Clear Cornea Research Articles

Case Report of Benign Diffuse Anterior Scleritis Associated with SARS-CoV-2

COVID-19 is an emerging infectious disease classified as a zoonotic illness caused by the SARS-CoV-2 strain of coronavirus. This enveloped, positive-sense, non-segmented RNA virus belongs to the order Nidovirales and the family Coronaviridae. Its primary mode of transmission is human-to-human through respiratory droplets. Ophthalmologists worldwide have reported various ocular manifestations associated with the infection. Recent studies have shown that SARS-CoV-2 binds to the cellular receptor for angiotensin-converting enzyme 2 (ACE2) and interacts with the transmembrane serine protease 2 (TMPRSS2), both of which are known to be expressed in the human cornea, retina, and conjunctival epithelium [1, 2]. The aim of this work is to present a case of a patient who developed diffuse viral scleritis related to COVID-19, detailing the diagnostic and therapeutic approaches as well as the patient's progression. We report the case of a 63-year-old man with a history of high triglycerides who developed flu-like symptoms and severe tiredness for over a week. A COVID-19 test came back positive. Ten days later, he had a painful, red right eye but no change in vision. An eye exam showed some redness in the conjunctiva, a clear cornea, and normal pressure in the eye. The fellow eye looked normal as well. He was treated with topical steroids and artificial tears, which helped initially. However, after finishing treatment, his symptoms worsened with more redness and pain, and now both eyes were affected. Further examination of the right eye showed swelling of the eyelid (preseptal cellulitis) and widespread redness in the conjunctiva. The Neosynephrine test was negative, and there was pain when moving the eye. The cornea was clear but had some superficial punctate keratitis, and the anterior chamber looked normal. The left eye also showed redness but was otherwise normal. A full lab workup (including blood tests and serologies for HSV1-2) came back normal. Considering his previous C

Successful corneal endothelium preservation in the management of epithelial downgrowth with 5-fluorouracil injections and membranectomy

A 74-year-old Chinese man underwent extracapsular cataract extraction in his right eye and developed a translucent iris membrane 4 months later. He was treated with two intracameral 5-FU injections and membranectomy at 2 weeks apart. At one year following the second membranectomy, the patient maintained a clear cornea without residual or recurrent membrane, an endothelial cell density of 1072 cell/mm2, a visual acuity of 20/50 and a normal intraocular pressure. Our technique of using dispersive and cohesive viscoelastics in protecting the corneal endothelium from intracameral 5-FU, helped preserve corneal endothelial cells and maintain corneal clarity at one year after surgery.

Autologous Contralateral and Ipsilateral Rotational Penetrating Keratoplasty - A Case Series and Mini-Review.

Corneal stromal opacities can severely impact visual acuity if they are located in the visual axis. Homologous penetrating keratoplasty (HPK) is usually the preferred surgical option in such clinical circumstances. However, autologous penetrating keratoplasty (APK) could be an immunologically safer alternative. The purpose of this study was to report the surgical technique, indications, and (dis)advantages of ipsilateral rotational and contralateral APK, as well as pre- and postoperative clinical findings of four patients who underwent contralateral APK. In ipsilateral rotational APK, eccentric trephination places the central corneal opacity at the excision edge, whereafter the corneal button is rotated to clear the visual axis. Contralateral APK is suitable for more specific clinical situations with corneal opacity in a functionally much better eye. Clear cornea of the (almost) blind eye suffering from a noncorneal pathology is transplanted to the potentially better seeing eye suffering from a corneal pathology, followed by HPK in the (almost) blind donor eye. After 18 months, potentially better-seeing eyes improved from logMAR 1.3 to 0.6 in visual acuity, with most HPK-treated weaker eyes matching preoperative levels. Considering ipsilateral rotational and contralateral APK before moving on straight towards HPK is crucial in select cases. Autologous contralateral keratoplasty should be preferred for patients with (1) corneal scars in a potentially better seeing eye and (2) a clear cornea in an (almost) blind eye, especially in cases of high risk for graft rejection.

Two-year Results of Gonioscopy-assisted Transluminal Trabeculotomy in Primary Congenital Glaucoma.

Gonioscopy-assisted transluminal trabeculotomy yielded a 45% reduction in intraocular pressure in primary congenital glaucoma, with a success rate of 86.6%. Hyphema was the most common complication. We did not encounter any vision-threatening complications. To assess the outcome of gonioscopy-assisted transluminal trabeculotomy (GATT) in primary congenital glaucoma (PCG) and identify the potential prognostic factors for adverse outcomes. This prospective study included patients aged <14 years, presenting with PCG from November 2019 till November 2021. We excluded eyes with hazy cornea, secondary glaucoma, peripheral anterior synechiae ≥ 90°, and eyes in which the extent of GATT was <270°. Success was defined as a final intraocular pressure (IOP)<18 mmHg with IOP reduction>20%. Primary outcomes were reduction in IOP and medications, secondary outcomes were complications and correlation of IOP reduction and surgical success with possible risk factors. We included 60 eyes of 50 patients aged 1-156 months (mean: 25.5±36.5). A 353°±21° incision was created, with 85% achieving a 360° incision. There was a significant reduction in IOP and medications at all follow-up intervals up to 2 years, with a mean of 45% IOP reduction. The final success rate was 86.6%, with 76.7% being controlled without medications. There was a significant positive correlation between the preoperative cup-to-disc ratio (CDR) and failure rates (P=0.03) and between the incision extent and the IOP reduction (r=0.4, P=0.001). Hyphema was the most common complication, affecting 33%, and resolved spontaneously in all cases. No vision threatening complications occurred. GATT is a safe and effective procedure in eyes with PCG and clear cornea, including eyes that had previous failed glaucoma surgery. Circumferential GATT is associated with more favorable outcomes, while eyes with a larger CDR are at a higher risk for failure.

Is opposite clear cornea incision useful still? – A tertiary institute experience

Objectives: Paired opposite clear corneal incision (OCCI), placed at the steepest meridian, during phacoemulsification cataract surgery is one of the options used to improve pre-existing astigmatism, which enhances the flattening effect. Our surgical technique for OCCI consists of a 2.75-mm stab clear corneal incision with a steel microkeratome. In this series, we retrospectively review the effect of OCCI on reducing preoperative corneal astigmatism done by a single surgeon. Materials and Methods: From October 2021 to May 2022, 53 eyes underwent phacoemulsification cataract surgery with OCCI. All eyes completed refractive analysis at least at postoperative month 1. Results: There were 22 males (45.1%) and overall mean age was 70.8years. Mean corneal astigmatism preoperatively was -1.98±0.57D. At postoperative month 1, the mean change in spherical equivalence was 0.97 ± 2.8D (P = 0.37). The mean reduction in corneal astigmatism was 1.07±0.83D (P &lt;.001). At postoperative month 6 (n = 17), mean reduction in corneal astigmatism compared to preoperatively was 0.89±0.74D (P = &lt;0.001). Mean corneal astigmatism increased between postoperative month 1 and month 6 at 0.15 ± 0.79D but this was not statistically significant. Age was not found to be correlated to change in astigmatism (r = 0.156). Conclusion: Paired OCCI is a useful technique to correct pre-existing astigmatism with no additional need to alter surgical setting.

Bilateral congenital tarsal kink syndrome with clear cornea

Congenital tarsal kink syndrome is a rare disease that causes inward rotation of the upper eyelid, leading to lacrimation, photophobia, blepharospasm, and corneal scarring. Most of the reports in the literature are unilateral cases. We report a 6-month-old male infant with bilateral tarsal kink syndrome without corneal abrasion or keratitis. The defect was corrected with transconjunctival tarsotomy with marginal rotational sutures. The postoperative outcome was satisfactory. Early diagnosis and treatment help to avoid visual complications in the long term. Increased awareness among pediatricians will help in early referral and faster management.

Penetrating femtosecond arcuate keratotomy presenting with corneal edema

We report a case of full-thickness penetration of an arcuate incision during femtosecond-assisted cataract surgery. A 78-year-old female underwent femto-cataract surgery with femto-arcuate incision. She presented with decreased vision and corneal edema 3 weeks later and was found to have full-thickness penetration of the arcuate incision with an internal wound gape. The patient was managed with closure of the internal wound gape using full-thickness corneal sutures. This resulted in a clear cornea with complete visual recovery. Careful depth setting via optical coherence tomography at the time of femto-cataract surgery is vital for minimizing the risk of this complication.

Automated Capsular Decompression to Avoid Argentinian Flag Sign in Intumescent Cataract.

We describe an alternative automated technique that consists of simultaneous anterior capsule puncture and decompression of the capsular bag by using an insulin needle attached to the aspiration tubing of the phacoemulsification device to prevent the occurrence of the "Argentinian Flag sign" during capsulorhexis in intumescent cataract. Instituto de Olhos de Assis and Center of Specialties Hoftalmed, located in the state of São Paulo, Brazil. Prospective interventional study. Eighty-eight eyes of 88 patients with white or intumescent cataracts were included in this study. Routine clear cornea incision, capsule staining with trypan blue, intracameral anesthesia, and ophthalmic viscoelastic device were used before the procedure. A 26-gauge needle was connected to the phacoemulsification aspiration tubing using a double male Luer connector for irrigation, and aspiration was inserted into the anterior chamber through a new paracentesis incision with the bevel facing down. Immediately after insertion, automated aspiration of the liquefied cortex was performed to remove anterior intralenticular material and achieve capsular decompression. Compression of the nucleus with the needle tip was performed to remove any liquefied material trapped between the posterior surface of the nucleus and the posterior capsule. All surgeries were performed using the same phacoemulsification and parameters. The rate of complete continuous capsulorhexis was observed and noted. No complications were observed in any of the cases. A single-stage, continuous, and well-centered capsulorhexis was achieved in 100% of cases. We conclude that a simultaneous puncture and decompression of the capsular bag using an insulin needle attached to the aspiration tubing of the phacoemulsification machine effectively avoided the "Argentinian Flag sign" in intumescent cataract surgery.

Can unilateral lattice dystrophy be triggered by cataract surgery in an elderly patient?

ABSTRACT Purpose Aim is to report unilateral lattice corneal dystrophy (LCD) possibly triggered after cataract surgery in an elderly patient and to demonstrate anterior segment optic coherence tomography (AS-OCT) findings. Case Report A 77-year-old male presented with irritation and photophobia in the left eye. His medical history revealed that the patient had undergone cataract surgery on the left eye 5 months ago and his symptoms exaggerated after the surgery. Best corrected visual acuity (BCVA) was 20/32 in OD and 20/63 in OS. Slit lamp examination indicated clear cornea with nuclear sclerosis in the right eye, multiple fine lattice lines at the level of middle stroma in the left eye. The lattice lines extended radially but did not involve the limbus. The overlying epithelium was intact. AS-OCT was consistent with LCD in the left eye with the presence of hyperreflective material at the level of the middle stroma. In contrast, AS-OCT in the right eye showed a normal, healthy cornea. Conclusion LCD is an inherited disease that can rarely present with unilateral involvement. Apart from its unilaterality and lack of limbal-limbal extension, the time of onset of the lattice lines is another distinguishing feature of this case report. Herein, clinical findings appeared at an older age compared to the literature. In addition, the occurrence of findings after phacoemulsification surgery has raised the question that environmental factors may trigger the emergence of unilateral LCD in patients with genetic predisposition. It is not yet known whether unilateral LCD is an asymmetric and asynchronous presentation of bilateral LCD or a different entity triggered by external factors. AS-OCT enables to demonstrate the corneal microstructural changes, and confirm the diagnosis of unilateral LCD by showing that the fellow eye is healthy.

A Successfully Treated Case of Invasive Ocular Surface Squamous Neoplasia Involving the Subtotal Cornea in a Monocular Patient: Management in a Resource-Constrained Setting

Abstract: We present a case of a 65-year-old monocular patient who was clinically diagnosed with ocular surface squamous neoplasia covering all but 2 clock hours of the limbus and almost the entire cornea. He underwent complete tumor excision followed by amniotic membrane transplantation. Postexcision, the patient had a clear cornea and stable ocular surface without inflammation or recurrence for 18 months of follow-up. The visual acuity improved to 6/18 from count fingers at face. The histopathology result uncovered squamous cell carcinoma of conjunctiva and cornea. The absence of recurrence can be attributed to complete excision and intraoperative mitomycin C.

Combined DSAEK With Cataract Surgery in a Patient With Fuchs Endothelial Corneal Dystrophy and Keratoconus After Corneal Crosslinking

Purpose: To report a combined Descemet stripping automated endothelial keratoplasty (DSAEK) with cataract surgery in a case of Fuchs endothelial corneal dystrophy (FECD) and keratoconus after corneal crosslinking combined with photorefractive keratectomy. Methods: We report a case of a 56-year-old woman with a history of subclinical keratoconus who underwent corneal crosslinking (CXL) plus 7 years ago. At presentation, the patient complained of blurry vision, which was more prominent in the morning over the past few years, and frequent changes of spectacle prescription ever since the initial treatment with CXL plus. Post-CXL plus corneal tomographies revealed progressive corneal flattening of 6.20 diopters (D) and 6.50 D in the right (OD) and left (OS) eye, respectively, in terms of mean keratometry values over a period of 7 years, which resulted in significant hyperopia. Corrected distance visual acuity (CDVA) at presentation was 20/50 in the OD and 20/200 in the OS. Slit-lamp examination revealed guttae (diagnosis of FECD) with associated posterior corneal edema and advanced nuclear sclerotic cataracts in both eyes. Combined DSAEK with cataract surgery was performed on the left eye. Results: One year after the combined procedure, CDVA improved to 20/25, with the correction of (−0.25, −4.25 × 25). Slit-lamp examination revealed a clear cornea without evidence of corneal edema or scarring. Corneal tomography indicated discontinuation of the corneal flattening in the left eye while the fellow eye continued to flatten. Conclusions: Combined DSAEK with cataract surgery provides an effective surgical option for patients with FECD after CXL plus procedures for keratoconus, offering fast visual rehabilitation and functional visual outcomes.

Intraoperative partial thickness compression suturing for descemet’s membrane detachment: A Novel technique

: To evaluate the efficacy of partial thickness transcorneal compression suturing with air desmetopexy in descemet’s membrane detachment (DMD) during cataract surgery: This is a retrospective review of records of patients who were managed for non-planar DMDs during phacoemulsification or small incision cataract surgery with partial thickness suturing with air descemetopexy in virgin eyes. : A total of fifteen cases were identified including 11 females and 4 males with average age of 67 years. All patients involved in the study underwent uneventful cataract surgery. All 15 cases involved in the study with DMD during cataract surgery were caused by intra-operative trauma during different instrumentations. Five cases had peripheral DMDs and ten cases had central DMDs. The average size of non-planar DMD was 4 mm. Ten cases had DMDs with scrolled margins. Eight patients achieved the best corrected visual acuity (BCVA) of 6/6 at the end of one month with clear corneas. Descemet’s membrane (DM) got completely attached at two weeks follow-up. The suture removal was done approximately after one month of follow-up. : Partial thickness transcorneal compression suturing with air desmetopexy in non-planar DMD is very helpful in recovering traumatic corneal edema during cataract surgery.

Outcome of Descemet membrane detachment repair using air descemetopexy and Descemet membrane suturing after cataract surgery

Outcome of Descemet membrane detachment repair using air descemetopexy and Descemet membrane suturing after cataract surgery

A novel method of evaluating the non-invasive tear film break-up time and progression of corneal opacification in dogs using imaging video.

This study aimed to determine the correlation of the parameters that indicate the status of the ocular surface with the prognosis of corneal opacification. Fifty dogs (96 eyes) were examined using a grid-line illuminator (non-invasive tear film break-up time (NIBUT)). Thirty dogs (54 eyes) were included in the final analysis based on the criteria. The NIBUT and tear film break-up time (TFBUT) results of the eyes included in the study were divided into three groups: Group 1 (< 5 s), Group 2 (5 to <10 s), and Group 3 (≥ 10 s). The Schirmer's tear Test 1 (STT-1) results of the included patients were also divided into three groups: Group 1 (< 5 mm/min), Group 2 (5 to <10 mm/min), and Group 3 (≥ 10 mm/min). The corneal opacity grades are divided into four scores, ranging from 0 to 3. The corneal opacity grade score (COS) of 0 indicates a completely clear cornea or only a trace of opacity. COS of 1, 2, 3 indicate the presence of a prominent corneal opacity that does not interfere with the visualization of the fine iris details, the opacity obscures the visibility of the iris and lens details and severe obstruction of the intraocular structure visibility, respectively. The mean difference in COS during the follow-ups for each group of NIBUT were 0.61 ± 0.92 (n = 28), 0.10 ± 0.32 (n = 10), 0.19 ± 0.40 (n = 16). The NIBUT groups were significantly correlated with COS (p-value = 0.073) at a 10% level of significance. Post-hoc test at a 10% level of significance revealed significant correlations between Groups 1 and 2 (p-value = 0.041) and between Groups 1 and 3 (p-value 0.104). Although the TFBUT and STT-1 groups did not show any significant correlation with COS. Eyes with NIBUT of <5 s were found to have a significantly higher chance of increased COS compared with eyes with NIBUT of >5 s in the grid-line illumination plate NIBUT test. Among NIBUT, STT-1, and TFBUT, NIBUT was the only test that showed significant associations with the changes in COS.

Giant ocular surface squamous neoplasia evaluated by spectral domain-optical coherence tomography

Giant ocular surface squamous neoplasia (OSSN) is difficult to manage due to extensive surface involvement and postsurgical complications. Preoperative evaluation by spectral domain-optical coherence tomography (SD-OCT) can aid in detecting the limits in the needed tissue excision, residual corneal bed, and epithelial transition in all quadrants of the limbus. We present a case of giant OSSN managed surgically with preoperative SD-OCT evaluation for excision with margin clearance and minimal complications. The postoperative period was uneventful with a clear cornea without limbal stem cell deficiency and recurrence.

Epithelial ingrowth in descemet membrane endothelial keratoplasty associated with vitreous loss

BackgroundEpithelial ingrowth is a rare but potentially sight-threatening complication caused by the invasion of corneal or conjunctival epithelial cells into the eye during ocular surgeries. DMEK is emerging as a widely used surgery for endothelial keratoplasty with its improved safety profile. We describe a case of epithelial ingrowth in the graft-host interface after uneventful DMEK associated with vitreous prolapse in the anterior chamber.Case presentationAn 81-year-old female with Fuchs endothelial dystrophy underwent DMEK for corneal decompensation following cataract surgery. During the DMEK procedure, vitreous prolapse was observed around the intraocular lens (IOL). Her early postoperative course was unremarkable, but a dense paracentral interface opacity was observed during the 3-month follow-up. The area of epithelial ingrowth was imaged with optical coherence tomography (OCT) as a uniform nodule with a discrete increase in interface hyperreflectivity. A low-energy YAG laser was applied to remove the opacity. She maintained good vision and clear cornea without reoccurrence after treatment.ConclusionsWe propose that, in addition to the introduction of epithelial cells during surgery, vitreous retention in the anterior chamber may be a risk factor by providing a scaffold that potentially aggravates epithelial ingrowth in DMEK. Our case demonstrated that early YAG intervention may disrupt interface epithelial cell growth, and the transmitted laser energy may fragment the scaffold vitreous noninvasively.

Cataract Surgery After Keratoplasty: How Should We Prepare?

Introduction : Cataract surgery following corneal transplantation demands special attention to corneal graft stability and optimization to allow for excellent IOL selection, as well as corneal graft preservation since lens removal damages the corneal endothelium. This study aimed to determine how we should prepare for cataract surgery after keratoplasty.&#x0D; Case Illustration : Case 1: A 34-year-old male has phacoemulsification in his right eye (last eye). He had a history of eye surgery, including, keratoplasty for RE in 2019, and vitrectomy for RE because of endophthalmitis. The pre-operative visual acuity is 0.5/60 with PAS and an irregular pupil. Post-operative VA 3/60 with BCVA 6/40. Last follow-up, the grafted cornea was still clear with normal IOP. Case 2: A 50- year-old female underwent phacoemulsification for both eyes (BE). She had histories of keratoplasty in 1986, 1989, and 1997 for BE. She also had extreme myopia for BE (RE S -17.00, LE S-14.00). Pre- operative VA was 1/60 of BE, and BCVA was 6/20 a month after surgery. During the last check-up, both transplant corneas were clear with normal IOP. Last visit, her both grafts remained clear.&#x0D; Discussion : &#x0D; Conclusion : IOL calculations are challenging due to inaccuracy in corneal measurements, astigmatism, or corneal pathology. The best time to perform surgery is at least 2 years after keratoplasty. We suggest using total keratometry in the K-6 formula or Haigis for the IOL formula. Good dispersive viscoelastic, operating away from the corneal endothelium, and employing low phaco-energy/fluids will help to deliver a clear cornea after surgery. Last, steroid treatment will enhance graft survival rate.

Re-descemet membrane endothelial keratoplasty (DMEK) with preservation of the original graft after free roll in anterior chamber: A case report

IntroductionLamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as Descemet Membrane Endothelial Keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management. Clinical caseAn 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24 h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber.She underwent re-DMEK with preservation of the original graft after 24 h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble.24 h after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9. ConclusionThe discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues.

Silicone oil as a corneal lubricant to reduce corneal edema and improve visualization during vitrectomy.

To evaluate the efficacy and safety of silicone oil (SO) as a corneal lubricant to improve visualization during vitrectomy. Patients who underwent vitreoretinal surgery were divided into two groups. Group 1 was operated on with initial SO (Oxane 5700) as a corneal lubricant. Group 2 was operated on with initial lactated ringer's solution (LRS) and then replaced with SO as required. Fundus clarity was scored during the surgery. Fluorescein staining was performed to determine the damage to corneal epithelium. Totally 114 eyes of 114 patients were included. Single SO use maintained a clear cornea and provided excellent visualization of surgical image. In group 1, the fundus clarity was grade 3 in 41/45 eyes and grade 2 in 4/45 eyes. In group 2, corneal edema frequently occurred after initial LRS use. The fundus clarity was grade 3 in 19/69 eyes, 2 in 37/69 eyes and 1 in 13/69 eyes (P<0.05). SO was applied in 29 eyes of initial LRS use with subsequent corneal edema, which eliminated the corneal edema in 26 eyes. Corneal fluorescein staining score in group 1 was 0 in 28 eyes, 1 in 11 eyes and 2 in 6 eyes, and 40, 20 and 9, respectively, in group 2 (all P>0.05). The use of SO as a corneal lubricant is effective and safe for preserving and improving corneal clarity and providing clear surgical field during vitrectomy.

Donut-shaped Corneal Allogeneic Intrastromal Segment as an Alternative to Deep Anterior Lamellar Keratoplasty in Advanced Keratoconus.

The aim of this study was to describe a new technique of selective corneal stromal transplantation for keratoconus treatment, donut-shaped CAIRS (corneal allogeneic intrastromal ring segment). A donut-shaped corneal graft is obtained using a double-bladed trephine. Descemet membrane, endothelium, and epithelium are all removed from the graft. Only stromal tissue is transplanted. A wide 360-degree intrastromal tunnel is created using the femtosecond laser, with a 30-degree angulation. The diameter is from 5.4 mm to 8 mm optical zone. After dehydration, the corneal graft is inserted into the tunnel. We report the clinical and tomographic outcomes after the procedure in 3 patients. The mean follow-up time after donut-shaped CAIRS was 6.01 ± 1.02 months. In case 1, best spectacle-corrected visual acuity improved from 20/150 to 20/40. In case 2, it improved from 20/400 to 20/40, and in case 3 from 20/200 to 20/40. The mean preoperative K was 57.3 ± 4.5 D and reduced to 44.2 ± 2.5 D after donut-shaped CAIRS. The mean spherical equivalent decreased from -9.8 ± 3.2 preoperatively to -3.2 ± 2.2 postoperatively. No intraoperative or postoperative complications were observed. Anterior segment OCT showed a mid-stroma implant, fusiform in shape, equidistant from the epithelium and endothelium. Donut-shaped CAIRS is a variation of the traditional CAIRS technique and showed to be an alternative option for keratoconus treatment, especially in moderate to advanced cases with a central clear cornea without scars. The technique is minimally invasive, and the visual axis remains untouched.