Combined Corneal Cross-Linking and Myoring Implantation in Advanced Keratoconus: Femtosecond Laser versus Manual Dissection

Background. Intrastromal corneal ring segments are widely adopted for keratoconus management. However, the complete ring (Myoring) was proposed to be superior in advanced cases. Myoring can be implanted either via femtoassisted or manual dissection techniques. A comparison between both techniques can delineate any differences in the outcomes. Methods. This was a prospective interventional case series study. Sixty-four eyes with progressive advanced keratoconus were enrolled: 36 and 28 had femtoassisted or manual Myoring, respectively. Uncorrected visual acuity (UCVA), corrected distance visual acuity (CDVA), maximal keratometry (K-max), spherical equivalent (SE) and corneal thinnest location were measured in all eyes preoperatively and at one, six, and 12 months postoperatively. Epi-off corneal cross-linking (CXL) was performed eight weeks after Myoring implantation for all cases. Results. Femtoassisted Myoring dissection significantly improved UCVA and CDVA from 0.1 +/- 0.06 and 0.18 +/- 0.1 preoperatively to 0.29 +/- 0.08 and 0.43 +/- 0.1 at 12 months. Also, manual technique similarly enhanced UCVA and CDVA from 0.11 +/- 0.05 and 0.2 +/- 0.1 preoperatively to 0.27 +/- 0.2 and 0.4 +/- 0.2 at 12 months. In terms of safety, while no cases of ring extrusion were encountered with the femtoassisted technique, six (21.4%) cases of extrusion were encountered in the manual group. Conclusion. Femtoassisted or manual Myoring technique followed by CXL is an effective choice for advanced progressive keratoconus. Although it did not reach a statistical significance, the high extrusion rate with manual dissection is a red flag to be considered.