Solving a tough case of Hexagonal Keratotomy

Featuring guest surgeon: Arun Gulani MD from Jacksonville, Florida, USA

This complex case involved a patient who underwent hexagonal keratotomy for treatment of hyperopia decades ago. This ended up causing instability in the cornea with the central optical zone having a massive amount of astigmatism. Dr. Gulani solved this case by first placing intra-stromal corneal ring segments and cross-linking. Then a few months later after corneal stability was achieved, the patient had cataract surgery with a toric IOL to address the mild residual astigmatism. The end result was excellent 20/30 uncorrected vision.

Here is the explanation in detail from Dr. Gulani:

Principles of LenzOplastique: Using Intra-Ocular Lens based surgeries (including Cataract surgery-PhacoPlastique) as an ART where despite complexities, optical manipulation is the goal of each step to achieve maximum vision in single or staged fashion with least interventional techniques guided by GPS (Gulani Planning System) to unaided, Best Vision Potential- Gulani AC, M.D.

So you realize that I need a detailed plan (Gulani 3T concept) before every surgery, meaning, technique (T) and technology (T) come last, I first determine “Target”.

To me, every cataract surgery also is LenzOplastique (“O” stands for Optimized vision) and demands due diligence prior to surgery: Do painstakingly determine and measure each and every refractive error, anatomical and physiological abnormality of each eye and then line all these up (like pins before bowling)  before aiming for a “Strike” .

This case is a prototype wherein, a 75 year old Nurse was referred with preoperative vision of CF4 feet with 23.50D Irregular Astigmatism, Keratometry of 88.90 D, s/p hexagonal Keratotomy on Keratoconus with unstable, scarred Cornea, High Myopia, Corneal Ectasia , Fuchs Dystrophy, Subluxated Cataract, Amblyopia and Exophthalmos.

The Keys in this case are:

  1. Pick all the Refractive, Anatomical and Physiological errors and in your mind, aim for the least interventional approach that will attempt to attack all of these with a single goal- “Vision without glasses”.
  2. Though safety and Confidence is paramount, don’t let the fear of how many problems there are, weaken your desire or goals. Also, you are always thinking “Least Interventional”.
  3.  So in this case; here is my thought process:
  4. Cataract surgery is absolutely needed (75 years old and opaque lens). Now, to perform accurate cataract surgery to clear the optical axis, counter high myopia and achieve lens implant based correctable astigmatism, we need a stable and accurate cornea.
  5. To achieve this accurate and measurable cornea without disruption of existent Hex K cuts or aggravating Fuchs dystrophy while controlling ectasia, flattening keratometry and also reducing a very high astigmatism made me select INTACS as that technique and technology choice. I call this, making the cornea  ”Sensible” or “Measureable”.
  • Thus my LenzOplastique™ plan unfolded for this case:
  • First, I proceeded with INTACS surgery and made my cornea “Measureable” while decreasing Keratometry and Astigmatism from 23.50D to 1.4D, controlling ectasia and not harming the Fuchs.
  • I then waited for 4 months to check on stability with repeated checks in between.
  • Now, with full confidence I proceeded with Cataract surgery and used a Toric Lens implant for that residual astigmatism and brought the patient to 20/30 without glasses.
  • Surgical Nuances:

“One your mind is decided, hands just follow” so I was unshakable in my resolve that this patient despite what every surgeon said to her must see and that too without glasses. So I needed to be gentle, accurate, take no stitch, nor induce any variables like moving lens implant-capsular diaphragm or incisional  leaks. So I performed a “No-Stitch” Intacs surgery (0.45) gently channeling in the dangerous zone just around the Hex K cuts to brace the cornea and stabilize that “Island”.

During cataract surgery, entry incision was tightly shelved, capsulorhexis (Trypan Blue stain for visiting surgeons) was small for two reasons; 1. So I could visualize the edges as outside that zone, visualization was a challenge due to reflections of central scar, Intacs and Hex K cuts and 2. So I could maintain a tight Lens Implant-Capsular diaphragm. Sutureless incision so not to induce any astigmatism no matter how tiny and ReSure sealant was used additionally after hydration.

Patient back to her life starting immediately and saw her face in the mirror for the first time in 60 years. Came dressed and resumed her lifetime ambition of caring for others. Photos and reactions included.A patient on camera (with no incentive) is the highest form of accountability- Gulani AC.

Note: Dr. Gulani states that he has obtained her permission for discussion of her case and showing her face in the photographs.

click below to watch and learn from this excellent video:


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