A 28-year-old patient presents for refractive surgery evaluation. Placido-based topography shows inferior steepening with an asymmetric bowtie pattern, I-S (inferior-superior) value of 1.6 D, and the Belin-Ambrosio Enhanced Ectasia Display (BAD-D) score is 2.1. Pachymetry shows central corneal thickness of 520 microns. The most appropriate management is:

• A Proceed with LASIK with thicker residual stromal bed planning
• B Perform PRK instead of LASIK to avoid flap-related ectasia risk
• C Advise corneal collagen crosslinking and defer refractive surgery until stabilization is confirmed ✓
• D Fit with rigid gas-permeable contact lenses as the only safe option

Explanation

The combination of inferior steepening, asymmetric topography, elevated BAD-D score (>1.6 indicates ectasia risk), and reduced central corneal thickness represents subclinical keratoconus or forme fruste keratoconus. Any ablative refractive surgery (LASIK, PRK, SMILE) is contraindicated as it may precipitate post-refractive ectasia. Corneal collagen crosslinking (CXL) stabilizes progressive keratoconus and should be performed first. Refractive correction after confirmed stabilization can be considered with surface ablation only in carefully selected cases.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.