CLINICAL SCIENCE
Additional Intrastromal Corneal Ring Segments in
Keratoconus
Hassan Hashemi, MD, Amin Nabavi, MD, Reza Bayat, MD, and Masoumeh Mohebbi, MD
Purpose: To evaluate the outcome of additional KeraRing
(Mediphacos, Belo Horizonte, Brazil) implantation in patients with
keratoconus with previously implanted INTACS (Addition Tech-
nology Inc, Fremont, CA) segments.
Methods: The KeraRing was implanted in 5 eyes of 3 patients with
keratoconus without removal of previous intrastromal corneal ring
segments. Tunnels were created manually. Snellen uncorrected
distance visual acuity (UDVA), corrected distance visual acuity,
refractive and keratometric values, and higher-order aberrations were
recorded before and after KeraRing implantation.
Results: UDVA, corrected distance visual acuity, subjective
refraction, and keratometric values were improved in 4/5 of cases
and remained stable during a median follow-up of 36 months.
UDVA improved from 20/200 and 20/100 to 20/100 and 20/40 in the
right and left eyes of patient 1, respectively, and from 20/200 to 20/
40 in both eyes of patient 2. The reduction in mean keratometric
value was 2.1 and 4.4 D in the right and left eyes of patient 1, and 1.4
and 1.9 D in the right and left eyes of patient 2, respectively. In
patient 3, UDVA (20/100) and mean keratometric value (52.4)
remained unchanged after second intrastromal corneal ring segment
implantation. Total higher-order aberrations were improved in all
cases. No intraoperative or postoperative complication was
observed. However, one of the cases reported glare under
scotopic conditions.
Conclusions: KeraRing implantation in properly selected eyes
with previously implanted INTACS could enhance final visual and
refractive outcomes.
Key Words: keratoconus, intrastromal corneal ring segment,
KeraRing
(Cornea 2018;37:574–579)
Received for publication September 17, 2017; revision received December 5,
2017; accepted December 8, 2017. Published online ahead of print
January 30, 2018.
From the Eye Research Center, Farabi Eye Hospital, Tehran University of
Medical Science, Tehran, Iran.
The authors have no funding or conflicts of interest to disclose.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.corneajrnl.com).
Correspondence: Masoumeh Mohebbi, MD, Eye Research Center, Farabi Eye
Hospital, Tehran University of Medical Science, Qazvin Square, Tehran,
Iran 1336616351 (e-mail: Msh.mohebbi@gmail.com).
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I ntrastromal corneal ring segment (ICRS) implantation is
a minimally invasive and reversible procedure that could
delay or even eliminate the need for keratoplasty in kerato-
conus (KCN).1,2 A variety of ICRS designs including
INTACS, INTACS SK (Addition Technology, Sunnyvale,
CA), and KeraRings SI-5 and SI-6 (Mediphacos, Belo
Horizonte, Brazil) with different cross-sectional shapes,
diameters, arc lengths, and thicknesses are currently
available.3
Poor visual and refractive outcome predictability is one
of the major drawbacks of ICRS implantation. Residual
myopia or astigmatism due to suboptimal reduction of corneal
steepness resulting in an unsatisfactory visual outcome may
be encountered after ICRS implantation.4–6 In addition, KCN
progression may occur after ICRS insertion.7 Removal of 1
segment, exchanging with another segment, repositioning of
the segments, or applying laser photoablation has been
described with variable effects in the case of unsatisfactory
results after ICRS implantation.8–11 Recently, 2 reports of
adding different intrastromal rings (segment or complete ring)
with promising outcomes were published.12,13 Coskunseven
et al12 described 3 keratoconic eyes with unsatisfactory visual
outcomes after INTACS implantation, which were treated by
implanting the KeraRing without explanting the INTACS.
They reported favorable results and improvement in
visual acuity.
This study was conducted to evaluate the long-term
outcome of adding the KeraRing in previously implanted
INTACS keratoconicpatients who had poor visual results.
MATERIALS AND METHODS
Five eyes from 3 patients with KCN who underwent
adjuvant KeraRing (Mediphacos, Belo Horizonte, Brazil)
implantation after INTACS between July 2012 and March
2013 were enrolled. This retrospective interventional case series
was conducted at Farabi Eye Hospital, Tehran, Iran. The ethical
board committee of the Tehran University of Medical sciences
approved the study protocol. Written informed consent was
obtained from participants for all procedures.
Surgical procedures were performed under general
anesthesia. The pupil center was chosen as the central point
for KeraRing tunnel formation; in the case of the decentered
INTACS, the central point was adjusted to prevent over-
lapping of INTACS and KeraRing tunnels. A 5-mm marker
was used to locate the ring tunnel and the incision site. A
radial incision approximately 1.2 mm in length was made on
the topographic steepest meridian. The tunnel depth was set at
Cornea  Volume 37, Number 5, May 2018
Cornea  Volume 37, Number 5, May 2018 Intrastromal Corneal Ring Segment

TABLE 1. Demographic and Detailed Pre- and Post-KeraRing Implantation Visual and Refractive Data of Patients
Preoperative 6-mo Postoperative 24-mo Postoperative Last Follow-Up Visit
Follow-
Age/ Up Cylinder Cylinder Cylinder Cylinder
Nom. Sex Time, mo UDVA CDVA (D) UDVA CDVA (D) UDVA CDVA (D) UDVA CDVA (D)
1 OD 27/F 30 20/200 20/50 25.50 20/100 20/40 22.75 20/100 20/32 22.75 20/100 20/40 23.00
OS 36 20/100 20/63 25.00 20/40 20/40 22.75 20/40 20/32 22.50 20/40 20/32 22.50
2 OD 30/M 40 20/200 20/50 25.00 20/40 20/32 22.50 20/40 20/40 22.00 20/40 20/32 22.00
OS 38 20/200 20/50 24.50 20/40 20/40 23.50 20/50 20/40 23.50 20/40 20/40 23.50
3 OD 28/M 32 20/100 20/50 28.00 20/63 20/50 26.50 20/100 20/50 27.00 20/100 20/50 27.00
Nom., number.

80% of the thinnest corneal thickness on the tunnel location
using a pachymetric map of the Pentacam (Oculus Optikg-
eräte GmbH, Wetzlar, Germany). The incision was made
using a diamond knife and a tunnel was created manually.
Manufacturer’s forceps and spatulas were used for proper
insertion of the KeraRing into the tunnel. A bandage contact
lens was placed on the cornea and removed after 3 days.
Topical chloramphenicol was prescribed every 6 hours for 1
week. Betamethasone eye drops were administered every 6
hours and were tapered off in 6 weeks. All surgical
procedures were performed by the same experienced anterior
segment surgeon (M.M.).
Arc length, thickness, and number of KeraRing segments
were selected after the manufacturer’s nomogram based on the
cone steepest meridian in a topographic map and subjective
refraction. Two 160 degrees/200-mm KeraRing SI-5 segments
were implanted in each eye of patient 1. Incisions were made at
a depth of 460 mm in the right eye and 480 mm in the left eye.
Single 160-degree/300-mm KeraRing SI-5 segments were inserted
in both eyes of patient 2. Incisions were made at depths of 440
and 450 mm in the right and left eyes, respectively. Two segments
of the SI-5 KeraRing, 120 degrees/200 mm and 120 degrees/
300 mm, were inserted with an incision at a depth of 440 mm in
patient 3.
Uncorrected distance visual acuity (UDVA), corrected
distance visual acuity (CDVA) (using Snellen chart), and
subjective refraction were evaluated before KeraRing implan-
tation and at 6 and 24 months postoperatively and at the final
follow-up visit. Pentacam imaging and iTrace aberrometry
(Tracey Technologies, Houston, TX) were also performed at
baseline and during the postoperative period. Total ocular
higher-order aberrations (HOAs) in the 4-mm optical zone
were reported in all visits.
RESULTS
Five eyes from 3 patients with a mean age of 28.3 years
were included in this study. Detailed pre- and post-KeraRing
visual, refractive, keratometric, and aberrometric measure-
ments are illustrated in Tables 1 and 2.
Patient 1
A 27-year-old woman with KCN was referred to our
clinic because of unsatisfactory visual outcomes 4 years after
bilateral INTACS implantation followed by collagen cross-
linking. UDVA was 20/200 in the right eye and 20/100 in the
left eye. CDVA was 20/50 with a subjective refraction of
23.00 to 5.50 · 120 in the right eye and 20/63 with

TABLE 2. Pre- and Post-KeraRing Implantation Keratometric and Aberrometric Data of Patients
Preoperative 6-mo Postoperative
Nom. Follow-Up Time, mo K1/K2 (D) Km (D) Total HOA, mm K1/K2 (D) Km (D) Total HOA, mm
1 OD 30 48.9/52.7 50.7 2.133 47.6/49.9 48.7 1.932
OS 36 47.6/51.5 49.7 1.834 45.1/46.4 45.5 1.543
2 OD 40 42.5/48.6 45.6 2.211 43.5/45.2 44.3 1.962
OS 38 44.3/48.7 46.4 2.033 42.5/46.4 44.4 1.915
3 OD 32 47.9/57.9 52.4 2.198 47.3/56.1 51.3 1.412
24-mo Postoperative Last Follow-Up Visit
Nom. K1/K2 (D) Km (D) Total HOA, mm K1/K2 (D) Km (D) Total HOA, mm
1 OD 47.8/49.6 48.7 1.916 47.8/49.4 48.6 1.926
OS 44.7/46.2 45.3 1.552 44.6/46.1 45.3 1.568
2 OD 43.3/45.2 44.2 1.853 43.3/45.2 44.2 1.866
OS 42.4/46.7 44.5 1.846 42.8/46.4 44.5 1.852
3 OD 48.1/56.6 52 1.378 47.7/56.3 51.7 1.369

K1/K2, flat/steep keratometric value.

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Hashemi et al
FIGURE 1. Preoperative Pentacam sagit-
tal curvature map of the right eye (top
left) and the left eye (top right) of patient
1 with a single-segment INTACS. Twenty-
four–month postoperative Pentacam
sagittal curvature map (middle row) and
slit photographs (bottom row) after Ker-
aRing implantation.
a subjective refraction of 22.00 to 5.00 · 70 in the left eye.
Keratometric values (flat/steep) and mean keratometric power
(Km) were 48.9/52.7 diopters (D) and 50.7 D in the right eye
and 47.6/51.5 D and 49.7 D in the left eye, respectively. Root
mean square for total HOAs was 2.133 and 1.834 mm in the
right and left eyes, respectively. Slit-lamp examination
revealed a single INTACS segment placed inferiorly in
both eyes.
It was decided to add the KeraRing ICRS without
explanting the INTACS in the left eye. Six months after
KeraRing implantation, UDVA and CDVA were improved to
20/40 and 20/40 with a subjective refraction of 21.75 to 2.75
· 90. Keratometric values decreased to 45.1/46.4 D (Km =
45.5 D). Total HAO was also improved to 1.543 mm.
Because the patient was happy with the result of
adjuvant ICRS, a decision was made to implant the KeraRing
in the other eye. Six months after KeraRing implantation,
UDVA was 20/100 and CDVA was 20/40 with a subjective
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Cornea  Volume 37, Number 5, May 2018
refraction of 21.00 to 2.75 · 80 in the right eye. Keratometric
measurements and total HOAs were 47.6/49.9 D (Km = 48.7
D) and 1.932 mm, respectively. At the final follow-up visit,
UDVA and CDVA were 20/100 and 20/40 in the right eye and
20/40 and 20/32 in the left eye, respectively (Table 1).
However, she complained of glare under scotopic conditions.
Preoperative and 24-month postoperative topography images
and postoperative slit-lamp photographs are shown in Figure 1.
Patient 2
A 30-year-old man was referred to our clinic 3 years
after bilateral INTACS implantation for KCN. An inferiorly
positioned single-segment INTACS was observed by slit-
lamp examination. UDVA was 20/200 in both his eyes.
CDVA was 20/50 with a subjective refraction of plano 25.00
· 40 in the right eye and 20/50 with a subjective refraction of
21.25 to 4.50 · 135 in the left eye. Measured K-readings
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Cornea  Volume 37, Number 5, May 2018
FIGURE 2. Preoperative curvature map of
the right eye (top left) and the left eye
(top right) of patient 2 with a single-
segment INTACS. Twenty-four–month
postoperative curvature map (middle
row) and slit photographs (bottom row)
after KeraRing implantation.
were 42.5/48.6 D (Km = 45.6) in the right eye and 44.3/48.7
D (Km = 46.4 D) in the left eye (Fig. 1). Total HOA was
2.211 mm in the right eye and 2.033 mm in the left eye. The
patient was dissatisfied with his vision, and KeraRing
implantation was performed in both his eyes, sequentially.
Refractive, visual, and keratometric results at 6- and 24-
month follow-up are illustrated in Tables 1 and 2. UDVA was
20/40 in both his eyes after 40 and 38 months of follow up for
the right and left eyes, respectively. CDVA was also
improved in both eyes; CDVA was 20/32 with a subjective
refraction of plano 22.00 · 50 in the right eye and 20/40 with
a subjective refraction of plano 23.50 · 140 in the left eye.
Keratometric values improved to 43.3/45.2 D (Km = 44.2 D)
and 42.8/46.4 D (Km = 44.5 D) in the right and left eyes,
respectively (Fig. 2). The total HOA was decreased to
1.866 mm in the right eye and 1.852 mm in the left eye.
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Intrastromal Corneal Ring Segment
Slit-lamp photographs after KeraRing implantation in the
presence of previous INTACS are shown in Figure 2.
Patient 3
A 28-year-old male patient with KCN visited our clinic
with a complaint of unsatisfactory visual acuity in his right
eye after ICRS implantation. Slit-lamp examination and
review of medical records revealed that an inferiorly posi-
tioned single-segment INTACS were implanted bilaterally 5
years earlier, which was followed by collagen cross-linking.
UDVA was 20/100 and CDVA was 20/50 with a subjective
refraction of plano 28.00 · 40 in the right eye. The
keratometric measurement was 47.9/57.9 D (Km = 52.4 D).
KeraRing ICRS was implanted in the right eye.
Although UDVA increased modestly to 20/63, CDVA
www.corneajrnl.com | 577
Hashemi et al
FIGURE 3. Preoperative (upper left) and
24-month postoperative (upper right)
curvature map of the right eye of patient
3. Postoperative slit-lamp photograph
(bottom) showed INTACS and 2 KeraRing
segments.
remained stable at the 6-month postoperative visit. Compar-
ing preoperative and 32-month postoperative data, showed no
change in UDVA and CDVA. Subjective cylinder and Km
were reduced only by 1 and 0.7 D, respectively. The total
HOA decreased from 2.198 to 1.369 mm. Preoperative and
24-month postoperative topography images and a postopera-
tive slit-lamp photograph are shown in Figure 3.
DISCUSSION
In this study, we reported the results of KeraRing
implantation in 5 eyes of 3 patients with KCN with a history
of INTACS insertion, without INTACS removal. KeraRing
implantation resulted in satisfactory visual and refractive
outcomes in 4 eyes of our cases, which remained stable
during long-term follow-up. The KeraRing was implanted
uneventfully, and no complication was observed in post-
operative examinations. KCN did not progress during the
follow-up period.
ICRSs come in different cross-sectional shapes, diam-
eters, arc lengths, and thickness profiles. The INTACS has
a hexagonal cross-section and is implanted in the 6.8-mm
optical zone, whereas the KeraRing has a triangular cross-
section. The SI-5 KeraRing is implanted in the 5.0-mm
optical zone and the SI-6 KeraRing is implanted in the 6.0-
mm optical zone.3 ICRSs flatten the cornea by having an arc-
shortening effect. Flattening effect may be greater if the ring
is placed closer to the visual axis.14 Some studies suggested
that KeraRing implantation resulted in greater improvements
in visual acuity compared with INTACS, partly because it
takes advantage of a smaller optical zone.15,16 However, there
are studies showing similar refractive and visual outcomes
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Cornea  Volume 37, Number 5, May 2018
using the INTACS or KeraRing.17 Residual astigmatism and
unfavorable visual outcome were partially corrected by
adding the KeraRing in 4/5 of our cases. Detailed evaluation
of preoperative and postoperative topography maps showed
that adding another ICRS induces a more central and flatter
cone with a more regular pattern in the central cornea,
although irregularity in the peripheral cornea may increase.
Similarly, Coskunseven et al12 reported favorable results in 3
cases of KeraRing implantation in the presence of the
previous INTACS. By contrast, Torquetti et al10 reported
that implantation of a second Ferrara segment did not improve
the outcomes. However, it is not clear that the improved
visual and refractive results in our cases are due to the
combined effect of the KeraRing and INTACS or the
KeraRing alone. In a study by Bali et al,9 the results of
INTACS explantation and KeraRing reimplantation were
evaluated in patients with KCN and post–laser in situ kera-
tomileusis ectasia. The refractive results and keratometric
parameters did not improve after 12 months; however, the
CDVA increased in 50% of patients. ICRS explantation and
implantation of new ICRS after an interval may have the
advantage of allowing the cornea to return to its original state
before reimplantation.8 Furthermore, nomograms for choos-
ing the new ICRS might be more accurate in this condition.
However, additional implantation of ICRS in the presence of
previous ones may theoretically provide the combined effect
of 2 types of ICRSs. Further studies are needed to compare
the outcomes of adding another ICRS and changing the
present segment to a different ICRS with a smaller
optical zone.
In our study, eyes with mild-to-moderate residual
astigmatism after INTACS implantation achieved more
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Cornea  Volume 37, Number 5, May 2018
satisfactory outcomes by adding the KeraRing. UDVA and
CDVA were improved after additional KeraRing implantation
in patients 1 and 2 who had a keratometric value (steep K) of
,51 D and a residual astigmatism of ,6 D. The reduction in
Km was 2.1 and 4.4 D in the right and left eyes of patient 1,
and 1.4 and 1.9 D in the right and left eyes of patient 2,
respectively. Previous investigations have shown that the
effect of ICRS may vary widely depending on the severity of
KCN. Some studies found that ICRS provided better visual
and refractive results in mild and moderate KCN.5,18,19
Although we studied only 5 cases, it could be suggested that
the results of previous studies on the virgin cornea may be
applicable in our study. High residual astigmatism (8 D
cylinder) after INTACS implantation in patient 3 may explain
the suboptimal effect. Applying the nomogram that was
originally proposed for the virgin cornea also may play a role
in this unsatisfactory outcome. Similar to our findings,
Coskunseven et al12 reported favorable results by adding
the KeraRing on the previously INTACS implanted cornea in
nonadvanced KCN. None of their cases had very steep
corneal or high residual astigmatism.
One of our cases (patient 1) reported glare in night
activities. Glare, especially under scotopic conditions, is
one of the main potential disadvantages of ICRS with
a small optical zone.6,20 Kaya et al20 showed that Ferrara
ICRS implantation is associated with decreased scotopic
contrast sensitivity, which was not identified in eyes with
INTACS. Furthermore, additional ICRSs may be implanted
even closer to the pupil center to avoid overlapping with
the preexisting ICRS tunnel. Therefore, we suggested that
adding another ICRS closer to the visual axis should be
reserved for patients with small scotopic pupils. However,
it should be noted that the pupil size in the Pentacam may
be inaccurate in the ICRS-implanted cornea. Pupils look
larger and irregular in both eyes of patient 1 (Fig. 1), which
is related to misidentification of the pupil margin by the
Pentacam due to shadows of ICRSs. This error could be
clearly observed in the Scheimpflug image (see Figure, Supple-
mental Digital Content 1, http://links.lww.com/ICO/A620).
Variability of ICRS outcome should also be considered
before planning to add another segment. Similar to patients
with virgin corneas, cases with previously implanted
ICRS may show unpredictable results after sequential
ICRS implantation.
In summary, KeraRing implantation in properly
selected eyes with previously implanted INTACS could
enhance the final visual and refractive outcomes. This method
could be a viable option, especially in patients with small
scotopic pupils to obtain better results in the case of
unacceptable outcomes after the first ICRS placement.
However, it should be compared with other alternatives
including exchanging the ring and laser ablation in future
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Intrastromal Corneal Ring Segment
studies. In addition, whether the proposed ICRS nomogram
for the virgin cornea is applicable to ICRS implanted corneas
needs further investigations.
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