BackgroundTo evaluate the safety and efficacy of an approach that combines corneal customized transepithelial therapeutic ablation to treat irregular corneal optics and accelerated corneal collagen cross-linking (CXL) to strengthen the corneal tissue and stop the progression of keratoconus. The transepithelial therapeutic ablation applied a novel concept named central corneal regularization (CCR) which could correct the corneal morphological irregularities and the eye’s spherocylindrical refractive error with minimal stromal tissue removal.MethodsRetrospective study. Eyes that underwent CCR combined with CXL were evaluated preoperatively and up to 12 months postoperatively for visual acuity, subjective refraction, corneal haze, pachymetry and maximum keratometry (Kmax).ResultsTwenty four eyes of 24 patients with a mean age of 28.92 ± 9.88 years were treated. The mean spherical equivalent (SE) refractive error changed from − 0.74 ± 1.17 D preoperatively to − 1.05 ± 1.52 D at 12 months postoperatively. The mean uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) improved. No eye lost lines of CDVA, 21 had a mean improvement of 3.21 lines. The mean cylinder error and Kmax value dropped from − 3.06 ± 1.83 D and 51.38 ± 3.29 D to − 1.04 ± 0.80 D and 48.70 ± 2.58 D, respectively. The mean haze score at 3, 6 and 12 months was 0.56, 0.19 and 0.06, respectively.ConclusionsCCR combined with CXL offers promising results as a safe and effective treatment in keratoconic patients.

PURPOSE: To analyze the optical consequences of epithelial remodeling in irregular corneas and their impact on the choice of different surface ablation techniques. METHODS: Anterior corneal and stromal surface topographies and epithelial thickness maps were analyzed in 24 eyes with irregular corneal optics. On two of the eyes, four different surface ablation techniques were simulated: (1) conventional anterior topography-guided photorefractive keratectomy (PRK), (2) transepithelial phototherapeutic keratectomy (PTK), (3) transepithelial anterior topography-guided PRK, and (4) stromal topography-guided PRK. RESULTS: Stromal surface topographies showed higher keratometric values, astigmatism, asphericity, and corneal higher order aberrations compared to topographies of anterior corneas covered by epithelium. Transepithelial anterior topography-guided PRK and stromal topography-guided PRK both resulted in regularized stromal surface, transepithelial PTK achieved partial regularization corresponding to the smoothing effect of the epithelial remodeling, and conventional anterior topography-guided PRK delivered after epithelial removal resulted in residual stromal surface irregularities. CONCLUSIONS: The difference in optical landscapes between the stromal and anterior surfaces in irregular corneas will represent a source of error when anterior topography-guided treatments are delivered on the deepithelialized stroma, as in conventional PRK. In contrast, anterior topography-guided ablations performed as transepithelial PRK and stromal topography-guided PRK delivered after epithelial removal address the full stromal irregularity, whereas transepithelial PTK alone may be used when topography-guided treatments are not possible. The authors conclude topography-guided PRK of irregular corneas should lead to significantly improved regularization only if it includes the effect of epithelial remodeling. [ J Refract Surg . 2022;38(8):529–537.]