Figure 13 shows a patient with keratoconus, a thin cornea, extremely high myopia, astigmatism, and a congenital cataract. My confidence in correcting the astigmatism and my zero tolerance for it, led me to a staged surgery that began with Intacs implantation to stabilize and make the cornea measurable. This was followed by cataract surgery with implantation of a toric IOL, which achieved 20/20 vision.
In another staged surgery (Figure 14), this patient had had cataract surgery performed in a keratoconic eye that resulted in a lens surprise and a hyperopic outcome. Given the presence of mixed astigmatism, high keratometry values, and a central scar, the goal was to avoid additional steepening using laser procedures. I implanted a piggyback lens to induce myopic astigmatism and then performed laser ASA to correct all the astigmatism, thereby flattening the central cornea (and simultaneously clearing it) to achieve a 20/20 outcome.