The U.S. approval of corneal collagen cross-linking for ectatic disorders provided achievement for so abounding patients with keratoconus, but the absolute account of CXL is if it can be accumulated with a refractive action to accord comedy freedom.
Topographic-guided PRK ablation patterns, which are now accustomed on the Alcon WaveLight platform, accept auspiciously adapted aberrant amaurosis and higher-order aberrations already in abounding patients ability cross-linking, but our ability is far from complete.
A agitation apropos to the timing of PRK exists: Should it be performed afore cross-linking or afterwards a few months of healing accept occurred? There are reasonable arguments to be fabricated on both sides, but one affair is clear: Most ectatic corneas can be cautiously advised with laser (even LASIK in some cases) and will abide abiding and chargeless from added ectasia.
Why is this important? Between 5% and 10% of patients presenting with absorption in corneal refractive anaplasty are angry bottomward because of affirmation of ectasia or forme fruste keratoconus. Abounding of these patients accept aberrant amaurosis and accept bootless with all-around and toric bendable acquaintance lenses and alike gas absorbent lenses; they appetite bigger eyes through surgery.
For some time, my colleagues in the CXLUSA abstraction accept performed a aggregate of collagen cross-linking with conductive keratoplasty, absorption the CK ysis over or adjoining to the steepest breadth of the cone. This ysis would abrade the cone and accord abiding advance in aberrant amaurosis already cross-linking was performed. Topographic-guided PRK offers an alike added absolute adjustment of about-face the cornea to abate irregularity.
Not all corneas can be absolutely corrected. Some ectatic eyes are acutely myopic, and alone so abundant tissue can cautiously be removed by PRK, alike in a cross-linked cornea. But debulking the abnormality and refractive breadth in these patients gives them a above advantage and enables them to accede bendable or bendable toric acquaintance lens abrasion in the future.
Another advantage that may action achievement is a baby breach IOL. AcuFocus is developing and has amorphous U.S. ytic trials of a lens implant that has a breach breach agnate to the Kamra corneal inlay. While its primary approval will be for alteration of presbyopia, this technology acutely has off-label allowances for patients with aberrant corneas acquired by ectasia or added disorders. For some patients with keratoconus, cross-linking may be the aboriginal footfall followed by lens implantation. Time and ytic acquaintance will acquaint us how abundant abnormality the baby breach can correct.
Meanwhile, abounding patients with keratoconus are accessible and accommodating to abide PRK ysis to advance their refractive absurdity and aberrant astigmatism. The technology is accessible and approved, and a growing anatomy of affirmation supports its safe use. I am one surgeon who is accessible to get started.
Disclosure: Hovanesian letters he is a adviser to Alcon.
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