Repeated Epithelium-Off Corneal Cross-Linking For Progressive Ectasia After Primary Treatment Failure
Published 2026 - 44th Congress of the ESCRS
Reference: POCOR165 | Type: Free paper | DOI: 10.82333/pfhf-1q29
Authors: Ms Michalina Ludwika Depczyńska* 1 , Carmen M. Rodríguez Villalobos 1 , Mark Hillen 2 , Léonard Kollros 3 , Emilio A. Torres-Netto 4 , Nikki L. Hafezi 2 , Craig Boote 5 , Farhad Hafezi 6
1ELZA Institute,Zürich,Switzerland;Faculty of Medicine, University of Geneva, Geneva,Switzerland, 2ELZA Institute,Zürich,Switzerland, 3ELZA Institute,Zürich,Switzerland;Institute of Optometry, University of Applied Sciences and Arts Northwestern Switzerland (FHNW),Olten,Switzerland;Lorella & Léonard OPTIC,Biel/Bienne,Switzerland, 4ELZA Institute,Zürich,Switzerland;Ocular Cell Biology Group, Center for Applied Biotechnology and Molecular Medicine, University of Zurich, ,Zürich,Switzerland, 5Centre for Optometry and Vision Science, Biomedical Sciences Research Institute, Ulster University,Coleraine,United Kingdom, 6ELZA Institute,Zürich,Switzerland;Ocular Cell Biology Group, Center for Applied Biotechnology and Molecular Medicine, University of Zurich, ,Zürich,Switzerland;USC Roski Eye Institute, University of Southern California,Los Angeles,United States;Department of Ophthalmology, NYU Grossman School of Medicine, ,New York,United States;Faculty of Medicine, University of Geneva, Geneva,Switzerland
Purpose
To evaluate the safety and efficacy of repeated epithelium-off corneal cross-linking (Re-CXL) in eyes demonstrating progressive keratoconus or post-LASIK ectasia following primary CXL failure.
Setting
Retrospective interventional case series conducted at the ELZA Institute, Zurich, Switzerland and at the University Hospital Carl Gustav Carus, Dresden, Germany.
Methods
Thirty-eight eyes of 32 patients (mean age 32.9±14.26 years; 36 keratoconus, 2 post-LASIK ectasia) with documented progression after primary CXL (increase in Kmax ≥1.0 D) underwent repeated epithelium-off CXL. The initial procedure followed a standard Dresden-based approach. Re-CXL was performed using individualized UV-A fluence protocols (mean cumulative fluence across both treatments 10.80±2.13 J/cm²). Corneal tomography (Pentacam HR) assessed Kmax, K1, K2, anterior radius of curvature (ARC, 3-mm zone), and thinnest pachymetry pre-Re-CXL, at 6 months, and at 1 year. Paired parametric and non-parametric tests evaluated changes (p<0.05). Correlation analyses explored associations between total fluence and keratometric response.
Results
Thirty-eight eyes completed 1-year follow-up after repeated epithelium-off CXL. Compared with pre-Re-CXL values, Kmax decreased significantly by 3.33 ± 2.72 D, K2 by 1.71 ± 1.65 D, and K1 by 1.36 ± 1.78 D (all p < 0.001). The anterior radius of curvature (ARC, 3-mm) increased by 0.36 ± 0.50 mm (p < 0.001), indicating significant corneal flattening. Thinnest pachymetry decreased by 14.89 ± 24.62 µm (p < 0.05), without endothelial decompensation or sight-threatening complications. Relative to baseline before primary CXL, final follow-up demonstrated reductions in Kmax (1.52 ± 4.33 D), K2 (1.13 ± 2.07 D), and ARC (3-mm) (0.47 ± 1.29 mm) (all p < 0.05), while the reduction in K1 was not statistically significant (p = 0.0504).
Conclusions
Repeated epithelium-off CXL effectively stabilizes progressive ectasia following primary treatment failure, with significant keratometric flattening and an acceptable safety profile at 1 year. While cumulative fluence was not significantly correlated with the magnitude of flattening, individualized retreatment appears to restore biomechanical stability in selected cases. Re-CXL represents a viable therapeutic option within the management algorithm of progressive ectatic disease.