Innovative combined intrastromal corneal ring graft and transPRK for advanced keratoconus: multicase report

Introduction: Refractive surgery can further compromise biomechanical stability in patients with ectatic corneas. This case series highlights a novel treatment approach combining intrastromal corneal ring graft (RinGraft) and transepithelial photorefractive keratectomy (transPRK), offering a promising alternative for improving outcomes in advanced keratoconus (KC). Patient and Clinical Findings: 3 patients with severe to advanced KC at a stable disease stage were treated at Bina Eye Hospital, Tehran, Iran. Their primary concern was significant visual impairment from irregular astigmatism and refractive errors. Clinical assessments confirmed ectatic corneal changes consistent with KC. Diagnosis, Intervention, and Outcomes: The diagnosis was severe to advanced KC. Patients first underwent RinGraft implantation to restore the cornea's structural stability. Owing to residual refractive error after RinGraft, transPRK was performed. Posttreatment evaluations showed marked improvement in uncorrected and corrected distance visual acuity, better keratometric values, and reduced higher-order aberrations. No intraoperative or postoperative complications were observed. All patients reported increased visual satisfaction during follow-up. Conclusions: The combined RinGraft and transPRK approach can improve structural integrity and visual function in severe to advanced KC. This method may serve as a safer, more effective alternative to keratoplasty in selected cases.