Efficacy Of Customized Photorefractive Keratectomy With Cross-Linking Vs. Cross-Linking Alone In Progressive Keratoconus: A Systematic Review And Meta-Analysis
Published 2025 - 43rd Congress of the ESCRS
Reference: FP19.12 | Type: Free paper | DOI: 10.82333/s8pv-pb11
Authors: David Shahnazaryan 1 , Aida Hajjar Sese* 2 , Marcela Espinosa-Lagana 1 , Sheraz Daya 1
1Ophthalmology,Centre for Sight UK,London,United Kingdom, 2Ophthalmology,King's College Hospital NHS Foundation Trust,London,United Kingdom
Purpose
This review evaluates the efficacy and safety of combining customized photorefractive keratectomy (cPRK) with corneal cross-linking (CXL) compared to CXL alone in improving visual and refractive outcomes in patients with progressive keratoconus.
Setting
This study is based on peer-reviewed journal articles following PRISMA guidelines.
Methods
A systematic search of MEDLINE, PubMed, Cochrane Library, and EMBASE was conducted through September 2024, following PRISMA guidelines. Both randomized controlled trials and non-randomized studies comparing CXL+cPRK with CXL alone were included, with a minimum follow-up of six months. Primary outcomes were uncorrected distance visual acuity and corrected distance visual acuity. Secondary outcomes included refraction, corneal structure, and higher-order aberrations. Meta-analysis was performed using standardized mean differences with 95% confidence intervals, applying a random-effects model where necessary. Sensitivity analysis was conducted using a leave-one-out approach. This study is registered in the PROSPERO database (CRD42024594757).
Results
Eight studies involving 731 eyes from 706 patients were analyzed. Compared to CXL alone, CXL+cPRK significantly improved uncorrected distance visual acuity (SMD = -0.39, 95% CI: -0.69 to -0.08, P = 0.01) and corrected distance visual acuity (SMD = -0.57, 95% CI: -0.96 to -0.18, P = 0.004), while also reducing refractive cylinder error. Additionally, CXL+cPRK reduced coma, total higher-order aberrations, coma-like aberrations, mean keratometry, and central corneal thickness. No significant differences were observed in endothelial cell count between the groups. Postoperative ectasia progression rates were comparable. Heterogeneity was primarily attributed to variations in surgical techniques, patient selection, and study designs.
Conclusions
Customized PRK combined with CXL provides superior postoperative visual acuity and optical quality compared to CXL alone while maintaining corneal stability. This combined approach offers a promising therapeutic strategy for managing progressive keratoconus.