June consultation #1.

A 21-year-old man was referred for refractive surgery evaluation. He had a history of advanced keratoconus that led to penetrating keratoplasty (PKP) in the right eye 2 years ago. Spectacle dependence and poor visual quality in this right eye is his chief concern. He cannot tolerate contact lenses. The uncorrected (UDVA) and corrected distance visual acuity (CDVA) were 20/400 and 20/50, respectively. The manifest refraction was -2.75 -8.00 × 165 in the right eye. He presented frank keratoconus in the left eye with a UDVA of 20/200 and a CDVA of 20/100. The manifest refraction was -6.0 -4.75 × 95. The intraocular pressure was normal, and the results from a slitlamp examination showed a clear corneal graft in the right eye. The topographic and tomographic maps revealed a high astigmatism (Figures 1 to 3). This case is about a refractive surgery option for refractive error after PKP in the right eye. What kind of refractive surgery (if any) would you recommend to this patient's right eye? Would you consider any modality of excimer laser? In this case, what are your limits for final? Would you consider intrastromal corneal ring segments (ICRS)? Would you consider a phakic intraocular lens (pIOL)?