Abstract
Customized cross-linking has been proposed as an alternative to conventional cross-linking in patients with progressive keratoconus, targeting greater flattening of the cone region and improved visual function. Epithelium-on cross-linking aims to reduce complications associated with epithelial removal, while the addition of oxygen aims to maintain treatment effect. Our study evaluates the combination of these novel treatment strategies to achieve a minimally invasive treatment targeting maximal functional outcomes. This prospective study included 42 eyes undergoing epithelium-on, accelerated, oxygen-supplemented, customized corneal cross-linking for progressive keratoconus. Outcome measures, including refraction, visual acuity, and corneal tomography were obtained at baseline and at 1, 3, and 6 months, and 1 year postoperatively. Logarithm of the minimum angle of resolution (logMAR) uncorrected visual acuity was significantly improved, from 0.87 ± 0.53 preoperatively, to 0.78 ± 0.56 1 year postoperatively (Wilcoxon rank sum test, p = 0.016). LogMAR best spectacle-corrected visual acuity was also significantly improved, from 0.19 ± 0.36 preoperatively, to 0.11 ± 0.33 postoperatively (p = 0.004). Manifest refractive cylinder was significantly decreased, from 4.50 ± 2.96 D preoperatively, to 3.27 ± 2.61 D postoperatively (p = 0.004). The baseline maximum keratometry (Kmax) was 53.04 ± 7.91 D, significantly flattening to 52.25 ± 7.31 D by 1 month, and remaining relatively stable at 1 year postoperatively (52.31 ± 7.50 D) (p < 0.001). No significant adverse events occurred in any eye. Epithelium-on, accelerated, oxygen-supplemented, customized corneal cross-linking is a promising new treatment approach, with reduced maximum keratometry, reduced astigmatism, and improved visual acuity at 1 year, with a favorable safety and patient comfort profile.
Highlights
Keratoconus is a bilateral corneal ectasia that results in progressive localized corneal thinning and steepening
In the conventional epithelium-off CXL treatment protocol, the central epithelium is debrided, riboflavin photosensitizer eye drops are applied to the exposed corneal stroma until riboflavin flare is observed in the anterior chamber, and the corneal surface is uniformly irradiated with a 9-mm circular beam of Ultraviolet A (UVA) [2]
Progression of keratoconus was defined as a ≥1.00 D increase in the maximum anterior curvature on corneal topography, or worsened corrected visual acuity accompanied by a ≥1.00 D increase in astigmatism confirmed in 2 or more examinations over the previous 12 months
Summary
Keratoconus is a bilateral corneal ectasia that results in progressive localized corneal thinning and steepening. In the conventional epithelium-off (epi-off) CXL treatment protocol, the central epithelium is debrided, riboflavin photosensitizer eye drops are applied to the exposed corneal stroma until riboflavin flare is observed in the anterior chamber, and the corneal surface is uniformly irradiated with a 9-mm circular beam of Ultraviolet A (UVA) [2]. Customized cross-linking treatment protocols have been introduced to harness this flattening effect to reduce corneal irregularity and improve visual function [5]. Several controlled clinical studies have demonstrated greater corneal regularization in eyes treated with epi-off customized cross-linking as compared to conventional broad beam CXL, with greater flattening in the areas of steepest corneal curvature, compensatory steepening in the untreated surrounding cornea, and resultant gains in visual function [9,10,11]
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