Epithelial Photorefractive Keratectomy and Corneal Cross-linking for Keratoconus: The Tel-Aviv Protocol.

PURPOSE To present the Tel-Aviv Protocol for patients with progressive keratoconus, which consists of epithelial photorefractive keratectomy (ePRK), and corneal cross-linking (CXL). METHODS This was a retrospective case series of 20 consecutive patients diagnosed as having progressive keratoconus at Care-Vision Laser Centers, Tel Aviv, Israel. The Tel-Aviv Protocol included laser epithelial ablation using the EX500 excimer laser (Alcon Laboratories, Inc., Fort Worth, TX) with 50% of the manifest refractive astigmatism (on the same axis) while the spherical ablation is added so as not to exceed a total of 50-µm ablation of the epithelium and anterior stroma. Afterward, all patients underwent CXL. Data collected included thinnest corneal thickness (TCT), subjective astigmatism, mean keratometric power, maximum keratometric power (Kmax), uncorrected distance visual acuity (UDVA), and corrected distance visual acuity (CDVA). RESULTS A total of 20 eyes of 20 patients with a mean age of 28.0 ± 6.5 years (range: 13 to 40 years) and a mean follow-up of 823 ± 337 days (range: 266 to 1,749 days) were included. There was a significant improvement in both UDVA (from 0.95 ± 0.73 to 0.22 ± 0.15 logMAR, P < .001) and CDVA (from 0.24 ± 0.13 to 0.13 ± 0.12 logMAR, P < .001) at the end of the follow-up period. There was a significant improvement in mean keratometry (from 46.86 ± 2.48 to 45.00 ± 2.27 diopters [D], P < .001), Kmax (from 48.18 ± 2.74 to 45.97 ± 2.55 D, P < .001), and Kmin (from 45.54 ± 2.35 to 44.03 ± 2.12 D, P < .001). TCT was significantly lower following the procedure (from 450.90 ± 35.99 to 404.90 ± 43.96 µm, P < .001). No complications and no progression in keratoconus severity were noticed during the follow-up period. CONCLUSIONS The Tel-Aviv Protocol for patients with progressive keratoconus provides good improvement in visual acuity and astigmatism while halting the progression of keratoconus. [J Refract Surg. 2019;35(6):377-382.].

[1]  M. Tsilimbaris,et al.  Combined transepithelial phototherapeutic keratectomy and conventional photorefractive keratectomy followed simultaneously by corneal crosslinking for keratoconus: Cretan protocol plus. , 2017, Journal of cataract and refractive surgery.

[2]  S. Zarei‐Ghanavati,et al.  Evaluation of Changes in Visual Acuity, Contrast Sensitivity and Aberrations in Patients with Keratoconus after Corneal Collagen Cross-linking , 2017, Journal of ophthalmic & vision research.

[3]  T. Koller,et al.  Customized Corneal Cross-linking: One-Year Results. , 2016, American journal of ophthalmology.

[4]  Y. Mostafa,et al.  One-Year Results of Simultaneous Topography-Guided Photorefractive Keratectomy and Corneal Collagen Cross-Linking in Keratoconus Utilizing a Modern Ablation Software , 2015, Journal of ophthalmology.

[5]  T. Sherwin,et al.  Keratoconus: an inflammatory disorder? , 2015, Eye.

[6]  Jingjing Li,et al.  Efficacy of Corneal Collagen Cross-Linking for Treatment of Keratoconus: A Meta-Analysis of Randomized Controlled Trials , 2015, PloS one.

[7]  G. Kymionis,et al.  Long‐term results of combined transepithelial phototherapeutic keratectomy and corneal collagen crosslinking for keratoconus: Cretan protocol , 2014, Journal of cataract and refractive surgery.

[8]  G. Snibson,et al.  A randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: three-year results. , 2014, Ophthalmology.

[9]  A. van der Lelij,et al.  A multivariate analysis and statistical model for predicting visual acuity and keratometry one year after cross-linking for keratoconus. , 2014, American journal of ophthalmology.

[10]  A. Fotouhi,et al.  Corneal collagen cross-linking with riboflavin and ultraviolet a irradiation for keratoconus: long-term results. , 2013, Ophthalmology.

[11]  Jeremy Wernli,et al.  The efficacy of corneal cross-linking shows a sudden decrease with very high intensity UV light and short treatment time. , 2013, Investigative ophthalmology & visual science.

[12]  G. Alessio,et al.  Photorefractive keratectomy followed by cross-linking versus cross-linking alone for management of progressive keratoconus: two-year follow-up. , 2013, American journal of ophthalmology.

[13]  S. Panagopoulou,et al.  Combined transepithelial phototherapeutic keratectomy and corneal collagen cross-linking for progressive keratoconus. , 2012, Ophthalmology.

[14]  S. Greenstein,et al.  Patient subjective visual function after corneal collagen crosslinking for keratoconus and corneal ectasia , 2012, Journal of cataract and refractive surgery.

[15]  Michael Mrochen,et al.  Equivalence of biomechanical changes induced by rapid and standard corneal cross-linking, using riboflavin and ultraviolet radiation. , 2011, Investigative ophthalmology & visual science.

[16]  D. O’Brart,et al.  A randomised, prospective study to investigate the efficacy of riboflavin/ultraviolet A (370 nm) corneal collagen cross-linkage to halt the progression of keratoconus , 2011, British Journal of Ophthalmology.

[17]  Peter S. Hersh,et al.  Natural history of corneal haze after collagen crosslinking for keratoconus and corneal ectasia: Scheimpflug and biomicroscopic analysis , 2010, Journal of cataract and refractive surgery.

[18]  C. McGhee.  2008 Sir Norman McAlister Gregg Lecture: 150 years of practical observations on the conical cornea – what have we learned? , 2009, Clinical & experimental ophthalmology.

[19]  K. Zadnik,et al.  Between-Eye Asymmetry in Keratoconus , 2002, Cornea.

[20]  E. Spoerl,et al.  Induction of cross-links in corneal tissue. , 1998, Experimental eye research.

[21]  W. M. Bourne,et al.  A 48-year clinical and epidemiologic study of keratoconus. , 1986, American journal of ophthalmology.