A 26-year-old wants LASIK. Corneal topography shows inferior steepening, an I–S (inferior–superior) asymmetry index of 1.8 D on Placido disc, and Scheimpflug imaging reveals posterior elevation of +18 µm above best-fit sphere at the thinnest point. The MOST appropriate management is:

• A Proceed with standard LASIK as topography is mildly abnormal
• B Advise against refractive laser surgery; screen for forme fruste keratoconus ✓
• C Perform PRK (surface ablation) which is safer than LASIK in this case
• D Perform SMILE which avoids flap creation and is safe in subclinical keratoconus

Explanation

Inferior steepening, I–S asymmetry >1.5 D, and elevated posterior elevation on Scheimpflug are hallmarks of forme fruste keratoconus (FFK), a contraindication to ALL laser corneal refractive surgery (LASIK, PRK, SMILE). Performing ablation on FFK risks postoperative ectasia — progressive corneal thinning and bulging. SMILE avoids flap creation but does not eliminate the risk of ectasia in subclinical keratoconus. These patients should be counselled about collagen cross-linking if progressive and offered phakic IOL (ICL) for refractive correction.

Reference: Khurana Comprehensive Ophthalmology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.