CASE REPORT Intisari Sains Medis 2021, Volume 12, Number 1: 290-293 P-ISSN: 2503-3638, E-ISSN: 2089-9084 Refractive exchange on patient: a case report

Published by Intisari Sains Medis Ivane Jessica Buddyman*, Cokorda Istri Dewiyani Pemayun, Ariesanti Tri Handayani

ABSTRACT Introduction: Keratoconus is a that visual acuity improved to 6/48. Corneal topography occurs when the becomes thin and irregularly supports the finding of Keratoconus. Management for (cone) shaped. Instead of being focused correctly on the this patient was Refractive Lens Exchange + Intraocular , this abnormal shape causes the light entering Lens + Capsular Tension Ring. Initially, This advised the to improperly refracted and manifested as a was differ from the patient expectation, as he wanted Department, Faculty of Medicine, distortion of vision. Refractive Lens Exchange is one type a LASIK procedure. An important reminder was given, Universitas Udayana, Sanglah General Hospital, of Invasive therapy in Keratoconus. Here we describe a that Keratoconus is contraindicated for LASIK and any Denpasar Bali case of Keratoconus managed by the Refractive Lens corneal surface ablation procedure. After series of Exchange procedure in our Center. procedure, the VA of the right eye was 6/15 PH 6/6, Case Description: A male, 25 years old, visited the with C - 4.00 x 1800 VA became 6/6. VA left eye was 6/18 clinic due to blurry vision since ten years ago. Every six PH 6/9, with C - 4,00 x 1800 VA became 6/9. Binocular *Corresponding to: months or a year, he needs to adjust his lens power. vision was 6/6. For near vision, S +3.00 was added for Ivane Jessica Buddyman; Ophthalmology Ophthalmology examination found visual acuity in the both . Department, Faculty of Medicine, Universitas right eye was 2/60 PH 6/60, and if using S-9.00, visual Conclusions: Refractive Lens Exchange + Intraocular Udayana, Sanglah Hospital Denpasar Bali. acuity improved to 6/30. Meanwhile, visual acuity in lens implantation is effective and safe procedures to [email protected] the left eye was 1/60 PH 6/60 and if using S–11.75, treat high in keratoconus cornea.

Keywords: keratoconus, Refractive Lens Exchange, , Capsular Tension Ring, LASIk Received: 2021-02-14 Cite This Article: Buddyman, I.J., Pematun, C.I.D., Handayani, A.T. 2021. Refractive lens exchange on keratoconus Accepted: 2021-04-12 patient: a case report. Intisari Sains Medis 12(1): 290-293. DOI: 10.15562/ism.v12i1.959 Published: 2021-04-30

INTRODUCTION suggested a higher prevalence among male could be achieved with corneal patients.2 The etiology of Keratoconus topography and Scheimpflug imaging Keratoconus is a common disorder in is multifactorial. Keratoconus can be or anterior segment Optical Coherence which the central or paracentral cornea associated with family history, ethnicity Tomography. Advanced keratoconus undergoes progressive thinning and (Asian and Arabian), mechanical factors can be diagnosed using only slit-lamp protrusion, resulting in a cone-shaped (eye rubbing, floppy ), ocular allergy. and manual keratometry, but for more cornea leading to irregular It can also be associated with systemic sensitive analysis, corneal topography and and visual deterioration. Keratoconus diseases, including atopic disease, Down corneal pachymetry should still be used.4,5 characteristically a bilateral but 1,2 syndrome, Ehlers-Danlos syndrome, Keratoconus is considered a asymmetric progressive disease. Osteogenesis Imperfecta, Sleep Apnea, contraindication for LASIK and corneal Keratoconus is a common disorder, and Mitral valve prolapse.1,2 surface ablation. Therefore, a complete with an incidence rate about 1 every Disease progression is manifested by examination of the eyes is a must to 2000 person. Onset usually occurs during a significant loss of visual acuity, which establish a correct diagnosis before puberty, and the progression rate is at a cannot be compensated with spectacles. attempting a therapy. Inappropriate peak in young age. Progression typically Visual acuity of 6/6 or a close to is difficult therapy on Keratoconus can cause more slows in the fourth decade of life and 3 to achieve with the increasing against- severe and permanent visual disturbances. is unusual after the age of 40 years. the-rule astigmatism. Additionally, Thus, it is obvious that a proper diagnosis is Keratoconus occurs in both genders. No Keratometry readings are commonly needed to provide satisfactory therapeutic gender predominance has been reported abnormal.3 Early detection for keratoconus results.1,5,6 previously, whereas recent reports have

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The of Keratoconus is complaint of blurred vision in both Ophthalmology examination found vision loss which occurs mainly due to eyes since ten years ago. At that time, he visual acuity (VA) of the right eye was 2/60 corneal protrusions or corneal scarring. prescribed a pair of glass with a power of Pinhole (PH) 6/60, and if using S-9.00, the Corneal thinning usually occurs in S -2.50. Every six months or a year, the VA became 6/30. The VA of the left eye the center of the cornea as well as in power of the glasses changes. Since two was 1/60 with PH increase to 6/60, and the infratemporal cornea. Advanced years ago, the patient used glasses with if using S -11.75, the VA becomes 6/48. keratoconus can develop , different power, the right was S -11.00 and Corneal examination of both eyes revealed which can cause corneal scars.5 the left was S -16.00. However, the patient cone-shaped cornea (Keratoconus), This article aimed to increase knowledge felt that his vision was still blurry and photographed in Figure 1. Other than in making a diagnosis, examining, uncomfortable, so the patient asked and that, the other anterior segments of both and considering the management of expressed his willingness about the LASIK eyes were within normal limits. Fundus Keratoconus cases to produce excellent procedure. examination of both eyes revealed well- and optimal visual acuity resolution by The patient was office workers who sat defined, rounded papillae of the second retelling our experience. in front of a computer screen for about cranial nerve (N.II), cup disc ratio was 0.3, 8-10 hours/day. The patient admitted that retinal lattice degeneration, macular reflex CASE DESCRIPTION he often rubbed his eyes, was allergic to (+). dust and often sneezed. Family history of The corneal topography of the right eye A male patient, 25 years old, came to wearing glasses, trauma, use, was steep K 56.38 D @ 92, Flat K 52.95 D the Ophthalmology Polyclinic with a the systemic disease was denied. @ 2, Astigmatism 3.43 D, Q - 0.82, Shape factor 0.82, diameter 7.1 mm, Axial I - S 2.98 D. On the left eye, the results were steep K 60.89 D @ 76, Flat K 55.65 D @ 166, Astigmatism 5.24 D, Q - 0.77, Shape factor 0.77, pupil diameter 6.9 mm, Axial I - S 6.65D. The right eye’s specular results showed a mean central corneal thickness (CCT) of 499, while the mean CCT of the left eye was 424. Anterior segment optical coherence tomography (OCT) of the right eye obtained an angle formed between the cornea and the at temporal was 460 and at the nasal was 4300, while in the left eye at the temporal was 360 and at the nasal Figure 1. Preoperative lateral eye view. was 390 (Figure 2). The patient was diagnosed with High Myopia + Keratoconus, both the right and left eye. The patient was planned to undergo Refractive Lens Exchange (RLE) + Intraocular Lens (IOL) + Capsular Tension Ring (CTR). The patient was fitted for IOLs with the barret formula. The axial length of the right eye was 23.23, K1 53.25 D, K2 54.25 D, IOL + 7.00 D; axial length left eye was 23.59, K1 53.75 D, K2 55.25 D, Figure 2. The corneal topography of the right (OD) and left (OS) eye. IOL + 4.00 D. The first day after the procedure (RLE + IOL + CTR), VA of the right eye was 6/9 and VA of left eye 6/45 PH 6/18. The both eyes showed subconjunctival , cornea showed corneal edema and Descemet fold, and IOL in place. A week and a month after surgery, the visual acuity in the right eye was 6/6. The visual acuity left eye was 6/45 PH 6/18, anterior segment of both eyes within normal limits, IOL (+). Figure 3. Corneal topography of both eyes

Published by Intisari Sains Medis | Intisari Sains Medis 2021; 12(1): 290-293 | doi: 10.15562/ism.v12i1.959 291 CASE REPORT

Eight months after surgery, the patient few clinical sign that could raise the is that it can maintain the normal contour complained of blurry vision in both clinician suspicion. Characteristic sign of of the cornea, thus improving the quality eyes. On ophthalmologic examination Keratoconus is Rizzutti sign, a focusing of of vision quickly and eliminating the need revealed VA of the right eye was 6/12 PH the light within the nasal limbus when a for surgery in the future. For cases 6/9 and VA of the left eye was 6/60 and penlight is shone from the temporal side, of high myopia and astigmatism, it can no improvement with pinhole. Anterior an early but nonspecific finding. Munson also be accompanied by Limbal Relaxing segment examination on both eyes found sign, an inferior deviation of the lower Incision (LRI) or implantation toric IOL.9,11 IOL and Posterior Capsular Opacification eyelid contour on downgaze, is also a late Disadvantage of RLE is that the patient’s (PCO). The patient was planned for nonspecific sign. Iron deposition within expectation for visual acuity is higher ND – Yag . The patient also the basal epithelium at the cone base forms than patients with , so it is underwent corneal topography, specular a Fleischer ring. Best seen with the slit- essential to provide thorough preoperative examination and anterior OCT on both lamp using a broad, oblique beam and the informed consent, uncorrected residual eyes. The corneal topography of the right cobalt- blue filter.1 Meanwhile, Corneal refractive errors during intraoperative IOL eye showed steep K 57.61 D @ 83; Flat K topography and tomographic have been insertion, and postoperative care.11,12 52.82 D @ 173; ∆K: 4.79 D; IS index 0.81 accepted as sensitive methods for early Lastly, it is important to mention that D; SAI 1.99; SRI 1.39. The topography of diagnosis, monitoring progression, and an untreated Keratoconus would likely the left eye is steep K 64.87 D @ 80; Flat K treatment of Keratoconus. In addition, to result in deterioration of vision. The 55.43 D @ 170; ∆K: 9.44 D; IS index 5.05 this advanced examination also used complication of keratoconus is vision loss, D; SAI 4.10; SRI 1.81 The average CCT in to visualise an irregular astigmatism, mainly as a result of irregular astigmatism the right eye showed a mean CCT of 444, improve contact lens fitting, detection of and myopia due to corneal protrusions and while the mean CCT of the left eye was 387 other corneal ectatic disorders, corneal corneal scarring. Corneal thinning usually (Figure 3). degeneration, trauma, scarring, corneal occurs in the center of the cornea as well Post-ND-YAG capsulotomy, the VA of surgery, corneal thickness, angle elevation as in the inferotemporal cornea. Advanced the right eye was 6/10 PH 6/7.5, with C - cornea, epithelial imaging dan analysis keratoconus can develop into corneal 4.00 x 1800 VA became 6/7.5. VA in the anterior segment.4,5,7 hydrops called acute keratoconus. The left eye was 6/15 PH 6/10, with C - 4.00 x The topographic pattern of eyes with Descemet layer breaks and is associated 1700 VA became 6/7,5. One month post- keratoconus usually shows inferonasal or with the stromal clefts that can cause the ND YAG capsulotomy, the VA of the right inferotemporal area of steepening in the aqueous humour to enter the stroma, eye was 6/15 PH 6/6, with C - 4.00 x 1800 central and the upper regions. Typically, causing corneal scars. Patients usually VA became 6/6. VA left eye was 6/18 PH a variation greater than 10.00 diopters report sudden vision loss and discomfort 6/9, with C - 4,00 x 1800 VA became 6/9. between the steepest and flattest curvatures in the eyes accompanied by pain and was 6/6, comfortable indicates keratoconus.5 Basically, the conjunctival injection.1 An early detection with adaptation. For near vision, +3.00 management of keratoconus is aimed to and proper treatment is the only way to was added for both eyes. improve the eyes refractive power. The save the vision. management include glasses, contact lens, DISCUSSION scleral lens, Intrastromal Corneal Ring CONCLUSION Segments, RLE, Penetrating Keratoplasty Keratoconus is a common disorder in (PK) or Deep Anterior Lamellar Keratoconus is a visual disturbance which the central or paracentral cornea Keratoplasty (DALK), Corneal Cross- that occurs when the cornea’s central or undergoes progressive thinning and Linking, CXL Plus, Accelerated Cross- paracentral shape undergoes progressive protrusion, resulting in a cone-shaped Linking. Keratoconus is a contraindication thinning and protrusion, creating a cornea and leads to irregular astigmatism cone-shaped cornea. Keratoconus is a 1,2 for LASIK and corneal surface ablation and visual deterioration. procedure. The weakening of the cornea contraindication for LASIK procedure and The reported prevalence of keratoconus during LASIK flap creation and tissue corneal surface ablation. Thus, a complete is highly variable, ranging from 0.0003% removal could significantly increase the examination of the eye is essential for proper in Russia, 2.3% in India, to 0.054% in 1,5,8 diagnosis before deciding on a specific 2 risk of progressive ectasia. the USA. A hereditary pattern is not RLE is the removal of the non-cataract treatment. A critical test to determine prominent or predictable, but positive lens with or without IOL implantation. Keratoconus’ presence or absence is a family histories have been reported in RLE surgical technique is similar to the conventional topography to see the cornea 6%–8% of cases. Genetic predisposition standard cataract surgery technique. The curvature and characteristics. RLE + IOL and environmental risk factors such as main element that distinguishes between implantation is one of the most effective eye rubbing, inflammation, atopy, hard RLE and standard cataract surgery is and safe procedures that could be offered contact lens wear, and oxidative stress all that in RLE, the crystalline lens still in its to treat high myopia due to Keratoconus. play a role in the onset and progression of Additionally, a scleral lens can be added to 1,2 normal anatomical conditions. As in this keratoconus. case, a high myopia is an indication for correct irregular astigmatism so optimal Keratoconus could be difficult to RLE.9,10 Advantage of the RLE procedure vision can be achieved. detect in its early phase. There are

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ETHICAL CONSIDERATION 2. Andreanos KD, Hashemi K, Petrelli M, 9. Alió JL, Grzybowski A, Romaniuk D. Refractive Droutsas K, Georgalas I, Kymionis GD. lens exchange in modern practice: when and The authors had gained consent from Keratoconus Treatment Algorithm. Ophthalmol when not to do it? Eye Vis Lond Engl. 2014;1:10– the patients to publish this case in an Ther. 2017;6(2):245–62. 10. 3. Romero-Jiménez M, Santodomingo-Rubido J, 10. Refractive Lens Exchange (Clear Lens academic journal without revealing any Wolffsohn JS. Keratoconus: A review. Contact Extraction) for Myopia Correction: personal identity and solely for educational Lens Anterior Eye. 2010;33(4):157–66. Background, History of the Procedure, Problem purposes. 4. American Academy of Ophtalmology. The [Internet]. Available from: https://emedicine. Science of . In: BCSC medscape.com/article/1221340-overview Refractive Surgery. San Fransisco: AAO; p. 29– 11. Srinivasan B, Leung HY, Cao H, Liu S, Chen CONFLICT OF INTEREST 36. (2019-2020). L, Fan AH. Modern and The authors stated no conflict of interest. 5. Anderson D. Understanding Corneal Intraocular Lens Implantation (Refractive Lens Topography [Internet]. AOA; 2017. Available Exchange) Is Safe and Effective in Treating from: https://www.aoa.org/Documents/ High Myopia. Asia-Pac J Ophthalmol Phila Pa. FUNDING optometric-staff/Articles/Understanding- 2016;5(6):438–44. Corneal-Topography.pdf 12. Horgan N, Condon PI, Beatty S. Refractive lens The author is independently responsible 6. Martin R. Cornea and anterior eye assessment exchange in high myopia: long term follow up. for this case report’s funding without with placido-disc keratoscopy, slit scanning Br J Ophthalmol. 2005;89(6):670–2. involving sponsorship or other funding evaluation topography and scheimpflug imaging tomography. Indian J Ophthalmol. sources. 2018;66(3):360–6. 7. Naderan M, Jahanrad A, Farjadnia M. Clinical AUTHORS CONTRIBUTION biomicroscopy and findings of keratoconus in a Middle Eastern population. All authors contributed equally in all Clin Exp Optom. 2017;101(1):46–51. phases of the study. 8. Denny P. Keratoconus: New Consensus, New Goals - American Academy of Ophthalmology [Internet]. Available REFERENCE from: https://www.aao.org/eyenet/article/ 1. American Academy of Ophtalmology. Corneal keratoconus-new-consensus-new-goals? Dystrophies and Ectasias. In: BCSC External plckFindCommentKey=CommentKey:%20 Disease and Cornea - Section 8. San Fransisco: 7a532b41-52cb-405a-b378-d52edeb73ff7 AAO; p. 161–8.

Published by Intisari Sains Medis | Intisari Sains Medis 2021; 12(1): 290-293 | doi: 10.15562/ism.v12i1.959 293