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Refractive Lens Exchange on Keratoconus Patient: a Case Report

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Refractive Lens Exchange on Keratoconus Patient: a Case Report CASE REPORT Intisari Sains Medis 2021, Volume 12, Number 1: 290-293 P-ISSN: 2503-3638, E-ISSN: 2089-9084 Refractive lens exchange on keratoconus patient: a case report Published by Intisari Sains Medis Ivane Jessica Buddyman*, Cokorda Istri Dewiyani Pemayun, Ariesanti Tri Handayani ABSTRACT Introduction: Keratoconus is a vision disorder that visual acuity improved to 6/48. Corneal topography occurs when the cornea 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 retina, this abnormal shape causes the light entering Lens + Capsular Tension Ring. Initially, This advised the eye to improperly refracted and manifested as a was differ from the patient expectation, as he wanted Ophthalmology 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 eyes. 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 myopia in keratoconus cornea. Keywords: keratoconus, Refractive Lens Exchange, Intraocular Lens, 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 eyelid), ocular allergy. and manual keratometry, but for more cornea leading to irregular astigmatism 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 290 Published by Intisari Sains Medis | Intisari Sains Medis 2021; 12(1): 290-293Open |access: doi: 10.15562/ism.v12i1.959 http://isainsmedis.id/ CASE REPORT The complication 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 corneal hydrops, 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, contact lens 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, pupil 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 iris 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 conjunctiva both eyes showed subconjunctival bleeding, 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 cataract 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).
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