Published in Interventional Mindset

Refractive Surgery Options for Vision Correction in Keratoconus

Eva Kim, MD

Eva Kim, MD

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Sit down with Eva Kim, MD, to review five refractive surgery techniques to improve vision in patients with stable keratoconus (KC).

On this episode of Interventional Mindset, Eva Kim, MD, sits down to discuss five refractive surgery techniques for patients with stable keratoconus (KC).
Dr. Kim is a cornea, cataract, and refractive surgeon and uveitis specialist as well as the Front Range Medical Director at ICON Eyecare in Denver, Colorado.

Identifying optimal keratoconus patients for refractive surgery

The ideal KC patient who may be a candidate for refractive surgery is someone with mild or moderate KC or those who have undergone corneal cross-linking (CXL) in one or both eyes, and after at least 1 year, has both stable KC and manifest refractions, noted Dr. Kim.
While CXL can halt disease progression, as a standalone procedure, it often does not suffice in rehabilitating functional vision.1 In addition, these patients can have difficulty tolerating eyeglasses, soft contact lenses, or scleral lenses—highlighting the value of providing them with alternative methods for vision correction, such as refractive surgery.

1. Phakic IOL surgery with ICL

One of her favorite ways to provide vision correction for stable KC patients is lens-based surgery, such as placing an implantable collamer lens (ICL). A key advantage of implanting an EVO ICL is avoiding corneal refractive surgery, which can be considered risky in KC patients (though some exceptions can be made for mild KC).
The EVO ICL (STAAR Surgical) is available in both a spherical and toric variety, and in her experience, most but not all KC patients require the toric ICLs for adequate correction of refractive error. The Visian Toric ICL is FDA approved to reduce myopic astigmatism with spherical equivalent ranging from -3.0D to ≤15.0D with cylinder of 1.0D to 4.0D.2
Due to the irregularity of the keratoconic cornea, it is wise to set an expectation for patients that ICLs will significantly improve their vision; however, glasses and or contacts will likely be necessary post-surgery to achieve best vision.

Pearl: Make sure to establish that KC patients have the appropriately sized anterior and posterior chambers to place an ICL with diagnostic imaging. The EVO ICL requires a true anterior chamber depth < 3.00mm, and while many KC patients are myopic, this does not automatically translate to being a candidate for ICL surgery.3

Want to see how to implant the EVO ICL? Check out EVO ICL: Indications, Patient Selection, and Surgical Tips!

Watch the video for a step-by-step walkthrough of how to implant an EVO ICL!

2. RLE with LALs

For KC patients who are stable post-CXL and presbyopic, light adjustable lenses (LALs, RxSight) can be a viable option. Placing an ICL in presbyopic patients, though possible, is usually not recommended because they would still be dependent on reading glasses, Dr. Kim noted.
The LAL is available in powers of +10D to +15D and +2D to +30D in 1D increments, with availability from +16D to +24D in 0.50D increments.4 In addition, the Light Delivery Device (LDD) can manage up to 2D of myopic or hyperopic spherical refractive error and up to 2D of astigmatism.
Dr. Kim noted that later this year, LALs will be available as low as -2D, and while the LAL+ is already available down to -2D, she recommended against using the extended depth of focus lens in KC patients due to their irregular cornea and the added risk of higher-order aberrations (HOAs).
In her practice, Dr. Kim uses LALs to debulk the astigmatism, and patients are usually happy to wear glasses with lower myopia and astigmatism correction as well as a progressive segment for near vision. She added that she has successfully eliminated almost up to 4D of astigmatism with LALs—though this isn’t possible for every patient.
Patients like the customizable nature of LALs, but it is important to set clear expectations that they may not achieve perfect vision, and it is unlikely that they will be able to pursue vision improvement with corneal refractive surgery following the procedure.

3. Toric IOL + LAL

For KC patients with high amounts of irregular astigmatism (i.e., more than 3D and up to 9D), LALs can’t correct even half of their astigmatism. Consequently, one potential approach is to first implant a high toric lens like a T9 and then subsequently stack a LAL on top of it in the capsular bag.
Thus, the toric IOL would debulk as much of the astigmatism as possible, and then any residual astigmatism could be addressed with LDD treatments on the LAL. As this is a newer technique, Dr. Kim explained that she currently has two patients who will undergo this procedure, and she is excited to see the results.

4. PRK + CXL

Another more recent approach to improving vision in KC patients is with simultaneous topography-guided, epithelium-off, photorefractive keratectomy (PRK) and same-day or next-day CXL.
This technique is called the Minneapolis Protocol for the Treatment of Keratoconus and is being developed and routinely exercised by Mark Lobanoff, MD.3 Although CXL is usually performed first and then PRK follows after 2 to 3 years of stability, using this approach means that the PRK will remove the corneal fibers in the stroma that were previously strengthened by CXL.
As such, if PRK is performed first and then followed by CXL, the epithelium will only be removed once—making the procedure safer and more convenient for patients.3 Moreover, all of the strengthened corneal fibers created by CXL remain, resulting in stable refractive results, while simultaneously reducing the irregularity of the cornea to improve vision.

Step-by-step guide to PRK + CXL

To perform this procedure, Dr. Lobanoff uses topography-guided PRK with Phorcides (a clinical decision support software) to correct the sphere and cylinder refractive error, and then he removes more than 50 microns of tissue, occasionally going up to 150 microns. Subsequently, he performs an efficient type of CXL using a new device called C2, which has enabled him to perform the procedure in under 10 minutes.3
The C2 is a cone-shaped device that suctions to the eye near the limbus and infuses riboflavin fluid into the chamber above the cornea uniformly to submerge it in riboflavin for 5 minutes. Afterwards, the device extracts the riboflavin fluid and fills the chamber with 100% oxygen using pressure while UV light is emitted from the top of the device to allow for a continuous flow of oxygen and an efficient continuous CXL reaction.3

Conclusion

With recent technological innovations, there are now a variety of options to provide vision correction to KC patients via refractive surgery.
These procedures include:
  • RLE with ICL
  • RLE with LAL
  • Stacking a toric IOL and LAL in the capsular bag
  • Sequential Contoura-based PRK with CXL
  1. Kankariya VP, Dube AB, Grentzelos MA, et al. Corneal cross-linking (CXL) combined with refractive surgery for the comprehensive management of keratoconus: CXL plus. Indian J Ophthalmol. 2020 Nov;68(12):2757-2772.
  2. Visian TORIC ICL (Implantable Collamer Lens) for Myopia. STAAR Surgical Company. https://www.accessdata.fda.gov/cdrh_docs/pdf3/P030016S001d.pdf.
  3. Kim E. Refractive Surgery in the Setting of Keratoconus. August 1, 2024. Accessed August 27, 2025. https://ophthalmologymanagement.com/issues/2024/august/refractive-surgery-in-the-setting-of-keratoconus/.
  4. Light Adjustable Lens and Light Delivery Device for the Correction of Aphakia and Reduction of Residual Astigmatism. RxSight. https://www.accessdata.fda.gov/cdrh_docs/pdf16/P160055D.pdf.
Eva Kim, MD
About Eva Kim, MD

Eva Kim, MD, is the Front Range Medical Director for ICON Eyecare, as well as a fellowship-trained uveitis and cornea/external diseases specialist and surgeon who specializes in cataract surgery and refractive surgery. In her many years of experience, Dr. Kim has performed almost 7,000 cataract surgeries with a complication rate of less than 0.4%.

Prior to her career at ICON Eyecare, Dr. Kim served as a comprehensive ophthalmologist, uveitis specialist, and Chief of Service at Northern California Kaiser Permanente. For 7 years, she also held the role of Lead Communications Consultant, focusing on elevating the quality of physician-to-physician and physician-to-patient communication and experience. For 5 years straight based on patient feedback, Dr. Kim was ranked 1st out of 258 Ophthalmologists in Northern California.

In 2013, Dr. Kim was elected to the Northern California Permanente Medical Group Emerging Leaders Cohort, a 2-year leadership and business course led by professors from the most prestigious business schools in the United States.

She also has over 8 years of medical research and resident teaching experience and is a member of the AAO, ASCRS, and has co-authored many published medical chapters, papers, and posters. Dr. Kim was also named a “Top Ophthalmology Doctor” by Denver’s 5280 magazine in 2023.

Outside of work, Dr. Kim loves spending time with her family. She and her husband Chuck have three amazing children who inspire her to be the best mother and doctor that she can be. As a family, they love to ski and attend the many sporting events in which the children are involved.

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