ESCRS - PP16.08 - Prospective Evaluation Of Pulsed, Accelerated, Customized Refractive Corneal Cross-Linking (Elza-Pace) To Improve Vision In Progressive Keratoconus

Prospective Evaluation Of Pulsed, Accelerated, Customized Refractive Corneal Cross-Linking (Elza-Pace) To Improve Vision In Progressive Keratoconus

Published 2026 - 44th Congress of the ESCRS

Reference: PP16.08 | Type: Poster | DOI: 10.82333/w45p-vk71

Authors: Prof. Dr Farhad Hafezi** 1 , A/Prof. Shady Awwad 2 , Dr Sabine Kling 3 , Mr Léonard Kollros 1 , Mrs Nikki Hafezi 1 , Mrs Michalina Depczynska 1 , Dr Emilio A. Torres-Netto 1

1ELZA Institute AG,Zurich,Switzerland, 2American University of Beirut,Beirut,Lebanon, 38. Computational Bioengineering Group,University of Berne,Nerne,Switzerland

Purpose

To evaluate one-year and two-year structural and functional outcomes of ELZA-PACE, a PTK-assisted, customized epithelium-on epithelium-off refractive corneal cross-linking technique designed to reduce topographic asymmetry and improve visual quality in corneal ectasia without stromal tissue removal.

Setting

Proespective single-site interventional study, conducted at the ELZA Institute, Zurich, Switzerland.

Methods

A total of 135 progressive and stable keratoconus eyes underwent ELZA-PACE with up to 14 J/cm2. The procedure combines (1) selective PTK-based epithelial removal over the tip of the cone, creating a localized epi-off zone within an otherwise epi-on cornea, (2) cone-centered riboflavin gradient formation, and (3) differentiated ultraviolet fluence delivery with highest energy densities over the ectatic region. Pre- and postoperative evaluation included Scheimpflug tomography (Pentacam HR), anterior segment OCT-based topography (MS-39), corneal biomechanics (Corvis ST), and standardized corrected visual acuity and refraction. Outcomes were assessed up to 24 months.

 

Results

ELZA-PACE produced substantial cone-centered flattening, with reductions in maximal keratometry of up to 12 diopters in selected cases in the absence of any signs of endothelial decompensation nor clinically relevant haze. Topographic and tomographic analyses demonstrated consistent reduction of corneal asymmetry and improved surface regularity. Biomechanical parameters indicated a redistribution of corneal stiffness consistent with targeted strengthening. Subgroup analyses revealed that preoperative cone morphology, demographic factors, patient age and ectasia status (stable vs progressive) influenced the magnitude of flattening and regularization. Structural improvements were accompanied by measurable functional gains in visual quality.

Conclusions

ELZA-PACE combines oxygen, riboflavin, and UV-fluence gradients to achieve individualized biomechanical regularization without stromal tissue ablation. Beyond focal cone flattening, a biomechanically mediated coupling effect contributes to broader corneal regularization. One-year and two-year data support the safety and efficacy of this second-generation customized refractive corneal cross-linking approach in progressive keratoconus.