Aim: To present and discuss the outcomes of the mini asymmetric radial keratotomy (MARK) and corneal cross-linking (CXL) combined intervention, also known as the “Rome protocol”, for patients with progressive stage I, II, and III keratoconus (KC) and contact lens intolerance (CLI). Design: Retrospective, observational study. Materials and methods: The postoperative outcomes of 48 eyes (35 patients) were selected and retrospectively analyzed, with an average follow-up of 3.8 years. To assess the efficacy of the MARK plus CXL combined protocol, mean keratometry, mean pachymetry, and best spectacle-corrected visual acuity were evaluated. Results: Mean keratometry improved in 90% of cases (from 48.3 D to 45 D), mean pachymetry improved in 83% of cases (from 439 to 460 μm), and best spectacle-corrected visual acuity improved in all cases (from +0.4 to +0.15 logMAR). Conclusion: The MARK plus CXL intervention effectively halted the KC progression and improved the visual acuity, which suggests that this combined procedure should be taken into account when considering refractive procedures combined with corneal cross-linking (CXL plus), if the relevant inclusion criteria can be satisfied.

Aim: This study aimed at assessing the therapeutic decisions made by an individual keratoconus specialist in the last 10 years, to treat patients with keratoconus. Materials and methods: We studied a case series and the descriptive analysis of individual cases treated by a single keratoconus specialist. Medical records of 636 patients totaling 1271 eyes were evaluated based on the therapeutic procedure used. Results: For the treatment of keratoconus, the specialist chose expectant (only spectacles) in 22.3% of the cases, contact lenses in 39.3%, implantation of intrastromal corneal ring segments (ICRS) in 27.7%, cross-linking in 0.9%, and penetrating keratoplasty in 8.5% of the cases. Conclusion: The keratoconus specialist preferred noninvasive therapeutic options to improve vision quality, such as spectacles and contact lenses. Clinical significance: Show the therapeutic preferences of a keratoconus specialist in order to compare with the daily practice.

Aim: To report an unusual case of a newly diagnosed bilateral superior keratoconus in an elderly patient. Background: We report a case of bilateral superior keratoconus in a 64-year-old woman who was diagnosed after having presented with hydrops in one eye. Case description: Uncorrected visual acuity was counting fingers from 3 and 1 meter for the right and left eyes, respectively. A superiorly located deep stromal scar and chronic corneal edema consistent with a diagnosis of corneal hydrops were noted for the left eye. Although the cornea was clear, there was superior corneal protrusion in the right eye. Pentacam and Orbscan demonstrated overlapping focal corneal thinning, increased back elevation, and steepening in the superior cornea. Anterior segment optical coherence tomography (AS-OCT) showed stromal and epithelial thinning in the superior cornea and significant compensatory epithelial thickening in the opposing quadrant. In light of these findings, a diagnosis of superior keratoconus was established. Conclusion: Superior keratoconus is a rare condition. Meticulous evaluation of corneal tomography and epithelial thickness profile is crucial for localizing the superior cone in keratoconus. Clinical significance: This is the first case report demonstrating epithelial thickness profile in a superior keratoconus case.

Aim: To report a case of acute hydrops with a large stromal cleft, in a case of keratoconus, managed with compression sutures and perfluoropropane (C3F8) descemetopexy and subsequent management of corneal vascularization in that eye with combination therapy of laser and anti-vascular endothelial growth factor (anti-VEGF). Background: Acute hydrops in keratoconus occurs following a tear or rupture in the Descemet's membrane (DM), resulting in aqueous percolating into the stroma. The presence of large stromal clefts in acute hydrops has been described as a known risk factor for delayed resolution and persistent edema, which in turn can incite inflammation and vascularization and thereby adversely affect the chances of graft survival later. We describe such a case managed effectively with a combination of different treatment modalities. Case description: A 12-year-old boy with keratoconus presented with acute hydrops in his left eye. The acute hydrops was managed with compression sutures along with C3F8 descemetopexy. Subsequent development of persistent deep corneal vascularization and recurrence of inflammation after the resolution of hydrops was managed with a combination of argon laser photocoagulation and intrastromal anti-VEGF injections, resulting in complete regression of the deep vascularization and resolution of inflammation. Conclusion: In our case, a combination of management modalities to address severe acute hydrops and its subsequent complications resulted in complete regression of the superficial and deep vessels, thus heralding an optimal outcome for a future corneal graft. Clinical significance: There are no definite guidelines for the management of acute hydrops in keratoconus. A customized and judicious combination of various treatment modalities described in the literature for acute hydrops and its sequelae can result in an accepted outcome, which can pave the way for an optimum result with elective treatments like keratoplasty later on.

Aim: The aim of the study is to report a case of pregnancy-associated progressive keratoconus with atypical horizontally aligned Vogt's striae. Background: Hormonal changes during pregnancy have been proposed as a risk factor for progressive keratoconus. There have been only a few cases of progressive keratoconus diagnosed with progression after pregnancy, without either an existing disease or an attributable cause. Case description: A 36-year-old New Zealand European woman presented with progressive myopic astigmatism following her first pregnancy. Stigmata of keratoconus were present on clinical examination and included horizontally aligned Vogt's striae. Tomography measurements confirmed the diagnosis with characteristic inferior corneal steepening and ectasia bilaterally. The patient was advised to abstain from eye rubbing, commenced topical olopatadine, and underwent corneal collagen cross-linking following delivery to prevent further keratoconus progression. Conclusion: Pregnancy-associated progressive keratoconus in a 36-year-old woman was documented after the pregnancy. Clinical significance: Atypical presentation features that include horizontally aligned Vogt's striae, advanced age at diagnosis, and rapid pregnancy-associated progression in a previously stable patient.