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. 2026 Sep 10;13:1853734. doi: 10.3389/fmed.2026.1853734

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© 2026 Zhang, Alió del Barrio, Bao and Alió.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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Three-panel clinical figure showing management of severe post-keratoplasty astigmatism during cataract surgery using a customized ultra-high-cylinder toric intraocular lens. Panel A shows the clinical appearance of the eye after penetrating keratoplasty. Panel B shows corneal topography demonstrating a steep and irregular cornea with marked asymmetric astigmatism. Panel C shows anterior segment OCT. The patient underwent phakic lens explantation, cataract extraction, and implantation of a customized toric posterior chamber intraocular lens to correct extreme residual corneal astigmatism. — Management of extreme post-keratoplasty astigmatism during cataract surgery using a customized ultra–high-cylinder toric IOL. (A) A 40-year-old male with keratoconus previously treated with penetrating keratoplasty (left eye), and astigmatic keratotomy presented with visually significant cataract and severe residual myopic astigmatism (>12.0 D). (B) Corneal topography (MS-39) showing a steep cornea with irregular, asymmetric astigmatism. (C) Anterior segment OCT showing posterior chamber phakic refractive lens implantation. A bilensectomy procedure was performed (phakic lens explantation followed by phacoemulsification), and a customized hydrophobic foldable toric posterior chamber IOL (sphere −2.50 D; cylinder −12.75 D at 141°) was implanted to address the extreme corneal cylinder. Postoperatively, uncorrected distance visual acuity improved substantially, with a marked reduction in refractive cylinder (approximately −12.00 D to −3.75 D by 3 months), and the IOL remained well centered without clinically relevant rotation. The corneal graft remained clear, with no evidence of rejection or decompensation during follow-up.