/32, the CDVA to 20/30, and the SE to -0.50 D. This case is the first to document the efficacy of CXL in corneal ectasia as a complication of primary RK in a nonkeratoconic or a keratoconus-suspect eye with an add-on IOL used to correct the residual refractive error., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To present a case of corneal ectasia after LASIK in a patient with previous arcuate keratotomy., Methods: Case report., Results: The patient underwent arcuate keratotomy in both eyes in 1997 for with-the-rule regular hyperopic astigmatism and uneventful bilateral LASIK for residual astigmatism 5 years later. Visual acuity and refraction remained stable for 5 years, when the patient noticed worsening visual acuity. Corneal topography showed progressive inferior steepening, confirming the diagnosis of ectasia. Corneal high-resolution optical coherence tomography revealed a normal LASIK flap. The patient had no risk factors for corneal ectasia other than previous incisional surgery., Conclusions: This case suggests that isolated arcuate keratotomy can be a significant risk factor for the development of corneal ectasia after LASIK., (Copyright 2013, SLACK Incorporated.)

Iatrogenic keratectasia has been reported subsequent to refractive surgery or trauma. Hexagonal keratotomy (HK) is a surgical incisional technique to correct hyperopia. A number of complications have been reported following this procedure, including irregular astigmatism, wound healing abnormalities and corneal ectasia. When visual acuity is poor because of ectasia or irregular astigmatism and contact lens fitting is not possible, penetrating or lamellar keratoplasty can be performed. Since incisions in refractive keratotomy are set at 90-95% depth of cornea, intraoperative microperforations are known to occur and lamellar keratoplasty may become difficult. We describe deep anterior lamellar keratoplasty (DALK) used to successfully manage keratectasia after HK. Pre DALK vision was 20/400 and post DALK vision was 20/30 two months after surgery. This report aims to show improved visual outcome in corneal ectasia secondary to HK. DALK can be a procedure of choice with proper case selection.

Purpose: To illustrate the hypothesis that corneal vertex centration is superior to entrance pupil centration when guiding an ablation by wavefront., Methods: In one case example of therapeutic retreatment for treatment zone decentration after primary radial keratotomy (RK) centered on the entrance pupil (line of sight), both a whole-eye wavefront-guided ablation profile (WASCA data) and a topography-guided ablation profile (Atlas data) were generated using the CRS-Master (Carl Zeiss Meditec) and compared. The patient had a large vertical angle kappa. Corneal topography demonstrated that the zone of flattening was decentered superiorly with reference to the corneal vertex and the patient reported severe night vision disturbances., Results: The wavefront-guided profile, centered on the line of sight, was symmetrical because the wavefront was dominated by spherical aberration induced by the primary RK treatment. On the other hand, the topography-guided profile, centered on the corneal vertex, was asymmetric with an inferior region of ablation, which would logically improve the topographic decentration. The topography-guided profile was chosen for photorefractive keratectomy using the MEL 80 excimer laser (Carl Zeiss). Ten months after the procedure, the treatment zone was topographically well centered on the corneal vertex. Whole-eye higher order root-mean-square (RMS) was reduced by 43% and corneal higher order RMS was reduced by 61%. The patient reported large subjective improvement in the quality of vision and marked reduction in night vision disturbances., Conclusions: This case provides evidence that wavefront data centered on the entrance pupil center may not represent the patient's view and the treatment zone should preferably be centered on the corneal vertex rather than the entrance pupil center., (Copyright 2012, SLACK Incorporated.)

Aim: To evaluate the safety and efficacy of laser in-situ keratomileusis (LASIK) in eyes with residual/induced refractive error following radial keratotomy (RK)., Design: Retrospective study., Materials and Methods: A retrospective analysis of data of 18 eyes of 10 patients, who had undergone LASIK for refractive error following RK, was performed. All the patients had undergone RK in both eyes at least one year before LASIK. Parameters like uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), contrast sensitivity, glare acuity and corneal parameters were evaluated both preoperatively and postoperatively. STATISTICAL SOFTWARE: STATA-9.0., Results: The mean UCVA before LASIK was 0.16±0.16 which improved to 0.64 ± 0.22 ( P < 0.001) after one year following LASIK. Fourteen eyes (out of 18) had UCVA of ≥ 20/30 on Snellen's acuity chart at one year following LASIK. The mean BCVA before LASIK was 0.75 ± 0.18. This improved to 0.87 ± 0.16 at one year following LASIK. The mean spherical refractive error at the time of LASIK and at one year after the procedure was -5.37 ± 4.83 diopters (D) and -0.22 ± 1.45D, respectively. Only three eyes had a residual spherical refractive error of ≥ 1.0D at one year follow-up. In two eyes, we noted opening up of the RK incisions. No eye developed epithelial in-growth till 1 year after LASIK., Conclusion: LASIK is effective in treating refractive error following RK. However, it carries the risk of flap-related complications like opening up of the previously placed RK incisions and splitting of the corneal flap.

We report a topography-wavefront-guided repair procedure in a patient with a decentered optical zone and significant higher-order aberrations (HOAs) following radial keratotomy 14 years previously. The CRS-Master custom ablation software was used to generate a topography-wavefront-guided ablation profile based on Atlas front corneal surface topography data, and the MEL 80 excimer laser was used to treat the patient. Very high-frequency digital ultrasound scanning (Artemis) was performed before and after surgery to measure epithelial and stromal thickness changes to evaluate the anatomical congruity of the planned and achieved irregular ablation. Nine months postoperatively, the optical zone centration was topographically improved and HOAs were significantly lower, with a 90% reduction in spherical aberration. The stromal thickness change map demonstrated that the profile of stromal tissue removed matched the irregular ablation profile. However, the measured stromal thickness change at the maximum point was 33% higher than the predicted ablation depth. The epithelial thickness change measured in this case indicates that topography-guided treatments could be improved by taking epithelial thickness changes into account., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the efficacy of riboflavin ultraviolet A (UV-A) corneal collagen cross-linking in the management of keratoconic corneal ectasia exacerbated by radial keratotomy (RK)., Methods: A patient with progressive corneal ectasia and hyperopic shift, occurring 10 years after RK performed in the left eye, was treated with riboflavin UV-A corneal collagen cross-linking according to the Siena protocol: Pilocarpin 0.1% drop (1 hour before), lidocaine 4% drops 15 minutes before, mechanical scraping of epithelium (9-mm-diameter area), preirradiation stromal soaking for 10 minutes in riboflavin 0.1%-dextrane 20% (Ricrolin; Sooft Italy) applied every 2 minutes, and 30 minutes of total exposure (6 steps of 5 minutes) to solid-state UV-A illuminator (Caporossi, Baiocchi, Mazzotta Vega X linker; CSO Opthalmics, Florence, Italy), energy delivered 3 mW/cm, and irradiated area 9 mm in diameter., Results: After the operation, uncorrected visual acuity and best spectacle-corrected visual acuity improved from 0.2 to 0.6 and from 0.3 to 0.8 Snellen lines, respectively, in a 12-month follow-up. Improved topographical K readings and corneal symmetry index were also recorded starting from the first postoperative month and continuing thereafter. No adverse effects were recorded after treatment., Conclusions: Riboflavin UV-A-induced corneal cross-linking seems to be a promising surgical option in the management of unstable corneal ectasia exacerbated by RK, particularly in eyes with preexisting keratoconus. A large cohort and longer follow-up are needed to determine its long-term efficacy in this clinical setting.

Purpose: To report on a patient with uncorrectable fluctuating astigmatism from multiple previous radial keratotomy (RK) procedures who successfully underwent a femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK) with big-bubble technique., Methods: A 60-year-old woman with a history of multiple RK procedures with 16 radial incisions and 4 Ruiz-style cuts had fluctuating corneal astigmatism with preoperative best contact lens-corrected visual acuity of 20/80., Results: Intraoperatively, a femtosecond laser-assisted zigzag pattern DALK was performed. Descemet baring was successfully achieved using the big-bubble technique without air escaping from the radial incisions, likely related to precise depth of base of posterior side cut made by laser. Postoperative best-corrected visual acuity is 20/25 with 1.3 diopter of astigmatism at 5 months., Conclusions: To our knowledge, this is the first report to use this technique in a cornea with RK incisions. Femtosecond lasers may promote the success of DALK in challenging corneas.

Purpose: To evaluate the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS) in patients with corneal ectasia after refractive surgery., Setting: Private clinic, Belo Horizonte, Brazil., Methods: Charts of patients with corneal ectasia after refractive surgery were retrospectively reviewed. The following parameters were studied: uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), keratometry, corneal asphericity, and pachymetry. All patients were evaluated by Scheimpflug scanning-slit tomography (Pentacam)., Results: Twenty-five eyes (20 patients) with corneal ectasia (20 after laser in situ keratomileusis, 4 after radial keratotomy, 1 after photorefractive keratectomy) were evaluated. Postoperatively, the mean UDVA increased from 20/185 to 20/66 (P = .005) and the mean CDVA, from 20/125 to 20/40 (P = .008). The mean asphericity decreased from -0.95 preoperatively to -0.23 postoperatively (P = .006). The mean pachymetry at the apex of the cornea increased from 457.7 microm +/- 48.7 (SD) preoperatively to 466.2 +/- 49.8 mum postoperatively (P = .025) and the mean pachymetry at the thinnest point, from 436.3 +/- 46.2 microm to 453.9 +/- 49.3 microm (P = .000). The mean keratometry decreased from 45.41 +/- 5.63 diopters (D) to 42.88 +/- 4.44 D, respectively; the decrease was statistically significant (P = .000)., Conclusion: Intrastromal corneal ring segment implantation significantly improved UDVA and CDVA in patients with corneal ectasia., ((c) 2010. Published by Elsevier Inc.)

A 28-year-old male who underwent uneventful radial keratotomy for myopic correction 8 years earlier presented with sudden decrease in vision in the right eye. Slitlamp examination revealed 16 healed radial corneal scars in both eyes along with marked corneal edema and conjunctival congestion in the right eye. The Scheimpflug cross-sectional image of the right cornea displayed an intrastromal aqueous cleft in communication with the anterior chamber, consistent with the diagnosis of acute hydrops. The topographic and pachymetric analysis of the left eye revealed increased paracentral elevation of the anterior and posterior corneal surfaces along with inferotemporal thinning, consistent with the presence of keratectasia in the fellow eye. The hydrops resolved with subsequent corneal scarring 2 weeks after medical therapy with topical steroids, hypertonic saline, cycloplegics, and lubricants. This case emphasizes the importance of a comprehensive preoperative topographic assessment to rule out subclinical keratoconus to minimize complications such as keratectasia and hydrops.

Purpose: To evaluate the safety of photorefractive keratectomy (PRK) with mitomycin-C (MMC) in eyes with hyperopia after radial keratotomy., Methods: Sixty eyes of 36 consecutive patients treated with corneal wavefront-guided PRK using an Esiris-Schwind excimer laser were prospectively evaluated. Corneal epithelium was mechanically removed, followed by photoablation and use of 0.02% MMC for 20 or 40 seconds. In 16 eyes (26.7%), MMC was applied for 40 seconds. These eyes underwent ablations deeper than 100 micron or had previous corneal sutures. Patients were followed up for 12 months., Results: The mean spherical equivalent (SE) before PRK was +4.27 D +/- 2.18, and the mean best corrected visual acuity (BCVA) was 0.174 +/- 0.139 (logMAR). The planned laser SE correction was +4.74 D +/- 2.11, resulting in an ablation depth of 78 +/- 28 microm (from 33 to 148). No intraoperative complications were observed. At one year, mean SE was +0.04 D +/- 1.03 (p<0.001) and mean BCVA was 0.079 +/- 0.105 (p<0.001). There was a gain of 2 or more lines of BCVA in 20 eyes (33.3%) and only one eye (1.7%) lost 2 lines. Correlation analysis showed that the improvement in BCVA was inversely related to preoperative BCVA (r=-0.694; p<0.001). Five eyes developed peripheral haze grade 2 or 3 and one eye had central trace haze. No significant correlation was found between central or peripheral haze and the number of radial incisions, depth of the ablation or postoperative BCVA. Mean preoperative endothelial cell count was 2,681 +/- 455 cel/ mm(2) and after one year was 2,481 +/- 378 cel/mm(2) (p=0.124). One eye developed keratectasia due to the progressive widening of an inferior radial incision, which was later sutured., Conclusion: PRK with MMC was safe after one year of follow-up for the reduction of hyperopia after radial keratotomy. A major improvement in BCVA was obtained with a small incidence of haze and other complications.

Purpose: To assess the efficacy, predictability and stability of corneal wavefront-guided photorefractive keratectomy (PRK) for correcting hyperopia and astigmatism after radial keratotomy., Methods: In a prospective study, 60 eyes of 36 consecutive patients were treated with corneal wavefront-guided PRK with 0.02% mitomycin-C using an Esiris-Schwind excimer laser. Corneal epithelium was mechanically removed. All patients were followed-up for 12 months., Results: The mean time between radial keratotomy and PRK was 18.4 years +/- 3.8 (SD); mean spherical equivalent (SE) before radial keratotomy was -4.35 diopters (D) +/- 1.55. Before PRK, the mean sphere was +5.00 D +/- 2.28, mean astigmatism was - 1.47 D +/- 1.06, mean SE was +4.27 D +/- 2.18, and the mean best-corrected visual acuity (BCVA) was 0.174 +/- 0.139 (logMAR). The planned laser SE correction was +4.74 D +/- 2.11. No intraoperative complications were noted. At 12 months, mean SE was +0.04 D +/- 1.03 (P<0.001), mean astigmatism was -1.03 +/- 0.75 D (P=0.015), mean UCVA was 0.265 +/- 0.197, and mean BCVA was 0.079 +/- 0.105 (P<0.001). There was a mean gain of 1 line of BCVA and 20 eyes (33.3%) gained 2 or more lines. Only one eye lost 2 lines. A significant decrease in coma (P=0.002), trefoil (P=0.004), spherical aberration (P<0.001) and quatrefoil (P=0.002) was observed. Forty eight eyes (80%) were within +/- 1.0 D of intended SE. Mean regression from 6 to 12 months was +0.17 +/- 0.67 D., Conclusion: Corneal wavefront-guided PRK was effective, predictable and stable after one year of follow-up for the treatment of hyperopia after radial keratotomy. A significant improvement in UCVA, BCVA and corneal aberrations was obtained. ClinicalTrials.gov Identifier: NCT00917657.

Objectives: To report a case of acute high hyperopia occurring after radial keratotomy and evaluate the extent of corneal wavefront aberration with a Hartmann-Shack aberrometer., Methods: A 45-year-old man had undergone bilateral radial keratotomy with four incisions for myopia 15 years earlier. The patient developed significant hyperopia and irregular corneal astigmatism in the left eye after the operation, reducing his best-corrected visual acuity., Results: The best-corrected visual acuity was 20/20 (with refraction of +0.25-1.50 diopters [D] x 169) in the right eye and 10/20 (with refraction of +9.5D-3.00D x 50) in the left eye. Topography showed marked flattening of the left cornea, and simulated retinal images of Landolt C circles were distorted in the left eye., Conclusions: This is a rare case in which radial keratotomy induced severe hyperopic shift. Wavefront analysis with a Hartmann-Shack aberrometer revealed severe irregular astigmatism with small clear zones.

Objective: The purpose of this case report is to explore the diagnosis and the treatment of a complication secondary to a radial keratotomy (RK) surgery. It illustrates the fact that, even more than 20 years after the procedure, corneas that underwent RK procedures may still be at risk for complications., Methods: The patient was seen in emergency department in September 2008 for a red and painful eye. Examination revealed a separation of one RK incision consequent to heavy eye rubbing. Treatment initiated for this condition is similar to treatment of minor corneal erosion and is explained., Results: After intensive lubrication, the condition healed in 2 weeks, without further complications., Conclusion: It is shown that patients after RK remain at risk for corneal complications over the years after their initial surgical procedures. Patients should be educated about the fragility of their cornea and globe and to do not rub their eyes. Eye care practitioners should reinforce these messages periodically. A close follow-up of post-RK patients is needed to keep these patients in optimal ocular health.