Outcomes of Femtosecond Laser-Assisted Arcuate Keratotomy in the Management of Keratoplasty-Related Astigmatism.

Background/Objectives: Post-keratoplasty astigmatism can limit visual recovery even after successful corneal transplantation. Femtosecond laser-assisted arcuate keratotomy (FSAK) has emerged as a method to reduce high residual astigmatism and enhance visual outcomes. This study aimed to evaluate the outcome of FSAK in treating astigmatism following keratoplasty. Methods: This retrospective study included 32 eyes from 31 patients who underwent FSAK after keratoplasty. Inclusion required complete suture removal, regular corneal topography, and the absence of additional ocular pathology or prior intraocular surgery. Data collected included uncorrected (UCVA) and best-spectacle-corrected visual acuity (BSCVA), manifest refraction, and tomographic parameters. The primary outcomes were changes in visual, refractive, and tomographic measures across the entire cohort, with further subgroup analysis between penetrating keratoplasty (PKP) and lamellar keratoplasty (LKP) eyes. Secondary outcomes were documentation of complications. Results: UCVA improved significantly from 0.92 ± 0.33 to 0.58 ± 0.39 LogMAR (p < 0.001). BSCVA showed a non-significant trend toward improvement from 0.32 ± 0.21 to 0.26 ± 0.22 LogMAR (p = 0.158). The manifest cylinder reduced significantly from -6.15 ± 2.75 D to -4.49 ± 2.92 D (p = 0.037). Corneal topography revealed significant postoperative steepening in keratometric values. While overall outcomes were comparable between the subgroups, LKP eyes demonstrated a greater myopic shift and a higher rate of overcorrection, whereas PKP eyes tended toward undercorrection. Conclusions: FSAK appears to be an effective approach for reducing post-keratoplasty astigmatism and improving uncorrected visual acuity. Given the biomechanical differences between graft types, individualized treatment planning based on graft characteristics may enhance surgical predictability and optimize outcomes.