Conservative Management of Intrastromal Corneal Ring Segment Extrusion Using Suture-Assisted Repositioning: A Case Series

Introduction

Intrastromal Corneal Ring Segment (ICRS) are an established surgical option for the management of corneal ectatic disorders, particularly keratoconus, where they improve corneal regularity, reduce refractive error, and delay or obviate the need for keratoplasty.¹ Despite their overall safety profile, ICRS implantation is associated with a spectrum of postoperative complications, among which segment extrusion remains one of the most visually and structurally significant.^2–4

ICRS extrusion typically results from a combination of biomechanical instability, progressive stromal thinning, superficial tunnel placement, and chronic epithelial breakdown overlying the segment.^5,6 Once exposure occurs, the compromised epithelial barrier increases the risk of infection, stromal melting, and irreversible corneal damage.⁷ Consequently, ICRS explantation is frequently recommended as the definitive management strategy, particularly in cases of recurrent exposure or failed conservative therapy.

However, removal of an ICRS may lead to loss of the corneal reshaping effect, progression of ectasia, and deterioration in visual function, especially in eyes that have limited remaining therapeutic options.⁶ In such cases, the decision to explant the segment represents a trade-off between preventing sight-threatening complications and preserving corneal biomechanics. While conservative measures such as bandage contact lens use, topical antibiotics and corticosteroids, and manual repositioning are commonly attempted, these strategies often provide only temporary epithelial healing, with a high risk of recurrent re-exposure.

Despite the clinical relevance of this dilemma, there is a paucity of literature describing structured, reproducible conservative surgical approaches aimed at salvaging extruding ICRS without resorting to explantation. Previous reports have largely focused on segment removal, tunnel revision, or subsequent keratoplasty, with limited emphasis on techniques that mechanically stabilize the overlying corneal tissue to promote durable epithelial healing while maintaining the segment in situ.^8–11

In this context, suture-assisted repositioning of extruding ICRS represents a logical yet underreported strategy. By providing localized mechanical support to the area of epithelial breakdown and stabilizing the repositioned segment within its original stromal tunnel, suturing may facilitate sustained epithelial closure and prevent recurrent extrusion, thereby preserving the intended biomechanical and refractive benefits of the ICRS.

The purpose of this study is to describe a conservative surgical technique of suture-assisted ICRS repositioning and to report clinical outcomes in a small case series. Unlike previously described approaches — which have largely focused on segment removal, tunnel revision, or keratoplasty — the technique presented here offers a structured, reproducible method of mechanically stabilizing the extruding segment in situ using anterior stromal suturing. This approach aims to offer an alternative to explantation in carefully selected patients, expanding the therapeutic armamentarium for the management of ICRS extrusion and addressing a gap in the current literature regarding conservative surgical salvage options.

The mechanism of focal ICRS exposure and the key steps of the suture-assisted repositioning technique are summarized in Figure 1.

Figure 1 Schematic illustration of focal Intrastromal Corneal Ring Segment (ICRS) exposure and the suture-assisted repositioning technique. (A) Focal ICRS exposure overlying the femtosecond-created stromal tunnel. (B) Interrupted 10–0 nylon supportive anterior stromal suture placed at anterior–mid stromal depth approximately 1–2 mm from the segment edge to re-bury the ICRS and support epithelial closure.

Results

Patient Characteristics

Two eyes of two patients with keratoconus who developed recurrent ICRS extrusion despite conservative management were included. In both cases, extrusion occurred in the absence of active infection or corneal melting. Prior to suture-assisted repositioning, multiple conservative measures—including bandage contact lens use, topical antibiotic and corticosteroid therapy, and manual repositioning of the ICRS—had failed to prevent recurrent exposure.

Baseline patient and segment characteristics are summarized in Table 1.

Table 1 Baseline Patient and Intrastromal Corneal Ring Segment Characteristics

Clinical Course and Epithelial Healing

Following suture-assisted repositioning, complete epithelial closure was achieved in both cases. No further episodes of segment re-exposure were observed during the follow-up period. Bandage contact lenses were maintained until stable epithelial healing was confirmed and exchanged at regular intervals.

In Case 1, epithelial stability was achieved and maintained with a single interrupted suture. The suture was retained for approximately 5–6 months and removed after sustained epithelial integrity was documented.

In Case 2, due to greater biomechanical instability and recurrent prior exposure, two vertically stacked interrupted 10–0 nylon sutures (Sharpoint™, Ref A9003N; Surgical Specialties Corporation) were required. The immediate postoperative slit-lamp appearance in Case 2, with the supportive sutures in situ and the ICRS re-buried, is shown in Figure 2. One suture was removed earlier, while the final suture was removed at approximately 5 months following placement. After suture removal, slit-lamp examination in Case 2 confirmed stable epithelial closure with the segment retained in situ (Figure 3). Clinical course, epithelial healing, postoperative management, and complications are summarized in Table 2.

Table 2 Clinical Outcomes Following Suture-Assisted ICRS Repositioning

Figure 2 Postoperative slit-lamp photograph immediately after suture-assisted (ICRS = Intrastromal Corneal Ring Segment) repositioning, showing the interrupted 10–0 nylon supportive anterior stromal suture with the segment re-buried within the stromal tunnel.

Figure 3 Slit-lamp photograph after suture removal, demonstrating stable epithelial closure with the intracorneal ring segment retained in situ and no recurrent exposure.

Visual and Topographic Outcomes

Throughout follow-up, visual acuity and corneal topography remained stable in both cases, with preservation of the corneal reshaping effect achieved by the ICRS. No clinically significant deterioration in uncorrected or corrected distance visual acuity was observed following suturing or after suture removal.

Corneal topographic parameters, where available, demonstrated no progression of ectasia following the procedure. The ICRS remained well positioned within the original stromal tunnel, without migration or re-extrusion. Visual acuity and corneal tomographic parameters before and after intervention are summarized in Table 3.

Table 3 Visual and Corneal Parameters Before and After Suture-Assisted Repositioning

Complications

No intraoperative complications occurred. During the postoperative period, no cases of infectious keratitis, stromal melting, endothelial compromise, or significant inflammatory reaction were observed. Both eyes tolerated prolonged suture retention without adverse events.

A summary of clinical outcomes and follow-up duration is provided in Table 2.

Discussion

ICRS extrusion remains one of the most challenging complications following implantation, often forcing clinicians to choose between repeated conservative measures with limited durability and definitive explantation with potential loss of biomechanical and refractive benefit.⁷ In this case series, suture-assisted repositioning provided sustained epithelial stability and successful retention of the ICRS without progression to infection, stromal melting, or keratoplasty, suggesting that this approach may represent a viable conservative surgical alternative in carefully selected cases.

Clinical Rationale and Mechanism

The pathogenesis of ICRS extrusion is multifactorial, involving progressive stromal thinning, localized biomechanical stress, superficial tunnel positioning, and chronic epithelial breakdown. Once exposure occurs, epithelial instability perpetuates a cycle of inflammation and mechanical trauma, predisposing to recurrent re-extrusion despite temporary healing with bandage contact lenses or topical therapy. While manual repositioning of the segment can restore its position transiently, lack of mechanical stabilization of the overlying corneal tissue often results in recurrence.

Suture-assisted repositioning addresses this limitation by providing localized mechanical support over the area of maximal vulnerability, effectively redistributing stress away from the segment edge and allowing sustained epithelial closure. By anchoring the corneal tissue anterior to the repositioned ICRS, suturing promotes epithelial healing while preserving the segment within its original stromal tunnel, thereby maintaining the intended corneal reshaping effect.

Comparison with Existing Management Strategies

Traditional management of ICRS extrusion has favored explantation, particularly in cases of recurrent exposure or failed conservative therapy.^1,6 Although explantation reliably eliminates the risk of infection, it may precipitate loss of refractive benefit, ectatic progression, and the need for subsequent keratoplasty, especially in advanced keratoconus.⁹ Alternative strategies described in the literature—including tunnel revision, segment exchange, or lamellar grafting—are more invasive and not universally applicable.^7,12

In contrast, the technique described in this series represents a minimally invasive, reversible, and tissue-sparing approach. Importantly, suturing does not preclude future explantation or keratoplasty if required, but rather serves as an intermediary step aimed at salvaging the segment in the absence of infection or melt.

Clinical Decision-Making Framework

Based on our experience, suture-assisted repositioning may be most appropriate in eyes with recurrent ICRS exposure despite conservative management, where the stromal tunnel remains intact and no active infection or corneal melting is present. Conversely, eyes with active keratitis, progressive stromal thinning, or impending perforation should proceed directly to explantation.² The number of sutures required should be individualized, with greater biomechanical instability or recurrent exposure favoring multiple anchoring points to improve load distribution.

Safety Considerations

A potential concern with this approach is prolonged suture retention in a compromised cornea. However, in both cases presented, sutures were well tolerated over several months without evidence of infection, inflammation, or endothelial compromise. Careful placement of anterior to mid-stromal sutures, avoidance of deep stromal penetration, and meticulous postoperative management are essential to minimizing risk. In both cases, strict sterile surgical technique was observed throughout the procedure. Postoperatively, patients received topical fluoroquinolone antibiotics for a minimum of four weeks and were monitored closely for early signs of infectious keratitis or stromal melt. Bandage contact lenses were exchanged at regular intervals under aseptic conditions to reduce the risk of microbial colonization. Patients were educated regarding the signs of infection — including increased redness, pain, or discharge — and instructed to present immediately for evaluation if any such symptoms developed. These combined measures likely contributed to the absence of infectious or inflammatory complications in this series.

Limitations

The primary limitations of this study include its small sample size and retrospective nature. Quantitative topographic and biomechanical data were limited, and longer-term follow-up is necessary to determine the durability of this technique over years rather than months. Anterior segment optical coherence tomography (AS-OCT) imaging before and after the procedure was not performed in these cases; future reports should include AS-OCT documentation to provide additional objective evidence of stromal tunnel integrity and suture positioning. Additionally, this approach may not be applicable to all cases of ICRS extrusion, particularly those associated with advanced ectasia or active inflammatory disease.

Conclusions and Clinical Implications

Suture-assisted repositioning of extruding ICRS offers a conservative surgical option that may preserve corneal integrity and refractive benefit while avoiding immediate explantation. In carefully selected patients, this technique can expand the management spectrum of ICRS extrusion and may delay or obviate the need for more invasive interventions.