TECHNIQUE Biologic stromal ring to manage stromal melting after intrastromal corneal ring segment implantation Elias Jarade, MD, Mohamad Issa, MD, Wassef Chanbour, MD, Pramod Warhekar, MD We report a new technique to replace a manufactured poly(methyl methacrylate) (PMMA) ring with a biologic stromal ring fashioned from human corneal donor tissue in eyes with stromal melting above the PMMA ring. The biologic stromal ring is prepared using manual or femtosecond laser trephination of a donor cornea to obtain a 360-degree ring that is denuded and adjusted to match the PMMA ring being replaced. The biologic ring is attached to the PMMA ring. The PMMA ring is pushed and retrieved from the other side, which installs the biologic ring in place. Six biologic stromal rings were implanted successfully in 5 eyes of 5 patients with previous stromal melting; no complications were reported up to 6 months postoperatively. The biologic stromal ring stopped and healed the melting, prevented further ring complications, and preserved the therapeutic refractive effect of the previously implanted PMMA ring. J Cataract Refract Surg 2019; 45:1222–1225 Q 2019 ASCRS and ESCRS Online Video C orneal stromal melting above a poly(methyl meth- acrylate) (PMMA) ring is one of the most feared complications of intrastromal corneal ring segment (ICRS) implantation. It is not uncommon and can occur after manual or femtosecond laser–assisted ICRS procedures. 1–3 Ring migration toward the inci- sion site is the most likely predisposing factor for corneal melting. However, originally thin corneas, super- ficial ring implantation, keratoconus progression with active corneal tissue loss, eyelid rubbing, corneal trauma, a sterile corneal ulcer, and a superficial corneal infec- tion might also precipitate stromal melting after ICRS implantation. 1 Ring migration with overlying stromal melting usually prompts immediate removal of the ring to prevent further damage to the cornea and hence the loss of the therapeutic effect of the ring. 4 Four stages of ring migra- tion have been identified. 4 In the early stages, ring migra- tion is treated by a suturing technique described by Jarade et al. 4 In this technique, 10-0 nylon sutures are placed to prevent recurrent migration. However, in stage 4, ring removal is the most commonly used method, with the goal of preventing complications such as infection and scarring. 4 Worsening of the corneal topography indices resulting from loss of the flattening effect have been reported after ICRS explantation. 5 However, the topographic effect was preserved in a recent study of patients who had simultaneous corneal crosslinking (CXL) and ICRS implantation. 6 We report a new technique to replace the manu- factured PMMA ring with a biologic ring fashioned from human corneal donor tissue. This stops and heals the melting, prevents further ring complications, and preserves the therapeutic refractive effect (as tissue- saving additive procedure) of the previously implanted PMMA ring. SURGICAL TECHNIQUE Biologic Stromal Ring Preparation Two methods were used to prepare the biologic ring. In the first method, trephination of the donor cornea was per- formed to obtain a 7.75 mm donor graft (for patients requiring keratoplasty). The remaining corneoscleral ring was trephined again with a 9.0 mm diameter trephine, re- sulting in a 0.625 mm wide, 360-degree corneal ring (Figure 1, B). Submitted: March 5, 2019 | Final revision submitted: April 30, 2019 | Accepted: May 16, 2019 From the Beirut Eye and ENT Specialist Hospital (Jarade, Issa, Chanbour) and Lebanese University (Jarade), Faculty of Medical Sciences, Beirut, Lebanon; Mediclinic Dubai Mall (Jarade) and the Mediclinic City Hospital (Warhekar), Dubai, United Arab Emirates. Corresponding author: Elias Jarade, MD, Beirut Eye and ENT Specialist Hospital, Al Mathaf-Square, PO Box 116-5311, Beirut, Lebanon. Email: ejarade@ yahoo.com. Q 2019 ASCRS and ESCRS Published by Elsevier Inc. 0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.05.022 1222