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Management of progressive keratoconus with partial topography-guided PRK combined with refractive, customized CXL – a novel technique: the enhanced Athens protocol

Authors Kanellopoulos AJ

Received 24 September 2018

Accepted for publication 19 December 2018

Published 2 April 2019 Volume 2019:13 Pages 581—588


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Scott Fraser

Video abstract presented by Kanellopoulos AJ.

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Anastasios John Kanellopoulos1,2

1Department of Ophthalmology, LaserVision Clinical and Research Institute, Athens, Greece; 2Department of Ophthalmology, NYU Medical School, New York, NY, USA

Purpose: To report a novel application of partial topography-guided photorefractive keratectomy combined with topographically customized, higher fluence, and variable pattern corneal cross-linking applied on the same day of the treatment of keratoconus.
Methods: A topography-guided partial photorefractive keratectomy treatment of maximum 30 mm over the thinnest cone area was applied initially followed by a 7 mm, 50 mm phototherapeutic keratectomy treatment to address epithelial removal. 0.02% Mitomycin C was applied for 20 seconds and then the exposed stroma was soaked with 0.1% riboflavin solution for 5 minutes. The cornea was then treated with a customized, variable-pattern and 20 mW/cm2 fluence for a total of 5–10 J, and up to 15 J of energy was delivered with the KXL-II device employing an active tracker. The center of the pattern that received the 15 J was topography-matched with the thinnest area of the cone. Visual acuity, refractive error, cornea clarity, keratometry, topography, pachymetry with a multitude of modalities and endothelial cell density were evaluated over 36 months.
Results: Keratoconus was stabilized in all cases. The severity of keratoconus stage by Amsler–Krumeich criteria improved from an average of 3.2 (1–4) to 1.8 (0–3). Uncorrected distance visual acuity changed from preoperative 20/80 to 20/25 at 6 months. A maximum astigmatic reduction of 7.8 D (5.3–15.6), and a significant cornea surface normalization (an index of height decentration improvement from 0.155 [±0.065] to 0.045 [±0.042]) were achieved by 1 month and remained relatively stable for 36 months postoperatively. Two cases delayed full reepithelialization for up to 9 days.
Conclusion: This paper introduces a novel technique in order to maximize the refractive normalization effect along with ectasia stabilization in young keratoconus patients. This may facilitate the use of less tissue ablation, in comparison to utilizing a homogeneous UV light beam for corneal cross-linking in Athens Protocol cases. It broadens the number of potential candidate cases that would have been limited to employ this technique due to tissue thickness limitations.

Keywords: corneal ectasia, corneal irregularity-normalization, therapeutic excimer ablation

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