Combined Phototherapeutic Keratectomy, Intracorneal Ring Segment Implantation, and Corneal Collagen Cross-Linking in Keratoconus Management

Purpose: To evaluate the efficacy, predictability, and safety of combined corneal collagen cross-linking (CXL), intracorneal ring segment (ICRS) implantation, and superficial phototherapeutic keratectomy (PTK) in patients with keratoconus. Methods: Fifty-five eyes received ICRS implantation, followed by CXL and PTK combination treatment. Patients were followed up for 6 months. Primary outcomes included Logarithm of the Minimum Angle of Resolution (LogMAR) uncorrected distance VA (UDVA) and corrected distance VA (CDVA), sphere, cylinder, mean spherical equivalent, index of surface variance, index of vertical asymmetry, keratoconus index, central keratoconus index, index of height asymmetry, and index of height decentration. Secondary outcomes were higher-order aberrations (HOAs), including HOA total, coma, spherical, secondary astigmatism, and trefoil. Results: At 6 months, there was a statistically significant improvement in UDVA, CDVA, sphere, and cylinder compared with baseline (P < 0.001). UDVA improved in 14% of the eyes to 20/25 and 96% had at least 20/40 or better spectacle corrected vision; 30.9% of the eyes were within +/- 0.5 diopter (D), 45.5% of the eyes were within +/- 1.0 D, and 74.5% of the eyes were within +/- 2.0 D. For CDVA, 1 eye (2%) lost 3 lines (but gained UDVA), 11% lost 1 line, 38% showed no change, and 49% gained between 1 and 8 lines of vision. Eighty-eight United Arab Emiratespercent of the eyes had at least 1 line of UDVA visual improvement, 79% improved by >= 2 lines, and 69% improved by >= 3 lines. HOA total, coma, spherical aberration, and secondary astigma- tism showed improvements of -0.87 (P < 0.001), -0.84 (P < 0.001), -0.10 (P = 0.002), and -0.15 (P = 0.035), respectively. Conclusions: A combined procedure of ICRS implantation, CXL, and PTK is effective, predictable, and apparently safe for patients diagnosed with moderate keratoconus.