PURPOSE: To compare standard epithelium-off corneal cross-linking (standard Epi-Off CXL) to corneal cross-linking with an epithelial flap (Epi-Flap CXL). METHODS: Patients who had undergone sequential bilateral CXL for progressive keratoconus were included in this comparative interventional case series. One eye was treated with the Epi-Off CXL technique and the fellow eye with the Epi-Flap CXL technique. Postoperative pain was measured using the Verbal Rating Scale and corneal densitometry using a Scheimpflug camera. Sex, age, corrected distance visual acuity, keratometry, and corneal thickness were also recorded. RESULTS: Twenty-four eyes of 12 patients with keratoconus with a mean age of 27.15 ± 5.15 years were included. The Verbal Rating Scale scores were significantly lower in patients who had Epi-Flap CXL on the first (1.00 [interquartile range (IQR): 0.00 to 1.00] vs 3.00 [IQR: 3.00 to 3.75], P = .01) and third (0.00 [IQR: 0.00 to 1.00] vs 1.00 [IQR: 0.00 to 1.00], P = .01) postoperative day compared to the Epi-Off CXL group. No pain was observed in both groups after the third day. After 12 months, the Epi-Flap CXL group showed significantly less anterior corneal haze (measured as corneal densitometry) compared to the patients treated with Epi-Off CXL ( P = .01). Both groups demonstrated stability of keratometry and corneal thickness at 12 months after CXL ( P < .01). CONCLUSIONS: Epi-Flap CXL is associated with less postoperative pain and anterior stromal haze in patients undergoing CXL for progressive keratoconus with no loss of efficacy. [ J Refract Surg . 2021;37(11):741–745.]

Purpose: To describe a new technique to deliver riboflavin into the corneal stroma during Corneal Cross-Linking (CXL) without the removal of corneal epithelium. Methods: Keratoconus patients underwent CXL for progressive keratoconus. Riboflavin was delivered by manually creating an epithelial pocket (CXL Epi-Pocket). Verbal rating scale was recorded postoperatively. Best-corrected visual acuity, keratometric indices, corneal thickness and corneal densitometry were recorded at baseline and at 12-month follow-up. Results: Eighteen eyes of 18 patients were included in the study. At a 12-month follow-up, best-corrected visual acuity, K1, K2 and densitometry values were stable. Maximum keratometry (Kmax) reduced from 55.31 ± 6.21 (SD) to 52.34d ± 4.12d (SD) (P value = 0.032). the thinnest point went from 441 ± 21.18 (SD) to 425.4 ± 19.02 (SD) um (P value = 0.041). The verbal rating scale at 1, 2 and 3 days postoperatively were 1.76 ± 0.19 (SD), 1.02 ± 0.51 (SD) and 0.28 ± 0.14 (SD). Conclusions: CXL Epi-Pocket is able to deliver riboflavin to halt the progression of keratoconus at a 12-month follow-up.

Purpose: To investigate the effect of Corneal Visualization Scheimpflug Technology tonometry (CST) on intraocular pressure (IOP).Design: Cohort study.Participants: Patients with and without primary open-angle glaucoma (POAG) were included. Methods: Intraocular pressure was measured using the Icare rebound tonometer (ICRT; Icare Finland Oy) and the biomechanically corrected IOP (bIOP) using the CST. Intraocular pressure was measured at baseline with ICRT, followed by a CST measurement in one eye with the fellow eye acting as a control. Icare measurements were repeated at 10 seconds and 1, 2, 4, 8, 15, 30, and 60 minutes in both eyes. The ratio of test eye IOP to fellow eye IOP was used to control for intrasubject variation.Main Outcome Measures: Intraocular pressure change following Corneal Visualization Scheimflug Technology tonometry.Results: Forty participants (mean age, 54.09 AE 20.08 years) were included comprising 20 patients with POAG and 20 patients with no ocular abnormalities other than cataract. Mean central corneal thickness was similar in those without POAG (547.4 AE 55.05 mm) and with POAG (520.22 AE 37.59 mm; P ¼ 0.14). No significant change was found in IOP measured with the ICRT in the fellow eye versus the 1-hour period in either the healthy (P ¼ 0.87) or POAG (P ¼ 0.92) group. Significant changes were found in IOP after CST measurement for both healthy (P < 0.01) and glaucomatous (P < 0.01) eyes. After the CST measurement, the IOP reduced continuously from a mean of 13.75 mmHg to 10.84 mmHg at 4 minutes for healthy eyes and from 13.28 mmHg to 11.11 mmHg at 8 minutes for glaucomatous eyes before approaching (83% for healthy eyes and 92% POAG eyes) the pre-CST measurement at 1 hour.Conclusions: Corneal Visualization Scheimpflug Technology tonometry causes a significant reduction in IOP in both glaucomatous and healthy eyes that lasts for at least 1 hour afterward. Ophthalmology

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