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Purpose: The aim of this study was to present the 3-year outcomes after simultaneous transepithelial phototherapeutic keratectomy (t-PTK) and conventional photorefractive keratectomy (PRK) followed by corneal crosslinking (CXL) for keratoconus., Methods: In this prospective, interventional case series, patients with progressive keratoconus underwent simultaneous t-PTK and conventional PRK followed by CXL (Cretan protocol plus). Visual, refractive, and topographic outcomes were evaluated along with endothelial cell density (ECD) preoperatively and at 1, 2, and 3 years postoperatively., Results: Twenty-two patients (31 eyes) were enrolled. No intraoperative or postoperative complications were observed in any of the patients. Logarithm of the minimum angle of resolution (logMAR) mean uncorrected and mean corrected distance visual acuity improved from 0.81 ± 0.40 and 0.18 ± 0.21 preoperatively to 0.38 ± 0.33 ( P < 0.001) and 0.06 ± 0.12 ( P < 0.001) at 3-year follow-up. Mean spherical equivalent improved from -5.39 ± 3.89 diopters (D) preoperatively to -2.29 ± 2.65 D ( P < 0.001) at 3 years postoperatively. Mean corneal astigmatism reduced from -4.70 ± 2.86 D preoperatively to -3.55 ± 2.45 D ( P = 0.001) at 3 years postoperatively. No ECD alterations were observed throughout the 3-year follow-up ( P > 0.05)., Conclusions: Simultaneous t-PTK and conventional PRK followed by CXL seems to be an effective and safe treatment for progressive keratoconus over 3-year follow-up., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare the long-term outcomes of corneal cross-linking (CXL) for the treatment of keratoconus using two different techniques for epithelial removal: transepithelial phototherapeutic keratectomy (t-PTK) and mechanical epithelial debridement., Methods: In this prospective, comparative, interventional case series, 26 patients (30 eyes) with progressive keratoconus underwent CXL treatment. Fifteen eyes (13 patients) underwent epithelial removal with t-PTK (Cretan protocol) and 15 eyes (13 patients) underwent mechanical epithelial debridement (Dresden protocol) during CXL. Visual, refractive, and keratometric outcomes were evaluated preoperatively and at 1, 2, 3, and 4 years postoperatively., Results: No intraoperative or postoperative complications were observed in any of the patients. In the Cretan protocol group, mean uncorrected (UDVA) and corrected (CDVA) visual acuity improved from 0.99 ± 0.42 and 0.33 ± 0.28 logMAR preoperatively to 0.75 ± 0.32 (P = .018) and 0.21 ± 0.16 (P = .024) logMAR at 4 years postoperatively, respectively. In the Dresden protocol group, mean UDVA improved from 0.83 ± 0.47 logMAR preoperatively to 0.63 ± 0.40 logMAR (P = .033) at 4 years postoperatively, whereas mean CDVA did not demonstrate a statistically significant improvement postoperatively (P > .05). In the Cretan protocol group, mean corneal astigmatism improved from -6.19 ± 4.54 diopters (D) preoperatively to -4.68 ± 3.10 D (P = .041) at last follow-up, whereas in the Dresden protocol group there was no statistically significant difference postoperatively (P > .05)., Conclusions: Epithelial removal with t-PTK during CXL (Cretan protocol) resulted in better visual, refractive, and keratometric outcomes compared with mechanical epithelial debridement over a long-term follow-up. [J Refract Surg. 2019;35(10):650-655.]., (Copyright 2019, SLACK Incorporated.)

Purpose: To evaluate the visual, refractive, and topographic outcomes after combined transepithelial phototherapeutic keratectomy (PTK) and conventional photorefractive keratectomy (PRK) followed simultaneously by corneal crosslinking (CXL) for keratoconus., Setting: Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece., Design: Prospective case series., Methods: Patients with progressive keratoconus had simultaneous conventional PRK followed by CXL; the corneal epithelium was removed using transepithelial PTK (Cretan protocol plus). The visual, refractive, and topographic outcomes and the endothelial cell density (ECD) were evaluated preoperatively and 1, 3, 6, and 12 months postoperatively., Results: Forty-three patients (55 eyes) were enrolled. The mean uncorrected and corrected distance visual acuities improved significantly from 0.98 ± 0.63 (SD) logarithm of minimum angle of resolution (logMAR) and 0.20 ± 0.23 logMAR preoperatively to 0.39 ± 0.35 logMAR (P < .001) and 0.08 ± 0.16 logMAR (P < .001) 12 months postoperatively, respectively. The mean spherical equivalent improved significantly from -4.67 ± 4.00 diopters (D) preoperatively to -2.24 ± 2.81 D (P < .001) at 12 months. The mean steep keratometry (K) and flat keratometry readings decreased significantly from 50.30 ± 5.00 D and 45.62 ± 3.10 D preoperatively to 46.27 ± 3.90 D (P < .001) and 43.46 ± 3.00 D (P < .001) 12 months postoperatively, respectively. No ECD alterations were observed throughout the follow-up (P > .05)., Conclusion: Combined transepithelial PTK and conventional PRK followed simultaneously by CXL was effective in corneal stabilization and vision improvement in keratoconic patients., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to present the long-term results of corneal collagen cross-linking (CXL) in patients with keratoconus., Methods: In this prospective, interventional case series, patients with progressive keratoconus underwent CXL treatment according to the Dresden protocol. Visual, refractive, and topographic outcomes along with endothelial cell density were evaluated preoperatively and at 1, 2, 3, 4, and 5 years postoperatively., Results: Twenty-one patients (25 eyes) were enrolled. The mean follow-up was 43.7 ± 12.2 (range, 24-60) months. Logarithm of the minimum angle of resolution (logMAR) mean uncorrected visual acuity and the mean best spectacle-corrected visual acuity improved significantly from 0.92 ± 0.54 and 0.29 ± 0.21 preoperatively to 0.63 ± 0.41 (P = 0.010) and 0.18 ± 0.18 (P = 0.011), respectively, at the last follow-up. Mean steep and mean flat keratometry readings reduced significantly from 52.53 ± 6.95 diopters (D) and 48.11 ± 5.98 D preoperatively to 49.10 ± 4.50 D (P < 0.001) and 45.58 ± 3.81 D (P = 0.001), respectively, at the last follow-up. The mean endothelial cell density was 2708 ± 302 cells per square millimeter preoperatively and did not change significantly (P > 0.05) at any postoperative interval (2593 ± 258 cells/mm at the last follow-up; P = 0.149)., Conclusions: CXL seems to be effective and safe in halting progression of keratoconus over a long-term follow-up period up to 5 years postoperatively.

Purpose: To present the long-term results of combined transepithelial phototherapeutic keratectomy (PTK) and corneal collagen crosslinking (CXL) for keratoconus., Setting: Vardinoyiannion Eye Institute of Crete, University of Crete, Heraklion, Crete, Greece., Design: Prospective case series., Methods: Patients with progressive keratoconus had combined transepithelial PTK and CXL (Cretan protocol). Visual and refractive outcomes and the endothelial cell density (ECD) were evaluated preoperatively and postoperatively., Results: Twenty patients (23 eyes) were enrolled; postoperatively 23 eyes were evaluated at 1 and 2 years, 11 at 3 years, and 7 at 4 years. The mean follow-up was 33.83 months±10.82 (SD) (range 24 to 56 months). No intraoperative or postoperative complications occurred. The mean uncorrected distance visual acuity improved significantly from 0.99±0.57 logMAR preoperatively to 0.61±0.36 logMAR at the last follow-up (P<.001) and the mean corrected distance visual acuity, from 0.27±0.24 logMAR to 0.17±0.14 logMAR (P=.018), respectively. The mean steep and mean flat keratometry readings decreased significantly from 53.39±7.14 diopters (D) and 47.17±4.87 D, respectively, preoperatively to 49.99±4.36 D (P<.001) and 45.47±2.95 D (P=.002), respectively, at the last follow-up. The mean corneal astigmatism improved significantly from -6.27±4.19 D preoperatively to -4.52±2.80 D (P<.001) at the last follow-up. No significant ECD alterations occurred (P>.05)., Conclusion: Combined transepithelial PTK and CXL was effective and safe in keratoconic patients over a long-term follow-up., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To use anterior segment optical coherence tomography (AS-OCT) to compare corneal stroma demarcation line depth after corneal collagen crosslinking (CXL) with 2 treatment protocols., Setting: Vardinoyiannion Eye Institute of Crete, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece., Design: Prospective comparative interventional case series., Methods: Corneal collagen crosslinking was performed in all eyes using the same ultraviolet-A (UVA) irradiation device (CCL-365). Eyes were treated for 30 minutes with 3 mW/cm(2) according to the standard Dresden protocol (Group 1) or for 10 minutes with 9 mW/cm(2) of UVA irradiation intensity (Group 2). One month postoperatively, 2 independent observers measured the corneal stroma demarcation line using AS-OCT., Results: Sixteen patients (21 eyes) were enrolled. Group 1 comprised 7 patients (9 eyes) and Group 2, 9 patients (12 eyes). The mean corneal stroma demarcation line depth was 350.78 μm ± 49.34 (SD) (range 256.5 to 410 μm) in Group 1 and 288.46 ± 42.37 μm (range 238.5 to 353.5 μm) in Group 2; the corneal stroma demarcation line was statistically significantly deeper in Group 1 than in Group 2 (P=.0058, t test for unpaired data)., Conclusion: The corneal stroma demarcation line was significantly deeper after a 30-minute CXL treatment than after a 10-minute CXL procedure with high-intensity UVA irradiation., (Copyright © 2014 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To report 3 cases of keratoconic patients who had progressive corneal topographic flattening during a 2-year follow-up period., Methods: Case series., Results: Three patients with bilateral keratoconus, each operated for advanced keratoconus in one of their eyes, were observed for possible progression of the disorder for a period of 2 years. During the 2-year follow-up period, topographic examination showed progressive corneal flattening in the nonoperated eye. Mean keratometry decreased in all patients, whereas topography showed significant flattening at the apex of the cone. Best-spectacle-corrected visual acuity increased in one of the patients, whereas the others had stable uncorrected and best-spectacle-corrected visual acuity during the follow-up period. All patients had positive family medical history for diabetes mellitus, but none of them was diabetic., Conclusions: This is the first report of topography-based keratoconus regression during a 2-year follow-up period.

A 29-year-old woman with keratoconus underwent posterior chamber toric implantable Collamer lens (Visian ICL; STAAR Surgical, Monrovia, CA) implantation 12 months after corneal collagen cross-linking with riboflavin and ultraviolet radiation-A. No intraoperative or postoperative complications were observed. Three months postoperatively, uncorrected distance visual acuity improved from counting fingers to 20/40 and corrected distance visual acuity improved from 20/100 to 20/30. Combined cross-linking treatment and posterior chamber toric phakic Collamer lens implantation in a two-step procedure seems to be an effective method for correcting keratoconus in patients with high myopia and astigmatism. Despite the encouraging results, longer follow-up is necessary to evaluate the outcomes of this approach., (Copyright 2011, SLACK Incorporated.)

Purpose: To report complications after the implantation of intrastromal corneal ring segments (Keraring; Mediphacos, Belo Horizonte, Brazil) in keratoconic eyes using a femtosecond laser (IntraLase; Advanced Medical Optics, Santa Ana, California, USA) for channel creation., Methods: Retrospective chart review of 531 patients (850 eyes) who underwent Keraring insertion using a femtosecond laser for channel creation. Intraoperative and postoperative complications were recorded., Results: Intraoperatively, there were 22 (2.7%) cases of incomplete channel formation. The rest of the intraoperative complications were galvo lag error (system malfunction) [five eyes (0.6%)], endothelial perforation [five eyes (0.6%)] and incorrect entry of the channel [two eyes (0.2%)]. Postoperatively, there were 11 (1.3%) cases of segment migration, two (0.2%) cases of corneal melting and one (0.1%) case of mild infection. The overall complication rate was 5.7% (49 cases out of 850 eyes)., Conclusion: In this study, intracorneal ring segment implantation using a femtosecond laser for channel creation was related to a number of complications. The most common complications were incomplete channel creation (intraoperatively) and segment migration (postoperatively)., (© 2009 The Authors. Journal compilation © 2009 Acta Ophthalmol.)

Purpose: To determine the possible effect of corneal collagen crosslinking (CXL) with riboflavin and ultraviolet A (UVA) on intraocular pressure (IOP) measurements by Goldmann applanation tonometry (GAT)., Setting: Institute of Vision and Optics, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece., Design: Prospective case series., Methods: This noncomparative study measured IOP by GAT before CXL and 6 months and 12 months after CXL., Results: The study evaluated 55 eyes (55 patients). There was a statistically significant increase in the measured IOP 6 months and 12 months after CXL (both P<.001). The mean measured IOP was 9.95 mm Hg ± 3.01 (SD) before CXL, 11.40 ± 2.89 mm Hg at 6 months, and 11.35 ± 3.38 mm Hg at 12 months. The change in IOP measurements at both postoperative examinations was not correlated with patient age, preoperative pachymetry, or preoperative keratometry readings., Conclusion: After riboflavin-UVA CXL in eyes with keratoconus, there was a significant increase in IOP measured by GAT that was probably caused by an increase in corneal rigidity., (Copyright © 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the combined effect of conductive keratoplasty (CK) followed by corneal collagen cross-linking (CXL) in 2 patients with keratoconus., Methods: CK spots were applied on the flatter side of the cornea followed by CXL using riboflavin and UV-A light., Results: Immediately after CK, a significant corneal topographic improvement was observed. The CK effect regressed 3 months postoperatively and remained unchanged until the sixth postoperative month in both patients., Conclusion: Corneal remodeling with CK in patients with keratoconus seems to have a temporary effect despite the subsequent application of CXL.

Objective: To study central corneal pachymetric variations during corneal collagen cross-linking (CXL) treatment with the use of riboflavin and ultraviolet A irradiation (UVA)., Design: Prospective, noncomparative, interventional clinical study., Participants: Fifteen keratoconic patients (19 eyes) were enrolled., Methods: All patients underwent riboflavin-UVA-induced corneal CXL. Intraoperative central corneal thickness (CCT) measurements using ultrasound pachymetry were performed during the procedure. Measurements were obtained after epithelial removal, after riboflavin drop instillation, and every 5 minutes (6 interval times) during UVA irradiation (30 minutes)., Main Outcome Measures: Central corneal thickness measurements., Results: Mean patient age was 26.9+/-6.5 years (range, 17-40 years). Ten were male and 5 were female. Mean preoperative CCT was 458.5+/-21.5 microm (range, 427-494 microm; 95% confidence interval [CI], 448-467 microm) and 415.7+/-20.6 microm (range, 400-468 microm; 95% CI, 406-426 microm) before and after epithelial removal, respectively. There was a statistically significant decrease (mean, 75 microm) of CCT between the epithelial removal interval (415.7+/-20.6 microm; range, 400-468 microm) and at the end of riboflavin solution instillation (340.7+/-22.9 microm; range, 292-386 microm; P<0.001). There was no statistically significant change in CCT during irradiation (P>0.05). There was no statistically significant difference between preoperative and 1-month postoperative endothelial cell count (preoperative, 2780+/-197 to 1-month postoperative, 2713+/-116; P = 0.14). No intraoperative, early postoperative, or late postoperative complications were observed in this patient series., Conclusions: During corneal CXL with the use of riboflavin and UVA irradiation, a statistically significant decrease of CCT was demonstrated.

Purpose: To present the results after simultaneous photorefractive keratectomy (PRK) followed by corneal collagen cross-linking (CXL) for progressive keratoconus., Methods: Twelve patients (14 eyes) with progressive keratoconus were prospectively treated with customized topography-guided PRK with the Pulzar Z1 (wavelength 213 nm, CustomVis) immediately followed by corneal collagen CXL with the use of riboflavin and ultraviolet A irradiation., Results: Mean follow-up was 10.69+/-5.95 months (range: 3 to 16 months). Mean preoperative spherical equivalent refraction (SE) was -3.03+/-3.23 diopters (D) and defocus was 4.67+/-3.29 D; at last follow-up SE and defocus were statistically significantly reduced to -1.29+/-2.05 D and 3.04+/-2.53 D, respectively (P<.01). Preoperative mean (logMAR) uncorrected visual acuity was 0.99+/-0.81 and best spectacle-corrected visual acuity was 0.21+/-0.19, which improved postoperatively to 0.16+/-0.15 and 0.11+/-0.15, respectively. The mean steepest keratometry was reduced from 48.20+/-3.40 D preoperatively to 45.13+/-1.80 D at last follow-up., Conclusions: Simultaneous PRK followed by CXL seems to be a promising treatment capable of offering functional vision in patients with keratoconus., (Copyright 2009, SLACK Incorporated.)

Purpose: To report the results of intrastromal corneal ring segment [ICRS] (KeraRing; Mediphacos, Belo Horizonte, Brazil) implantation using a femtosecond laser (IntraLase Corp, Irvine, California, USA) in keratoconic patients., Design: Retrospective, noncomparative, interventional study., Methods: Thirty-two keratoconic patients (50 eyes) who underwent ICRS insertion using a femtosecond laser for channel creation and completed at least one year of follow-up were included in this study. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refraction, topographic findings, and adverse events were assessed., Results: No intraoperative complications were demonstrated in this series of patients. At the first postoperative day, segment migration to the incision site was seen in three eyes (6%; early postoperative complication). To avoid melting, we repositioned the migrated segment away from the incision site. Serious second migration was not seen and we did not need to reposition any segment again. At the last postoperative examination, there was a statistically significant reduction in the spherical equivalent refractive error compared with that observed at the examination before implantation (mean +/- standard deviation, -5.62 +/- 4.15 diopters [D; range, -23.62 to 0.50 D] to -2.49 +/- 2.68 D [range, -11.12 to 3.5 D]; P < .001). The UCVA before implantation was 20/40 or worse in 47 eyes (94%; range, counting fingers to 20/30), whereas at the last follow-up examination, 14 (28%) of 50 eyes had a UCVA of 20/40 or better (range, counting fingers to 20/25). Nine eyes (18%) maintained the preimplantation BSCVA, whereas 39 eyes (68%) experienced a BSCVA gain of one to four lines at the last follow-up examination. Only in two eyes (4%; two patients) with advanced keratoconus (stage III) was there a decrease of up to two lines. Despite this deterioration in BSCVA, the patients did not want to remove the ICRSs, because there was an increase of UCVA. No late postoperative complications were observed during the follow-up period., Conclusions: ICRS (KeraRing) implantation using femtosecond laser for tunnel creation is a minimally invasive procedure for improving visual acuity (both UCVA and BSCVA) in keratoconic patients.

Purpose: To evaluate long-term follow-up of Intacs microthin prescription inserts (Addition Technology, Inc, Fremont, California, USA) for the management of keratoconus., Design: A long-term (five years) retrospective, follow-up study., Methods: Seventeen eyes of 15 patients with keratoconus ages 24 to 52 years (mean age +/- standard deviation [SD], 34.0 +/- 10.5 years) who had completed five years of follow-up (mean follow-up +/- SD, 67.2 +/- 7.5 months; range, 58 to 78 months) were included. Two Intacs segments of 0.45-mm thickness were inserted in the cornea of each eye, aiming at embracing the keratoconus area to try to achieve maximal flattening., Results: No late postoperative complications occurred in this series of patients. At five years, the spherical equivalent error was statistically significantly reduced (pre-Intacs, mean +/- SD -5.54 +/- 5.02 diopters [D]; range, -12.50 to 3.63 D; -3.02 +/- 2.65 D; range, -8.25 to 1.88 D) (P = .01). Pre-Intacs uncorrected visual acuity (UCVA) was 20/50 or worse in all eyes (range, counting fingers to 20/50), whereas, at the last follow-up examination, 10 (59%) of 17 eyes had UCVA of 20/50 or better (range, counting fingers to 20/32). Six eyes (35%) maintained the pre-Intacs best spectacle-corrected visual acuity (BSCVA) and one eye lost 3 lines of BSCVA, whereas the rest of the 10 eyes (59%) experienced a gain of one up to 8 lines., Conclusions: After five years, intracorneal ring segments implantation improved UCVA, BSCVA, and refraction in the majority of the keratoconus patients. There was no evidence of progressive sight-threatening complications in this study.

Purpose: To determine the morphologic changes in human corneas over time following radiofrequency-based conductive keratoplasty (CK) treatment., Design: Prospective, observational case series., Methods: In a single-center study six human corneas of six patients with localized peripheral keratoconus underwent CK treatment followed by penetrating keratoplasty. Three spots were applied in the periphery of each cornea (6 mm optical zone). Corneal buttons were examined with light and electron microscopy at different postoperative intervals up to 6 months post-CK., Results: In samples assessed on day one post-CK, small areas of detachment between the basal layer of epithelial cells and Bowman's layer were observed. At 1 week after the CK procedure, the epithelium appeared almost normal. Endothelium and Descemet's membrane had no alterations. In all samples, thermally induced misconfiguration of collagen fibers, described as "crumpled" changes of collagen layers, was observed reaching 75% to 80% of the stromal depth. The area of alterations had a cylindrical shape with a diameter of 120 mum., Conclusions: The conductive keratoplasty procedure produced collagen "crumpling and splitting" changes in human corneas, which were observed during the follow-up of 6 months. Areas adjacent to treatment site were minimally damaged.

Purpose: To prospectively study the effects of the use of Intacs microthin prescription inserts for the management of keratoconus., Design: Prospective nonrandomized clinical trial., Methods: Thirty-three eyes of 26 keratoconus patients (17 males and 9 females) ages 21 to 51 years (mean age, 32 +/- 9.7 years) were included in the current study. All patients had clear central corneas and contact lens intolerance. Patients were excluded if any of the following criteria applied after the preoperative examination: previous intraocular or corneal surgery; history of herpes keratitis; diagnosed autoimmune disease; and systemic connective tissue disease. Two Intacs segments of 0.45-mm thickness were inserted in the cornea of each eye, aiming at embracing the keratoconus area to try to achieve maximal flattening. Preoperative examination included uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), manifest refraction, keratometric data, and corneal topography., Results: Intacs were successfully implanted in all eyes. In one eye Intacs were removed after 3 months because of their improper (superficial) placement. The follow-up ranged from 1 to 24 months (mean: 11.3 months). The mean UCVA significantly improved from 0.13 +/- 0.14 (range, counting fingers [CF]-0.5) to 0.39 +/- 0.27 (range, CF-1.0) (P <.01). Of 33 eyes, 2 eyes lost 1 line of UCVA, and 3 eyes maintained the preoperative UCVA, whereas the rest (28 eyes) experienced a 1- to 10-line gain. The mean BCVA also improved from 0.47 +/- 0.31 (range, CF-1.0) to 0.64 +/- 0.26 (range, 0.1-1.0) (P <.01). Of 33 eyes, 4 eyes experienced 1- to 2-line loss of BCVA, 4 eyes maintained the preoperative BCVA, whereas the rest (25 eyes), experienced a 1- to 6-line gain. Of 3 patients (3 eyes) with unsatisfactory results, 1 patient improved with one segment removal and in 2 patients the segments were permanently removed. One of these eyes underwent successful PKP., Conclusions: With mean follow-up of 11.3 months, intracorneal ring segments implantation improved UCVA and BCVA in the majority of the keratoconus patients. Even though the results are encouraging, concern still exists regarding the predictability as well as the long-term effect of such an approach for the management of keratoconus.

Purpose. To present a case of a keratoconic patient who underwent epithelial removal with transepithelial phototherapeutic keratectomy (t-PTK) using a 213-nm solid-state laser system followed by corneal collagen cross-linking (CXL) with riboflavin and ultraviolet-A (UVA) irradiation. Methods. Case report. Results. A twenty-four-year-old male with keratoconus underwent CXL treatment after epithelial removal with t-PTK using a solid-state laser system. No intra- or early postoperative complications were found. One month postoperatively, uncorrected visual acuity (UCVA) improved from 20/63 to 20/32 while best spectacle-corrected visual acuity (BSCVA) improved from 20/40 to 20/25. Corneal topography revealed a significant improvement which remained stable during the six-month followup period. Conclusions. Epithelial removal with t-PTK before CXL could improve patient's visual outcome. [ABSTRACT FROM AUTHOR]