In a recently published case report in the journal American Journal of Ophthalmology Case Reports, our team (Prof. Farhad Hafezi and Dr. Emilio Torres-Netto), in collaboration with Brazilian colleagues Drs. Ricardo Nosé and Bruno Fontes, describes an unusual case of a “CTK-like syndrome” following sequential intracorneal ring segment (ICRS) implantation and corneal cross-linking (CXL) in a young patient with progressive keratoconus.
This case provides unique insights into how combined ICRS and CXL can lead to significant corneal remodeling, flattening, and opacification, raising new considerations for clinical care.
Understanding ICRS and CXL
Intracorneal ring segments are small implants placed in the corneal tissue to reduce irregular curvature, thereby improving visual clarity in keratoconus cases. Corneal cross-linking, on the other hand, involves riboflavin and UV-A light to increase corneal stability, which stops disease progression by strengthening the corneal collagen fibers.
CTK-like Syndrome in Keratoconus Treatment
In this case, a 31-year-old with advanced keratoconus presented unexpected corneal changes—marked flattening of up to 20.3 diopters (D), along with opacification and central thinning. These changes mimicked central toxic keratopathy (CTK), a rare, non-inflammatory condition previously observed after laser procedures but now seen post-CXL. Notably, CTK usually follows laser procedures, presenting with corneal opacity, thinning, and a hyperopic shift, all of which are documented here.
Implications for Keratoconus Management
Our findings highlight the importance of considering procedural sequencing. While both ICRS and CXL offer keratoconus patients substantial benefits, performing ICRS prior to CXL may heighten the risk of pronounced corneal changes. This case underscores the need for diligent monitoring in sequential treatments to optimize outcomes and patient safety. Moving forward, our team aims to investigate additional cases to further evaluate this procedural combination and better understand patient-specific responses.
Reference
B.M. Fontes, R.M. Nosé, F. Hafezi, E.A. Torres-Netto, CTK-like Syndrome: Corneal Opacity and Flattening Following Sequential Intracorneal Ring Implantation and Corneal Crosslinking, American Journal of Ophthalmology Case Reports (2014), ePub ahead of print. https://doi.org/10.1016/j.ajoc.2024.10219
