Keratoconus is an ectatic corneal disorder that causes severe vision loss. Surgical options allow us to correct, partially or totally, the induced refractive error. Intracorneal ring segments (ICRS) implantation represents a minimally invasive surgical option that improves visual acuity, with a high success rate and a low overall complication rate. Corneal allogenic ICRS consists of ring segments derived from allogenic eye bank-processed donor corneas. Selective topography-guided transepithelial photorefractive or phototherapeutic keratectomy combined with CXL is another way in selected cases to improve spectacles corrected distance visual acuity. The microphotoablative remodeling of the central corneal profile is generally planned by optimizing the optical zones and minimizing tissue consumption. Phakic intraocular lens (PIOL) implant is considered in patients with stable disease and acceptable anatomical requirements. The two types of pIOLs, depending on their implantation inside the eye, are anterior chamber-pIOLs, which fixate to the anterior surface of the iris by using a polymethomethacrolate claw at the two haptics, and posterior chamber-pIOLs. In patients with both cataracts and keratoconus, the correct IOL power is difficult to obtain due to the irregular corneal shape and K values. Toric IOL is recommended, but carefully judging the topography and the possible need of subsequent keratoplasties.

Purpose: To assess the medium- and long-term outcomes of keratopigmentation (KTP) as a surgical alternative to change the cosmetic appearance of healthy eyes. Methods: A prospective, interventional, consecutive, multicenter, series of cases of cosmetic KTP was included in the study. Forty consecutive patients underwent KTPs with mineral micronized pigments using a femtosecond laser–assisted intrastromal or superficial technique. Main outcomes were cosmetic evaluation, subjective patients' satisfaction, and complications. The outcomes were evaluated at 6 months after the last operation and then yearly. Results: This study included 79 eyes of 40 patients, with a mean age of 34 ± 11 years; femtosecond laser–assisted intrastromal keratopigmentation was performed in 39 patients (97.5%) and superficial automated keratopigmentation in 1 patient. Mean follow-up was 29 months (range 6–69). Observer's evaluation was excellent in 90% of cases, and patient's satisfaction was excellent in 92.5% of cases. Twenty-eight eyes (35.4%) were reoperated; of them, 7 eyes (8.9%) had 2 color touch ups and 4 eyes (5.1%) had 3 color touch ups. After the retreatments, all the patients were satisfied with the cosmetic aspect. Light sensitivity at first month was the most common complication (30%), followed by change in the color (7.5%), color fading (5%), and visual field limitations in a case with 4.5-mm pupil size (2.5%). One patient with a previous laser in situ keratomileusis developed corneal ectasia. Conclusions: Cosmetic KTP achieves good cosmetic results and is associated with high patient satisfaction. Most of the complications could be managed adequately. It might offer a safe and effective new surgical alternative for those patients motivated to change the apparent color of their eyes.

Anterior segment optical coherence tomography (AS-OCT) is a modality that uses low-coherence interferometry to visualize and assess anterior segment ocular features, offering several advantages of being a sterile and noncontact modality that generates high-resolution cross-sectional images of the tissues. The qualitative and quantitative information provided by AS-OCT may be extremely useful for the clinician in the assessment of a wide spectrum of corneal infections, guiding in the management and follow-up of these patients. In clinical practice, infections are routinely evaluated with slit-lamp biomicroscopy, an examination and imaging modality that is limited by the physical characteristics of light. As a consequence, the depth of pathology and the eventually associated corneal edema cannot be accurately measured with the slit-lamp. Therefore, it represents a limit for the clinician, as in vivo information about corneal diseases and the response to treatment is limited. Resolution of corneal infection is characterized by an early reduction in corneal edema, followed by a later reduction in infiltration: both parameters can be routinely measured with standardized serial images by AS-OCT.

An increasing number of people are seeking elective cosmetic change of eye color. We review the surgical techniques, outcomes and complications arising from the various existing surgical alternatives, including cosmetic iris implants—which based on the available evidence should be considered malpractice—as well as laser iris depigmentation and cosmetic keratopigmentation. Laser iris depigmentation has been used clinically for aesthetic purposes without receiving official approval or licensing. The technique can be performed in an outpatient clinic thanks to the use of neodymium: yttrium–aluminum–garnet (Nd:YAG) lasers, but scientific literature data about this treatment is very limited. Cosmetic iris implants are neither CE-marked nor Food and Drug Administration (FDA)-approved, and lead to severe complications arising from their placement including uveitis, hyphema, glaucoma, cataract, corneal endothelial damage and severe vision loss. Management of complications resulting from iris implants might require several surgical procedures, and the follow-up is difficult among these poorly informed patients. Keratopigmentation is the most extensively studied technique and had long been investigated before being introduced into clinical practice: already introduced centuries ago, it was recently developed, reporting adequate levels of safety and efficacy. The medium- and long-term cosmetic outcomes of keratopigmentation and patient satisfaction have been the subject of recent reports. The available level of evidence suggests that cosmetic keratopigmentation is the best evidence-supported surgical choice for patients seeking a permanent cosmetic eye color change. Still, additional investigation is needed to optimize the outcomes, minimize postoperative complications and further develop this and other new surgical alternatives such as laser procedures.

Purpose: To assess the 3-year clinical results of the 18 mW 7 J/cm² transepithelial enhanced fluence pulsed light M accelerated crosslinking in the treatment of progressive keratoconus (KC) with chemically enhanced hyper-concentrated riboflavin solutions without iontophoresis and with air-room oxygenation. Setting: Siena Crosslinking Center, Siena, Italy. Methods: Prospective pilot, open non-randomized interventional study including 40 eyes of 30 young adult patients over 21 years old (10 simultaneous bilateral) with early (Stage I and II) progressive KC undergoing TE-EFPL 18 mW/7 J/cm² ACXL (EFPL M TECXL). The 12 min and 58 s pulsed light (1 s on/1 s off) UV-A exposure treatments were performed with a biphasic corneal soaking using Paracel I 0.25% for 4 min and Paracel II 0.22% for 6 min riboflavin solutions and New KXL I UV-A emitter (Glaukos-Avedro, Waltham, USA) at an air room of 21% oxygenation. All patients completed the 3-year follow-up. Results: CDVA showed a statistically significant improvement in the third postoperative month (Δ + 0.17 d. e.) with a final gain of +0.22 d. eq. AK showed a statistically significant decrease in the sixth postoperative month (Δ − 1.15 diopters). K itmax showed a statistically significant decrease at 1-year follow-up (Δ − 1.3 diopters). The coma value improved significantly by the sixth month (Δ − 0.54 µm). MCT remained stable during the entire follow-up. No adverse events were recorded. Corneal OCT revealed a mean demarcation line depth at 282.6 ± 23.6 μm. Conclusions: Transepithelial enhanced fluence pulsed light M accelerated crosslinking with chemically enhanced riboflavin solution halted KC progression in young adult patients without iontophoresis and no intraoperative oxygen supplementation addressing the importance of increased fluence.