Long-Term Visual Outcomes, Corneal Stability, And Haze Formation After Prk, Prk With Cross-Linking, And Transepithelial Prk With Cross-Linking In Eyes With Suspected Keratoconus

To compare long-term visual outcomes, corneal stability, and procedure-related complications following photorefractive keratectomy (PRK), PRK combined with corneal collagen cross-linking (PRK+CXL), and transepithelial PRK combined with cross-linking (Trans-PRK+CXL) in eyes with suspected keratoconus.

Single tertiary referral eye centre.

This retrospective comparative study analysed eyes with suspected keratoconus that underwent PRK, PRK+CXL, or Trans-PRK+CXL at a single tertiary referral centre. Long-term clinical outcomes were evaluated with particular emphasis on uncorrected and corrected distance visual acuity, refractive and topographic stability, signs of ectatic progression, and postoperative corneal haze formation. All procedures were performed using standardised surgical protocols and patients were followed longitudinally.

All three surface ablation techniques achieved meaningful and sustained improvements in visual acuity over long-term follow-up. Procedures incorporating corneal cross-linking demonstrated greater corneal stability and a lower tendency toward ectatic progression compared with PRK alone. Visual and refractive outcomes were broadly comparable between PRK and Trans-PRK combined with cross-linking. However, the addition of cross-linking to conventional PRK was associated with a higher incidence of postoperative corneal haze, whereas transepithelial PRK combined with cross-linking showed a more favourable balance between corneal stability and haze formation.

In eyes with suspected keratoconus, surface ablation procedures can provide satisfactory long-term visual outcomes when careful patient selection is applied. The addition of corneal cross-linking enhances long-term corneal stability but may increase the risk of postoperative haze, particularly when combined with conventional PRK. Transepithelial PRK combined with cross-linking may represent a balanced surgical approach, maintaining visual performance while offering biomechanical reinforcement. These findings support an individualised strategy when selecting refractive procedures for eyes at potential biomechanical risk.