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

Figure 7.

Clinical decision framework for individualized management of visually significant astigmatism in keratoconus. The diagram presents alternative and complementary treatment pathways according to disease progression, corneal phenotype, visual function, corneal thickness, optical regularity, and lens status. Management options include observation or optical correction, corneal cross-linking, customized PRK, intracorneal ring segments, CAIRS, phakic intraocular lenses, cataract surgery, and keratoplasty. The framework emphasizes that treatment is phenotype-driven and that patients do not necessarily proceed through all interventions.

Individualized clinical decision framework for managing visually significant astigmatism in keratoconus. The branches represent alternative or complementary pathways selected according to disease activity, corneal phenotype, and the dominant source of visual limitation; patients do not necessarily proceed through all interventions. In particular, the feasibility of combined customized PRK + CXL should be determined by an integrated assessment of the planned ablation depth, residual stromal thickness, baseline corneal thickness, and CXL safety margin, with these practical criteria mainly based on (8). The indications and safety considerations for ICRS are mainly based on (10). ACD, anterior chamber depth; CAIRS, corneal allogeneic intrastromal ring segments; CDVA, corrected distance visual acuity; CXL, corneal collagen cross-linking; DALK, deep anterior lamellar keratoplasty; HOA, higher-order aberration; ICRS, intracorneal ring segments; IOL, intraocular lens; pIOL, phakic intraocular lens; PKP, penetrating keratoplasty; PRK, photorefractive keratectomy; RGP, rigid gas-permeable; TCT, thinnest corneal thickness.