Stepwise Combination of Femtosecond Astigmatic Keratotomy With Phacoemulsification and Toric Intraocular Lens Implantation in Treatment of Very High Postkeratoplasty Astigmatism

Purpose: To report the outcomes of stepwise combined femtosecond astigmatic keratotomy (FSAK) and phacoemulsification with toric intraocular lens (TOL) implantation in the treatment of very high astigmatism after either penetrating keratoplasty or deep anterior lamellar keratoplasty. Methods: This is a retrospective, interventional case series including 8 eyes of 6 patients with very high astigmatism [>= 8.00 diopter (D)] after either penetrating keratoplasty or deep anterior lamellar keratoplasty who underwent FSAK, followed by phacoemulsification and toric IOL implantation. Outcome measures were corneal and manifest astigmatism and uncorrected and best spectacle-corrected visual acuity (UCVA, BSCVA). Results: The average age was 58.9 +/- 5.1 years. The average followup time was 40.9 +/- 43.8 months. Outcome measure changes after both FSAK and toric IOL implantation were: corneal astigmatism improved from 13.56 +/- 4.81 D to 4.48 +/- 2.83 D (P < 0.001), manifest astigmatism improved from 9.15 +/- 3.86 to 1.46 +/- 0.88 D (P = 0.011), UCVA improved from 1.69 +/- 0.45 LogMAR (Snellen equivalent similar to 20/980) to 0.23 +/- 0.11 LogMAR (Snellen equivalent similar to 20/33, P < 0.001), and BSCVA improved from 1.01 +/- 0.71 LogMAR (Snellen equivalent similar to 20/200) to 0.19 +/- 0.11 LogMAR (Snellen equivalent similar to 20/30, P = 0.015). BSCVA and UCVA at the last follow-up were 20/40 or better in all patients. All procedures were uneventful. Two eyes underwent photorefractive keratectomy after FSAK to regularize and further reduce astigmatism before toric IOL implantation. One patient underwent temporary compression suturing because of FSAK overcorrection. Conclusions: Combined stepwise use of FSAK and phacoemulsification with toric IOL implantation was an effective and apparently safe approach in patients with very high postkeratoplasty astigmatism. Additional treatment using photorefractive keratectomy may be beneficial in some cases.