Visual rehabilitation in moderate keratoconus: combined corneal wavefront-guided transepithelial photorefractive keratectomy and high-fluence accelerated corneal collagen cross-linking after intracorneal ring segment implantation

Hun Lee, David Sung Yong Kang, Byoung Jin Ha, Jin Young Choi, Eung Kweon Kim, Kyoung Yul Seo, Tae-Im Kim, Hun Lee, David Sung Yong Kang, Byoung Jin Ha, Jin Young Choi, Eung Kweon Kim, Kyoung Yul Seo, Tae-Im Kim

Abstract

Background: To investigate the effects of combined corneal wavefront-guided transepithelial photorefractive keratectomy (tPRK) and accelerated corneal collagen cross-linking (CXL) after intracorneal ring segment (ICRS) implantation in patients with moderate keratoconus.

Methods: Medical records of 23 eyes of 23 patients undergoing combined tPRK and CXL after ICRS implantation were retrospectively analyzed. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), corneal indices based on Scheimpflug tomography, higher-order aberrations (HOAs), and corneal biomechanical properties were evaluated before and after ICRS implantation, and at 1, 3, and 6 months after combined tPRK and CXL.

Results: There were significant improvements in final logMAR UDVA and logMAR CDVA, and reductions in sphere, MRSE, and all corneal indices from baseline. Significant improvements in logMAR UDVA and reductions in sphere, MRSE, maximal keratometry, keratometry at the apex, mean keratometry, and keratoconus index were noted after ICRS implantation. After tPRK and CXL, significant improvements in logMAR UDVA and logMAR CDVA, and reductions in cylinder and all corneal indices were observed. There were significant improvements in final root mean square HOAs and coma aberrations from baseline, but no changes from baseline after ICRS implantation. Significant reductions in final radius and deformation amplitude from baseline were noted.

Conclusions: Combined tPRK and accelerated CXL after ICRS implantation in moderate keratoconus appears to be a safe and effective treatment, providing an improvement in visual acuity, corneal indices, and HOAs.

Trial registration: retrospectively registered (identification no. NCT03355430 ). Date registered: 28/11/2017.

Keywords: Combined corneal wavefront-guided transepithelial photorefractive keratectomy and accelerated corneal collagen cross-linking; Intracorneal ring segment implantation; Keratoconus.

Conflict of interest statement

Ethics approval and consent to participate

Ethics approval was retrospectively obtained by the Institutional Review Board of Yonsei University College of Medicine, Seoul, South Korea (4–2016-0403). All patients provided informed written consent for their medical information to be included in analysis and for publication.

Consent for publication

Not applicable (no identifying patient data).

Competing interests

Dr. Kang is consultant to Avedro Inc. and SCHWIND eye-tech-solutions. The remaining authors have no proprietary or financial interest in the materials presented herein.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Changes in refractive outcomes, maximal keratometry, and corneal higher-ordrer aberrations in patients with moderate keratoconus who underwent combined corneal wavefront-guided transepithelial photorefractive keratectomy and high-fluence accelerated corneal collagen cross-linking after intracorneal ring segment implantation. Preop = preoperative; ICRS = intracorneal ring segment implantation; tPRK-CXL = corneal wavefront-guided transepithelial photorefractive keratectomy and corneal collagen cross-linking; MRSE = manifest refraction spherical equivalent; RMS HOAs = root mean square higher-order aberrations. Error bars represent standard error of the mean (*P < .05, **P < .01, ***P < .001)
Fig. 2
Fig. 2
In this patient with moderate keratoconus, combined corneal wavefront-guided transepithelial photorefractive keratectomy (tPRK) and high-fluence accelerated corneal collagen cross-linking (CXL) after intracorneal ring segment (ICRS) implantation achieved a progressive flattening of the cone, as compared to baseline (a). Representative corneal topography changes after ICRS implantation (b), and at 3 and 6 months after combined tPRK and accelerated CXL (c and d)
Fig. 3
Fig. 3
Difference map in patient with moderate keratoconus who underwent combined corneal wavefront-guided transepithelial photorefractive keratectomy (tPRK) and high-fluence accelerated corneal collagen cross-linking (CXL) after intracorneal ring segment (ICRS) implantation. Although the majority of curvature changes occur by combined tPRK and CXL, ICRS implantation also serves to provide 20–30% additive effects. (a) axial map (difference), left; after ICRS implantation alone versus before ICRS implantation (baseline), right; 6 months after tPRK and CXL versus after ICRS implantation alone, (b) tangential map (difference), left; after ICRS implantation alone versus before ICRS implantation (baseline), right; 6 months after tPRK and CXL versus after ICRS implantation alone

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