Visual And Refractive Outcomes Of The Tel-Aviv Protocol For Keratoconus – First 400 Cases

To evaluate the visual and refractive outcomes of epithelial photorefractive keratectomy (ePRK) combined with corneal cross-linking (CXL) - the Tel-Aviv Protocol - in a large consecutive series of patients with progressive keratoconus.

Retrospective comparative study, Care Vision Laser Center, Tel Aviv, Israel.

In this large-scale retrospective case series, consecutive eyes of patients with progressive keratoconus who underwent the Tel-Aviv Protocol at Care-Vision Laser Centers, Tel Aviv, Israel, were reviewed. The procedure consisted of a customized 50-µm laser ablation of the epithelium and anterior stroma using the EX500 excimer laser (Alcon Laboratories, Inc., Fort Worth, TX), targeting 50% of the manifest refractive astigmatism, followed by standard CXL. Data collected included pachymetry, keratometric values, spherical equivalent (SEQ), manifest refraction, uncorrected visual acuity (UCVA), and best-corrected visual acuity (BCVA). These parameters were recorded preoperatively and at the final postoperative examination.

The cohort comprised 400 eyes of 309 patients (73.0% male) with a mean age of 28.14±9.25 years and a mean follow-up of 810.60±1,025.17 days. Significant improvements (P<0.001) were seen: decimal BCVA from 0.61±0.22 to 0.75±0.21, UCVA from 0.20±0.19 to 0.50±0.29. Average keratometry decreased from 46.54±2.89 to 44.72±2.83D, K maximum from 48.04±3.39 to 46.05±3.28D, and K minimum from 45.04±2.70 to 43.38±2.63D. SEQ improved from -2.99±3.04 to -1.14±2.07D, sphere from -1.31±3.03 to -0.19±1.96D, and cylinder from -3.36±1.77 to -1.92±1.53D. Pachymetry decreased from 460.70±37.04 to 410.41±49.41 μm. Postoperative UCVA gains of ≥1, ≥2, and ≥3 lines occurred in 76.3%, 62.2%, and 48.4% of eyes, respectively; BCVA gains were 61.5%, 39.2%, and 24.3%.

In the largest reported series to date, the Tel-Aviv Protocol demonstrates significant improvement in both uncorrected and best-corrected visual acuity, with substantial reduction in keratometric values, astigmatism, and spherical equivalent, while maintaining a modest reduction in corneal thickness comparable to standard CXL with epithelial removal alone. These results confirm the efficacy and safety of the Tel-Aviv Protocol as a treatment option for progressive keratoconus.