Original Research Article- Keratoconus

European Journal of Ophthalmology

1–8
Results of intrastromal corneal ring © The Author(s) 2023
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corneal transplantation

Jordana Sandes Barbosa Soares1 ,

Luís Fernando Oliveira Borges Chaves1, Leonardo Torquetti2,
Paulo Ferrara de Almeida da Cunha3, Marcia Toledo1,
Guilherme Rocha4 and Leopoldo Magacho1

Abstract
Purpose: To evaluate the safety and efficacy of the surgery of intracorneal ring segment implantation with 320° of arc
(320-ICRS) in patients with advanced keratoconus stage IV and maximum keratometry (Kmax) above 60 D.
Methods: A prospective, interventional case series study evaluating 25 eyes of 19 patients with keratoconus stage IV and
Kmax > 60D in which 320-ICRS were implanted using VisuMax® femtosecond. Uncorrected distance visual acuity
(UDVA), corrected distance visual acuity (CDVA), keratometric values (mean - mean-K, flat - K1, and steep - K2), max-
imum keratometry (Kmax), tomographic astigmatism, refractive astigmatism and asphericity (Q) were assessed preopera-
tively and at 3, 6 and 12 months after the procedure.
Results: The UDVA improved from 1.03 ± 0.28 LogMAR (20/200) to 0.54 ± 0.21 LogMAR (20/60), (p < 0.001), the
CDVA (with glasses) improved from 0.63 ± 0.29 LogMAR (20/80) to 0.31 ± 0.16 LogMAR (20/40),(p = 0.004), K1 reduced
from 54.41 ± 4.46 D to 49.36 ± 4.11 D (p < 0.001), K2 reduced from 61.15 ± 4.37 D to 53.715 ± 4.05 D, (p < 0.001),
mean-K reduced from 57.55 ± 4,17 D to 51.44 ± 3,94 D (p < 0.001), Kmax reduced from 69.80 ± 8.20 D to 63.43 ± 6.31
D (p < 0.001) and asphericity (Q) changed from −1.57 ± 0.35 to −0.77 ± 0.56 (p < 0.001). A total of 89.9% patients reached
BCVA wearing scleral contact lens 0.2 LogMAR(20/25).
Conclusion: 320-ICRS to treat advanced keratoconus appears to be an efficacious and safe procedure, being a surgical
alternative to delay or even prevent corneal transplantation.

Keywords
cornea / external disease, penetrating keratoplasty, examination techniques: corneal topography/Keratometry corneal
optics, refractive surgery in children

Date received: 25 November 2022; accepted: 26 July 2023

Introduction
Keratoconus is a chronic, progressive, bilateral, non-
inflammatory, typically asymmetric corneal condition
with progressive curvature, protrusion and thinning of
the corneal stroma.1 The approach to the treatment of ker-
atoconus has greatly evolved in recent decades, and
research has been conducted in search of methods to
promote stabilization of the condition in order to avoid
or delay corneal transplantation.2
1
Cornea Department, Center for Reference in Ophthalmology, Federal
University of Goiás,Goiânia (GO), Brazil
2
Cornea Department, Center for Excellence in Ophthalmology, Pará de
Minas, Brazil
3
Cornea Department, Paulo Ferrara Eye Clinic, Belo Horizonte, Brazil
4
Cornea Department, Brasilia Ophthalmological Hospital; Av. L2 Sul
SGAS 607 Módulo G, Brasilia 70.200-670, Brazil
Corresponding author:
Jordana Sandes Barbosa Soares, Bueno Medical Center Ophthamlmology,
Rua t-29, 358, sala 1012. 74210-050. Goiânia-GO-Brazil.
Email: jordana.oftalmo@gmail.com
2 European Journal of Ophthalmology 0(0)
Typically, the treatment for advanced keratoconus is
based on deep anterior lamellar keratoplasty or penetrating
keratoplasty. However, both options may be associated
with eventual intraoperative and postoperative complica-
tions, often severe.3 For this reason, safe therapeutic alter-
natives have been studied in an attempt to avoid or even
delay the need for corneal transplantation.4
The benefits of ICRS have been established in the litera-
ture for the treatment of keratoconus, with much less risk
involved, showing to be an effective and safe alternative
for the treatment of the condition.5–9 However, the intra-
corneal ring has been limited to eyes with Kmax
(maximum keratometry) values less than 58 D, as larger
curvatures could be associated with worse visual outcomes
and more complications, such as extrusion.10
Despite the existing studies on ring implants addressing
the outcomes of intracorneal ring implantation in advanced
keratoconus, these studies are limited to patients with
maximum curvatures lower than 60D.8,11,12 This is the
first study to show the results of the Ferrara ring of 320°
of arc (AJL, Vitoria, Spain) as an alternative therapy in
patients with advanced keratoconus, grade IV, with
Kmax > 60D, intolerant to contact lens, and with indication
for corneal transplantation.
Patients and methods
This prospective, interventional case series study evaluates
a total of 25 eyes of 19 patients with keratoconus stage IV,
according to the ABCD Keratoconus Staging ranking13
and Kmax > 60D, implanted with 320-ICRS. Uncorrected
distance visual acuity (UDVA), corrected distance visual
acuity (CDVA), keratometric values (mean - mean-K,
flat - K1, and steep - K2), maximum keratometry
(Kmax), tomographic astigmatism, refractive astigmatism
and asphericity (Q) were assessed preoperatively and at
the final follow-up visit 12 months after the procedure.
The survey was conducted, with the approval of the
ethical committee, in Ver Hospital de Olhos, Goiania,
Brazil. All research adhered to the tenets of the
Declaration of Helsinki and all patients gave their informed
consent prior to the study.
Preoperatively, all patients had corrected distance visual
acuity (CDVA) of 0.3 logMAR (20/40) or worse, and
inability to wear corneal or scleral contact lens, with previ-
ous indication of corneal transplantation. All patients
underwent surgery in October 2019, performed by the
same surgeon, using VisuMax® femtosecond laser.
Patients with central keratoconus, and thickness in ring
track > or equal to 400 microns were included in the
study. Patients with corneal opacities, those who had
undergone previous surgeries, patients with cataracts, stra-
bismus or any fundus condition that could damage the sur-
gical outcome were excluded.
The ring implanted was the ICRS Ferrara ring® (AJL,
Ophthalmics, Vitoria, Spain), with 320° of arc in a 5 mm
optical zone. In patients with a ring track thickness of
400 to 500 microns, 1 segment of 320/20 was implanted,
and in patients with a track thickness > 500 microns, 1
segment of 320/25 was implanted.
Examination protocol
Preoperative and postoperative evaluation included a com-
prehensive ophthalmologic examination with uncorrected
distance visual acuity (UDVA) and CDVA, spheric refrac-
tion, and manifest refractive astigmatism (MRA). Slip-
lamp examination, Goldmann tonometry, fundus examined
12 months action, corneal tomography (Pentacam, Oculus,
Optikgerate, Wetzlar, Germany).
The following corneal tomography data between pre-
operatively and 1, 3, 6, 9 a 12 months postoperatively
were evaluated: flat and steep corneal keratometry, dK
and respective axis, mean keratometry, maximum kerato-
metry and average corneal asphericity as 30 angle (Q 30).
Surgical techniques
All surgical procedures were performed under topical anes-
thesia with 2 anesthetic drops, 1 min before the procedure
of proxymetacaine hydrochloride 0,5% (Anestalcon,
Alcon Laboratories, Inc., Fort Worth, TX),. Incision and
stromal tunnel were both created by using a femtosecond
laser VisuMax® (Carl Zeiss Meditec, Oberkochen,
Germany). As it was a 320° arch ring, and all patients
had central nipple type keratoconus, we implanted all the
rings in the 90° axis. Laser parameters included: (1) inci-
sion placed at 90 degree in all patients, (2) incision and
tunnel depth of 70% of corneal thickness at the thinnest
point in the ring track, (3) inner diameter of 4.6 mm, (4)
outer diameter of 6.0 mm, (5) entry cut length of
1.2 mm, (6) entry cut thickness of 1 um, (7) ring energy
of 1.3 mJ, and (8) entry cut energy of 1.3 mJ.
After incision and tunnel creation, the ICRS was
inserted into the circular tunnel using an implantation
forceps. The postoperative regimen included moxifloxacin
0.5% and dexamethasone 0.1% eye drop (Vigadexa®,
Alcon Laboratories, Inc.) four times a day for 10 days
and topical lubrificant with Polyethylene Glycol 400
0.4% also four times a day (Systane UL®, Alcon
Laboratories, Inc.) No intraoperative complications
occurred.
Follow-up evaluation
Postoperative visits were schedule for 1 day, and 1,3,6,9
and 12 months. On the sixth postoperative month, the
Zenlens™ (Solótica) scleral contact lens test was per-
formed on all patients.
Soares et al.
Vector analysis
Vector analysis of MRA and dK changes between pre-
operatively and the final follow-up visit at 12 months
were performed using Alpins vector analysis.14
All vector calculations for the Alphins method were
performed using VECTrAK (version 2.4.6; ASSORT
Pty. Ltd., Cheltenham, Australia). The followings vectors
were determined and evaluated: Target induced astigma-
tism (TIA), which is the vector of the proposed change
in the cylinder for each treatment, surgically induced astig-
matism (SIA), which is the vector of the actual change
achieved.
The tomographic and refractive vector astigmatism
obtained with the implantation of intracorneal ring with
320° of arch in eyes with advanced keratoconus was ana-
lyzed. In view of that, representative graphs were gener-
ated. In this analytical process, the closer the points are
to the blue line, the greater the proximity to the target.
The points above the blue line represent eyes with overcor-
rection of astigmatism, while the points below the blue line
represent eyes with undercorrection of astigmatism. The
black line represents the trend line: the steeper it is, the
higher the correlation between surgical induced (SIA)
and target induced astigmatism (TIA).
Statistical analysis
Statistical analyses were performed supported by the stat-
istical package SPSS, version 26.0 (SPSS Inc, Chicago,
IL). The sample profile was characterized by absolute fre-
quency (n) and relative frequency (%) for categorical vari-
ables, as well as mean and standard deviation for
continuous variables. A P value of less than 0.05 was con-
sidered statistically significant.
Calculation of the sample size
Sample size was calculated for each variable assessed
using the software G.Power® 3.1 (Franz Faul,
Universitat Kiel, Germany). It found a minimum estimate
of 19 eyes (95% CI: 11 to 26) at a 5% significance level,
95% confidence interval and 99% sampling power to
detect statistically significant differences.
The parameter used in the calculation of the sample size
was the mean difference of all parameters presented in
Table 1, using the same G.Power® 3.1 method. In this
way, an ‘n’ was obtained for each parameter. Based on
the simple calculations of the confidence interval for
these ‘n’ samples, the minimum estimate with the lower
and upper limit was obtained. Therefore, it was demon-
strated that the ‘n’ sample estimate was adequate for all
parameters
Based on this, the mean difference and standard devi-
ation of the preoperative and postoperative periods were
3
verified, and the mean difference of all other parameters
reviewed were used together for the sample estimate.
Based on these parameters, the more significant the differ-
ence between the pre and postoperative periods, the
smaller the “n” needed to achieve a 99% sample power.
Since the “p” value was highly significant between the pre
and postoperative analysis, the “n” needed to achieve a
95% sample power, considering this significance level of
5% and confidence interval of 99%, was 19 eyes.
Safety and efficacy criteria of the proposed
treatment
One criterion to evaluate the safety of the treatment was the
mean postoperative CDVA higher than the mean preopera-
tive CDVA. Another criterion was based on observed loss
of more than one line of sight in the corrected visual acuity
at the end of the follow-up. The procedure would be con-
sidered safe if less than 10% of the patients lost more than
one line of sight. An additional safety criterion considered
was the rate of complications: if there were less than 10%
of complications inherent to the surgery, the procedure
would be considered safe.
The mean postoperative UDVA higher than the mean
preoperative CDVA was the criteria to examine the effect-
iveness of the proposed treatment. It was considered the
distribution of corrected distance visual acuity, comparing
pre- and post-operative - here, vision corrected with glasses
was another parameter of treatment efficacy. Surgery
would be considered effective in this regard if the majority
of patients reached a visual acuity corrected with glasses
better than or equal to 20/40.
Another parameter considered to evaluate treatment
efficacy was the number of patients who had their VA
restored with the use of scleral contact lens after
320-ICRS implantation. The procedure would be consid-
ered effective if the majority achieved VA wearing lens
better than or equal to 20/25.
Results
A Total of 25 eyes of 19 patients were included. The mean
age was 22.8 ± 7.9 years (range: 15 to 31 years). In 19 eyes
was implanted a 320/200 ring and in 6 eyes was implanted a
320/250 ring. One eye was excluded of the analysis because
we had to explant the ring after 15 postoperative days.
The table below discloses the pre and postoperative
values of the main variables analyzes, showing the preopera-
tive progress on the 12th postoperative month (Table 1).
Spherical equivalent
Figure 1 Shows the stability of SE refraction between pre-
operative and postoperative intervals
4 European Journal of Ophthalmology 0(0)

Table 1. Visual acuity, refraction and tomography outcomes

Postoperative (month)

Preoperative 1 3 6 12 z p*

CDVA (logMAR) 0.63 ± 0.29 0.45 ± 0.18 0.36 ± 0.24 0.33 ± 0.19 0.31 ± 0.16 14.93 0.004
UDVA (logMAR) 1.03 ± 0.28 0.75 ± 0.32 0.63 ± 0.28 0.64 ± 0.24 0.54 ± 0.21 28.50 <0.001
Spheric (D) −9.52 ± 4.62 −6.60 ± 4.27 −5.49 ± 4.28 −5.05 ± 3.66 −5.13 ± 3.53 12.51 0.018
K1 (D) 54.41 ± 4.46 49.93 ± 3.93 48.90 ± 3.97 48.89 ± 4.13 49.36 ± 4.11 43.88 <0.001
K2 (D) 61.15 ± 4.37 54.92 ± 3.66 53.88 ± 3.49 54.09 ± 4.20 53.75 ± 4.05 39.04 <0.001
mean-K (D) 57.55 ± 4.17 52.27 ± 3.57 51.24 ± 3.55 51.40 ± 3.80 51.44 ± 3.94 44.09 <0.001
Kmax (D) 69.80 ± 8.20 66.48 ± 7.03 64.77 ± 5.21 63.90 ± 6.48 63.43 ± 6.31 22.58 <0.001
Q 30 degree −1.57 ± 0.35 −0.78 ± 0.44 −0.92 ± 0.47 −0.80 ± 0.52 −0.77 ± 0.56 31.67 <0.001
A (mm) 3.97 ± 0.16 3.22 ± 0.89 2.97 ± 0.91 3.03 ± 1.06 2.85 ± 1.19 30.47 <0.001
B (mm) 3.98 ± 0.12 3.93 ± 0.24 3.88 ± 0.27 3.88 ± 0.35 3.88 ± 0.35 6.93 0.131
C (mm) 2.87 ± 0.58 2.73 ± 0.64 2.72 ± 0.66 2.81 ± 0.63 2.79 ± 0.72 27.98 <0.001
* Friedman’s ANOVA test.
UDVA: Uncorrected distance visual acuity; CDVA: Corrected distance visual acuity; K1: Flat Keratometry; K2: Steep keratometry; Km: mean keratometry;
Kmax: maximum keratometry; Q 30 degree: average asphericity at 30-degree angle.

Figure 1. Stability of spherical equivalent refraction during

postoperative intervals. Figure 2. Target induced astigmatism (TIA) vs. surgically
induced astigmatism (SIA) with implantation of the 320-degree
arc intracorneal ring in eyes with advanced keratoconus.

Vector astigmatism Safety, treatment failure, and complications. Among the 25

Vector analysis of corneal astigmatism changes. Figure 2
illustrates the relationship of the target induced astigma-
tism (TIA); surgically induced astigmatism(SIA). The cor-
rection index is the ratio SIA / TIA. The correction index is
preferably 1.00; it is higher than 1.00 if an overcorrection
occurs and less than 1.00 if there is an undercorrection. In
this case the correction index was 0.53, meaning an under-
correction of the tomographic astigmatism.
Figure 3 discloses the distribution of tomographic
vector astigmatism before and after the implantation of
intracorneal ring with 320 degrees of arch in eyes with
advanced keratoconus.
eyes evaluated, one (1) eye lost two lines of sight
(4.5%), one (1) eye lost one line of sight (5%), three (3)
eyes maintained the same visual acuity (14%), two (2)
eyes gained two lines of sight (9%), and 18 eyes gained
three (3) or more lines of sight (68%).
One of the safety criteria was the mean postoperative
CDVA greater than the mean preoperative CDVA. The
mean postoperative CDVA was 20/40 (0.31 ± 0.16
LogMAR), better than the mean preoperative CDVA (20/80
or 0.63 ± 0.29 LogMAR).
The procedure was considered safe, in that 9.5% of
patients lost one or more lines of sight (<10%) and only
Soares et al. 5

Figure 3. Distribution of tomographic astigmatism before and

after implantation of intracorneal ring with 320 degrees of arch. Figure 4. Safety graph illustrating the changes in the snellen
lines according to corrected distance visual acuity after 12
months postoperatively.

4% of patients undergoing ring implantation with 320

degree of arch (one patient) had a complication inherent
to the procedure (Figure 4). No intraoperative complica-
tions were observed. One patient’s eye developed an infec-
tious stromal infiltrate on the ring track day 7 of the
postoperative period, and was prescribed with Vigamox
antibiotic eye drops every two hours. However, as the
patient had no improvement, the therapy was changed to
fortified antibiotic eye drops (ceftazidime and gentamicin)
and, as there was no improvement either, it was necessary
to explant the ring. There was no sequel. No cases of ring
extrusion, perforation or migration were observed.

Treatment efficacy
Figure 5 illustrates the distribution of the percentage of
patients with corrected distance visual acuity in preopera-
tive and the postoperative uncorrected distance visual
acuity. Postoperatively, 70% of the patients had corrected
distance visual acuity better than or equal to 20/40
(Figure 6). All patients underwent scleral contact lens
testing six months after surgery. Figure 7 shows that
80.9% of patients had visual acuity better than or equal
to 20/25 after 12 months of the scleral contact lens
surgery. The mean postoperative UDVA was 20/60
(0.54 ± 0.21 LogMAR), higher than the mean preoperative
CDVA which was 20/80 (0.63 ± 0.29 LogMAR). All these
points confirm the efficacy of the proposed treatment.
Discussion
Corneal transplantation has been considered to be the best
option of treatment for visual rehabilitation in patients with
advanced keratoconus.15,16 large sample cohort studies
Figure 5. Effectiveness of intracorneal ring implantation surgery
illustrating the percentage distribution of postoperative
uncorrected distance visual acuity (UDVA) and preoperative
corrected distance visual acuity (CDVA).
shows that the rate of need of graft procedure in keratoco-
nus patients can vay from 12 to 21.6%.17,18 However,
visual rehabilitation in transplant patients can be slow
and unsatisfactory, especially due to high post-transplant
astigmatism, corneal irregularity, anisometropia, and risk
of rejection.19
Many studies adopted as exclusion criteria for intracor-
neal ring implantation, patients with corneal curvatures
greater than 60D, showing low effectiveness for the treat-
ment of more advanced cases of the condition.10,20 Other
studies have shown high rate of complications, such as per-
sistent epithelial defects, anterior and posterior corneal
6 European Journal of Ophthalmology 0(0)
Figure 6. Percentage distribution of patients according to the visual acuity achieved postoperatively wearing glasses (CDVA)
comparing pre- and post-surgery.
Figure 7. Percentage distribution of patients according to the
visual acuity achieved postoperatively wearing contact t lens
(CDVA).
perforations, extension of the incision to the visual axis,
superficialization and extrusion of the ring.21,22
The progress of intracorneal ring implantation surgery
resulting from the advent of the femtosecond laser has con-
siderably changed this scenario, making the surgery safe
and efficient even in very advanced cases. In the current
study, in which rings were also implanted with the aid of
the femtosecond laser, there was no extrusion. This sup-
ports the descriptions that laser-assisted intracorneal ring
implantation is more predictable and safer. Another
factor that has contributed to this new scenery is the
advent of new designs of corneal ring segments, such as
long-arch rings with smaller diameters capable of flatten-
ing the cornea in a more significant way, thus proving to
be more suitable for more advanced cases.23,24 Previous
studies on intracorneal ring implantation in advanced ker-
atoconus did not include eyes with keratometry greater
than 65 D.11,12,24,25 This is an important differential in
this study, since one of the inclusion criteria was Kmax
greater than 60 D (ranging from 60 D to 87.4 D). Thus,
it allowed assessing the behavior of the intracorneal ring
in eyes with such high keratometry for the very first time.
The rate of complications in the present study was low
(only one case) and no case of extrusion or superficializa-
tion of the ring was observed. This is a frequent concern in
extreme cases, and proved this is a safe procedure. The
current study allowed us to observe that in central kerato-
conus with extreme curvatures (Kmax 83D), the major
thinning was located outside the ring track. Therefore, all
eyes included had a thickness greater than 400 microns
in the track, making the ICRS implantation safe.
A previous study compared visual and refractive out-
comes in eyes with advanced keratoconus that underwent
deep anterior lamellar keratoplasty (DALK) with those
undergoing intracorneal ring implantation. The results
Soares et al.
showed statistically significant visual improvement in both
groups, with greater gain in vision in the DALK group.
However, although DALK involves lower risks of rejec-
tion compared to penetrating transplantation, intracorneal
ring surgery has been suggested as an alternative treatment
with satisfactory results, considering the greater ease of
ring implantation technique, associated with fast post-
operative recovery and low complication rates involved
when compared to transplantation. All these suggest it is
a good alternative prior to transplantation.25
A recent study comparing different treatment
approaches for advanced keratoconus also considers that,
although in some aspects DALK shows more satisfactory
results than intracorneal ring implantation, patients
should go through each stage of treatment, respecting the
proper indications and observing potential complications
inherent to each procedure. According to Rocha et al,
14.28% of patients who underwent DALK presented post-
operative complications, and 17.86% were unable to wear
contact lenses to complement visual improvement. On the
other hand, no complication was observed in the group that
had the ring implant.26 Only one case of complication was
observed in this study; 70% of patients achieved corrected
distance visual acuity better than or equal to 20/40 (0.3
logMAR), and 80% of patients achieved visual acuity
better than or equal to 20/25 (0.1 logMAR) with the use
of scleral contact lenses, reporting comfort with use.
It is worth mentioning that the intracorneal ring implant-
ation, especially in advanced cases, is not a refractive pro-
cedure, since the main objective is not to reach the best
uncorrected distance visual acuity, but to reestablish the
patient’s corrected vision, wearing either glasses or
contact lenses.27
A study that evaluated the results of INTACS in
advanced keratoconus defined the procedure as effective
when most patients achieved a CDVA better than or
equal to 20/40 (0.3 logMAR). Another parameter used as
a criterion of effectiveness would be the mean post-
operative uncorrected distance vision better than the
mean preoperative corrected distance vision.11 Although
criterion is more valuable for refractive procedures, since
the ring surgery does not aim at obtaining good uncor-
rected distance visual acuity, observing the results found
in this present study, most patients (70%) reached CDVA
wearing glasses better than or equal to 20/40, and the
average preoperative CDVA was 0.63 logMAR (20/80),
worse than the average UDVA postoperatively that was
0.54 logMAR (20/60).
According to the safety criteria proposed by this study,
intracorneal ring implantation would be considered safe if
the mean postoperative CDVA was greater than the mean
preoperative CDVA, if the loss of lines of sight was less
than 10%, and if complication rate was below 10%. The
results show that mean pre-op CDVA was 0.6 logMAR
(20/80) and the post-op CDVA was 0.31 logMAR (20/40),
7
only 9.5% of patients lost lines of sight, and the complication
rate was only 4% (1 case). Therefore, we can consider the
procedure safe.
This study showed that patients with keratoconus in
advanced stages may benefit from the intracorneal ring
implantation, which proved to be an effective and suggests
to be a safe technique with low risks of complications.
Therefore, considering its feasibility, it should be a proced-
ure to be considered before indicating corneal
transplantation.
Higher keratometric values alone, announced as predic-
tors of unsatisfactory results, are not limiting factors for the
indication of intracorneal ring implantation.
One of the limitations of the present study was the
absence of a control group of patients submitted to
corneal transplantation, both lamellar and penetrating, a
treatment traditionally recommended for cases of advanced
keratoconus, to allow a comparison with the results of the
intracorneal ring implantation with 320° of arch for
advanced keratoconus. Since this was a preliminary case
series study, will be needed studies with larger sample
sizes and longer follow up time to support the results dis-
closed in the present study.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: Drs.
P. Ferrara, G. Ferrara, have a financial interest in the Ferrara
intrastromal cornea ring. The remaining authors have no financial
or proprietary interest in the materials presented herein.
ORCID iD
Jordana Sandes Barbosa Soares https://orcid.org/0000-0001-
6990-9798
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