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Safalı F, Ocak SY, Argon BD, Karaca G, Elçioğlu MN. Evaluation of the results of contact lens assisted corneal cross-linking treatment in keratoconus patients with thin corneas. Jpn J Ophthalmol 2024; 68:225-232. [PMID: 38557918 DOI: 10.1007/s10384-024-01055-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 02/20/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE We aimed to compare the efficacy and safety of accelerated contact lens-assisted cross-linking (CA-CXL) with Lotrafilcon B and Comfilcon A lenses in keratoconus (KC) patients with thin corneas. STUDY DESIGN Retrospective, single-center study. MATERIALS AND METHODS We retrospectively included 51 eyes of 39 KC patients with corneal thickness <400µm after epithelial scraping (Epi-off), who underwent accelerated CA-CXL treatment with Lotrafilcon B (n=20) and Comfilcon A (n=31). Uncorrected and corrected distance visual acuity (UDVA and CDVA), manifest refraction values, corneal topographic data and endothelial cell density were recorded at preoperative and postoperative 1st, 3rd and 6th month controls. RESULTS CDVA in the Comfilcon A group was higher than CDVA before surgery at 6 months postoperatively (p<0.001). When the two lenses were compared, CDVA was found to be significantly higher in the Lotrafilcon B group in the preoperative, postoperative 1st month and 3rd month values, but there was no significant difference between the postoperative 6th month values (p=0.028, p=0.018, p=0.044, p=0.181, respectively). The maximum keratometry (Kmax) value at the 6th month after surgery in the Comfilcon A group was significantly lower than in the Lotrafilcon B group (p=0,009). There was no significant difference between the endothelial cell density values between the groups (p=0.623, p=0.609, p=0.794, p=0.458, respectively). There was no significant difference between the progression, regression, and stability rates of the two groups (p=0.714). CONCLUSIONS Accelerated CA-CXL with Lotrafilcon B and Comfilcon A silicone hydrogel lenses is a safe and effective method to stop progression in patients with thin corneas.
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Affiliation(s)
- Fidan Safalı
- Prof.Dr.Cemil Tascioglu City Hospital, Istanbul, Turkey.
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Nieuwsma A, Vander Zee BL, Berdahl JP, Ibach M, Ferguson TJ, Terveen D. Evaluating the safety and efficacy of epi-off corneal cross-linking in patients with thin corneas due to keratectasia. Ther Adv Ophthalmol 2023; 15:25158414231197064. [PMID: 37720204 PMCID: PMC10504847 DOI: 10.1177/25158414231197064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/07/2023] [Indexed: 09/19/2023] Open
Abstract
Background Corneal cross-linking (CXL) is a safe and effective procedure for slowing keratectasia progression in eyes with a corneal thickness of at least 400 µm. Limited research has evaluated the safety and efficacy of epi-off CXL in corneas thinner than 400 µm. Objective To evaluate the safety and efficacy of CXL to slow keratectasia progression in eyes with <400 µm preoperative corneal thickness. Design Retrospective chart review. Methods This retrospective chart review included 37 eyes who underwent epi-off, iso-osmolar riboflavin corneal CXL with a preoperative thinnest point of the cornea <400 µm and had at least 6-12 months of follow-up. Preoperative and postoperative uncorrected visual acuity, best-corrected visual acuity (BCVA), thinnest point of the cornea, flat keratometry, steep keratometry, maximum keratometry (Kmax), need for penetrating keratoplasty, and cases of endothelial failure were recorded. Data were collected at baseline and months 3, 6, 9, and 12 post-CXL. Results Following cross-linking, 18 eyes (47%) had improved BCVA, 13 (35%) had an unchanged BCVA, and 6 eyes (16%) had a worse BCVA (p = 0.05). The mean postoperative BCVA was 20/81 (0.61 LogMAR) compared to 20/121 (0.78 LogMAR) preoperatively (p = 0.06). Kmax decreased an average of 1.1 D at 3-month (p = 0.53) and 3.4 D at the furthest follow-up (p = 0.10). At the farthest follow-up, 22.7% of eyes had >1 D of Kmax steepening. No patients required keratoplasty and there were no cases of endothelial failure in the follow-up period. Conclusion This research supports the safety and efficacy of epi-off, iso-osmolar CXL in eyes with <400 μm baseline corneal thickness with no patients requiring penetrating or endothelial keratoplasty, a trend toward improvement in BCVA, and Kmax flattening. In the future, prospective studies would be helpful to confirm these findings.
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Affiliation(s)
- Abigail Nieuwsma
- University of Texas Health, San Antonio, TX, USA
- University of South Dakota Sanford School of Medicine, Sioux Falls, SD, USA
| | - Brandon L. Vander Zee
- University of South Dakota Sanford School of Medicine, 3140 Limekiln Avenue, Madison, WI, 53719, USA
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Uysal BS, Ozmen MC, Yuksel M, Aydın B, Bilgihan K. Comparison of safety and efficacy of silicone hydrogel contact Lens-assisted CXL and accelerated CXL in keratoconus patients with thin corneas. Eur J Ophthalmol 2023; 33:44-51. [PMID: 36062606 DOI: 10.1177/11206721221125029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of silicone hydrogel contact lens-assisted corneal cross-linking (CL-CXL) and compare 12-month visual and topographic outcomes with accelerated CXL using hypo-osmolar riboflavin (A-CXL) in keratoconus patients with thin corneas (below 400 μm with epithelium). METHODS This retrospective study included 27 eyes of 27 keratoconus patients who underwent CL-CXL (n = 14) or A-CXL (n = 13). Uncorrected and corrected distance visual acuity (UDVA and CDVA) and data obtained from corneal topography were analyzed at baseline and again at 6- and 12-month follow-ups. Corneal demarcation line depth (DLD) was measured at one month, and changes in the corneal endothelial cell density (ECD) at 12 months were also assessed. RESULTS Mean UDVA improved significantly in both groups at 12 months (all p < 0.05). Maximum keratometry (K-max) decreased by 1.04 ± 1.90 D in the CL-CXL group and by 0.87 ± 1.89 D in the A-CXL group at 12 months, which was not statistically significant (all p>0.05). Total corneal higher-order aberrations (HOAs) analysis showed a significant improvement in only the CL-CXL group at 12 months (p = 0.041). Average DLD was 227.18 ± 65.60 μm in the CL-CXL group and 245.30 ± 66.84 μm in the A-CXL group (p = 0.275). No significant change in ECD was found in either group (all p>0.05). Mean changes in UDVA, CDVA, K-max, K-mean, HOAs, and ECD were not statistically significant between the groups (all p>0.05). CONCLUSIONS Silicone hydrogel CL-assisted CXL seems as effective as A-CXL in halting keratoconus progression in thin corneas with no side effects during the one-year follow-up period.
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Affiliation(s)
- Betul Seher Uysal
- Department of Ophthalmology, 37511Gazi University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Cuneyt Ozmen
- Department of Ophthalmology, 37511Gazi University Faculty of Medicine, Ankara, Turkey
| | - Murat Yuksel
- Department of Ophthalmology, 37511Gazi University Faculty of Medicine, Ankara, Turkey
| | - Bahri Aydın
- Department of Ophthalmology, 37511Gazi University Faculty of Medicine, Ankara, Turkey
| | - Kamil Bilgihan
- Department of Ophthalmology, 37511Gazi University Faculty of Medicine, Ankara, Turkey
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Long-term visual, refractive, tomographic and aberrometric outcomes of corneal collagen crosslinking (CXL) with or without hypoosmolar riboflavin solution in the treatment of progressive keratoconus patients with thin corneas. Graefes Arch Clin Exp Ophthalmol 2021; 260:1225-1235. [PMID: 34837507 DOI: 10.1007/s00417-021-05314-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/27/2021] [Accepted: 07/01/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE To evaluate the long-term visual, refractive, tomographic, and aberrometric outcomes of corneal collagen crosslinking (CXL) with or without hypoosmolar riboflavin solution in the treatment of progressive keratoconus patients with thin corneas. METHODS Charts of consecutive progressive keratoconus patients with thinnest corneal thickness less than 470 µm who underwent corneal collagen CXL with or without hypoosmolar riboflavin solution and using a standardized protocol for treatment and examinations were analyzed retrospectively. The indication for hypoosmolar riboflavin use was a central corneal thickness less than 400 µm as measured by ultrasound pachymetry after epithelial debridement and before exposure to ultraviolet A (UVA) light. Uncorrected distance visual acuity (UDVA), best spectacle-corrected distance visual acuity (CDVA), manifest refraction, slit lamp biomicroscopy, corneal tomography, corneal aberrometry, and endothelial cell counts were evaluated at baseline and yearly at all postoperative follow-up examinations until month 36. The outcomes of corneal CXL procedure performed using hypoosmolar riboflavin were compared to those performed using the standard procedure. RESULTS Twenty-three eyes (19 patients) were treated using hypoosmolar riboflavin application, and 30 eyes (28 patients) were treated using the standard procedure. Compared to baseline, the mean UDVA, CDVA, and keratometric readings improved statistically significantly in both groups at postoperative year 3, without any statistically significant between-group differences. Progression was not observed in any patient eye in either group. No significant endothelial cell loss and no sight threating complication were observed in any patient eye. CONCLUSION At 3 years follow-up, the safety and efficacy of CXL using hypoosmolar riboflavin solution seems to be similar to that of standard CXL in progressive keratoconic eyes with thin corneas. The visual, refractive, keratometric, tomographic and aberrometric outcomes of the two procedures were comparable, as well.
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Seyyar SA, Mete A, Kimyon S, Tıskaoğlu NS. Outcomes of customized topographic guided epithelial debridement for corneal collagen cross-linking. Int Ophthalmol 2021; 42:1273-1280. [PMID: 34727264 DOI: 10.1007/s10792-021-02114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the outcomes of corneal collagen cross-linking performed with customized epithelial debridement technique in progressive keratoconic corneas. MATERIALS AND METHODS Forty eyes of 40 patients were included in the study. We performed an ophthalmologic examination and recorded the uncorrected visual acuity, best corrected visual acuity (BCVA), central corneal thickness at the thinnest point (t-CCT), flat meridian keratometry (K1), steep meridian keratometry (K2), endothelial cell density (ECC), hexagonal cells (HEX), and coefficient of variation of cell areas (CV) measured preoperatively and at the 1st, 3rd, 6th and 12th months postoperatively. RESULTS The mean UCVA and BCVA were increased (p < 0.05). The mean flattest and steepest K readings were decreased (p < 0.05). The mean t-CCT decreased in the first months after treatment and increased after 6 months. The mean t-CCT was thicker at 12 months compared to pretreatment status (p < 0.05). The mean ECC and CV were not significantly different between follow-up intervals (p > 0.05). The mean HEX was statistically increased (p > 0.05). CONCLUSIONS Corneal collagen cross-linking performed with customized epithelial debridement technique is a successful alternative method for stopping the progression of keratoconus after 12 months of treatment.
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Affiliation(s)
- Sevim Ayca Seyyar
- Kocaeli Derince Education and Research Hospital Ophthalmology Department, İbni Sina, Lojman Sk., 41900, Derince, Kocaeli, Turkey.
| | - Alper Mete
- Gaziantep University Hospital Ophthalmology Department, Gaziantep, Turkey
| | - Sabit Kimyon
- Gaziantep University Hospital Ophthalmology Department, Gaziantep, Turkey
| | - Nesime Setge Tıskaoğlu
- Ersin Arslan Education and Research Hospital Ophthalmology Department, Gaziantep, Turkey
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Omar HA, El-Agha MSH, Hassaballah MA, Khalil NM. Safety and Efficacy of Epithelial Island Crosslinking in Keratoconus with Thinnest Pachymetry less than 400µ. Middle East Afr J Ophthalmol 2021; 28:11-17. [PMID: 34321817 PMCID: PMC8270024 DOI: 10.4103/meajo.meajo_186_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 12/08/2020] [Accepted: 02/03/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE: To evaluate the efficacy and safety of epithelial-island crosslinking (EI-CXL) in keratoconus with corneas thinner than 400 µm. METHODS: Twenty-six patients (30 eyes) underwent EI-CXL (preserving the epithelium over the thinnest area), using standard protocol (3 mW/cm2 for 30 min). Uncorrected and best spectacle-corrected distance visual acuity (UCDVA, BCDVA), manifest refractive spherical equivalent (SEQ), mean simulated keratometry (Kmean), maximum keratometry (Kmax), and thinnest corneal thickness (TCT) were determined preoperatively and at 1, 3, 6, and 12 months following CXL. Endothelial cell count (ECC) was determined preoperatively and at 6 months. Anterior segment optical coherence tomography (AS-OCT) was done at 1 month to determine the depth of the corneal stromal demarcation line (DL). RESULTS: After 1 year, mean UCDVA improved from 1.29 preoperatively to 1.17 (P = 0.001) and BCDVA from 0.62 to 0.57 (P = 0.011). Mean manifest SEQ decreased from -7.63 to-7.32D (P = 0.001). Mean Kmean decreased from 54.92 to 54.81D (P = 0.045), and Kmax from 67.60 to 67.42D (P = 0.072), and mean TCT changed minimally from 377.17 to 375.30 µ (P = 0.11). The mean ECC decreased from 2329 to 2268 cells/mm2 (2.6% decrease, P < 0.001). AS-OCT showed a DL in 29 out of 30 eyes at an average depth of 215.9 µ under the spared epithelium, and 299.9 µ in the de-epithelialized cornea. CONCLUSION: EI-CXL halted keratoconus progression over a 1-year period. This was associated with statistically significant endothelial loss, but less than seen with conventional epi-off CXL in thinner corneas.
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Affiliation(s)
- Hisham A Omar
- Department of Ophthalmology, Kasr Al Ainy School of Medicine, Cairo University, Giza, Egypt
| | | | - Mohamed A Hassaballah
- Department of Ophthalmology, Kasr Al Ainy School of Medicine, Cairo University, Giza, Egypt
| | - Noha M Khalil
- Department of Ophthalmology, Kasr Al Ainy School of Medicine, Cairo University, Giza, Egypt
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Crosslinking of Thin Corneas: a Modern Vision of the Problem. Literature Review. ACTA BIOMEDICA SCIENTIFICA 2020. [DOI: 10.29413/abs.2020-5.5.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Akkaya S, Ulusoy DM, Duru Z, Demirtaş AA. Long-term Outcomes of Accelerated Corneal Cross-linking in the Treatment of Keratoconus: Comparison of Hypotonic Riboflavin Solution With Standard Riboflavin Solution. J Refract Surg 2020; 36:110-117. [DOI: 10.3928/1081597x-20191218-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/17/2019] [Indexed: 11/20/2022]
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Whether Keratectasia Area Shown in Corneal Topography Is Appropriate for Evaluating the Effect of Corneal Cross-Linking for Keratoconus: A 12-Month Follow-Up Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1762537. [PMID: 31073520 PMCID: PMC6470445 DOI: 10.1155/2019/1762537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/03/2019] [Accepted: 03/20/2019] [Indexed: 11/24/2022]
Abstract
Purpose To analyze the keratectasia area (KEA) shown in corneal topography before and after corneal cross-linking (CXL) in patients with progressive keratoconus (KC) and figure out whether KEA is appropriate for evaluating the effect of CXL. Methods A retrospective analysis was conducted in 34 eyes from 24 progressive KC patients who have underwent CXL from 2015 to 2017. Area with K-value more than 47D shown in the corneal topography was marked and identified as KEA. Keratometry (K1, K2, and Kmax), KEA, thinnest corneal thickness (TCT), and endothelial cell density (ECD) were evaluated preoperatively or at months 3, 6, and 12 postoperatively. The changes of KEA before and after operation were evaluated. The relation of KEA and other parameters, including Kmax and TCT, was analyzed. Results Linear regression model revealed the KEA, Kmax, K1, and K2 decreased after CXL in model y = 0.9622 -0.02408 x (P<0.05), y = 0.9982 -0.003469 x(P<0.05), y = 0.9977 + -0.001347 x(P<0.05), y = 0.9992 + -0.001779 x(P<0.05) (y represents KEA, Kmax, K1, or K2; x represents time (month)). The KEA is significantly decreased in early stage (before month 3) (P<0.05); however, the Kmax, K1, and K2 have no significant decrease in early stage (P= 0.09, 0.19, 0.32). Conclusions The KEA is more sensitive than K-value in describing the morphological changes of cornea after CXL, especially in early stage after treatment.
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Deshmukh R, Hafezi F, Kymionis GD, Kling S, Shah R, Padmanabhan P, Sachdev MS. Current concepts in crosslinking thin corneas. Indian J Ophthalmol 2019; 67:8-15. [PMID: 30574883 PMCID: PMC6324097 DOI: 10.4103/ijo.ijo_1403_18] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Corneal cross-linking (CXL), introduced by Wollensak et al. in 2003, is a minimally invasive procedure to halt the progression of keratoconus. Conventional CXL is recommended in eyes with corneal thickness of at least 400 microns after de-epithelialization to prevent endothelial toxicity. However, most of the keratoconic corneas requiring CXL may not fulfill this preoperative inclusion criterion. Moderate-to-advanced cases are often found to have a pachymetry less than this threshold. There are various modifications to the conventional method to circumvent this issue of CXL thin corneas while avoiding the possible complications. This review is an update on the modifications of conventional CXL for thin corneas.
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Affiliation(s)
- Rashmi Deshmukh
- Cornea, Cataract and Refractive Services, Centre for Sight Hospital, New Delhi, India
| | - Farhad Hafezi
- ELZA Institute, Dietikon/Zurich; Laboratory for Ocular Cell Biology, University of Zurich, Zurich, Switzerland; University of Southern California, Roski Eye Institute, Los Angeles, CA, USA; Department of Ophthalmology, University of Wenzhou, Wenzhou, China
| | - George D Kymionis
- Athens Medical School, University of Athens, Athens, Greece; Jules Gonin Eye Hospital, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sabine Kling
- Ophthalmic Personalized treatment and imaging cluster (OPTIC), Department of Information Technology and Electrical Engineering Swiss Federal Institute of Technology Zurich (ETHZ), Switzerland
| | - Rupal Shah
- Centre for Sight Hospital, Vadodara, India
| | - Prema Padmanabhan
- Department of Cornea and Refractive Surgery, Sankara Nethralaya, Chennai, India
| | - Mahipal S Sachdev
- Cornea, Cataract and Refractive Services, Centre for Sight Hospital, New Delhi, India
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Kato N, Konomi K, Shinzawa M, Kasai K, Ide T, Toda I, Sakai C, Negishi K, Tsubota K, Shimazaki J. Corneal crosslinking for keratoconus in Japanese populations: one year outcomes and a comparison between conventional and accelerated procedures. Jpn J Ophthalmol 2018; 62:560-567. [PMID: 29987530 DOI: 10.1007/s10384-018-0610-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 06/06/2018] [Indexed: 01/03/2023]
Abstract
PURPOSE We retrospectively investigated the efficacy of corneal crosslinking (CXL) on progressive keratoconus in a Japanese population and compared the outcomes of conventional and accelerated CXL. STUDY DESIGN A retrospective cohort study METHODS: A total of 108 consecutive eyes in 95 patients (75 men; 21.9 ± 6.2 years) with progressive keratoconus were enrolled. The epithelium was ablated in all eyes. After presoaking the corneal stroma in riboflavin, UV-A was irradiated at 3.0 mW/cm2 (conventional CXL) for 30 min on 23 eyes and 18.0 mW/cm2 for 5 min (accelerated CXL) on 85 eyes. Best spectacle-corrected visual acuity (BSCVA), manifest refraction, keratometric value, corneal thickness, corneal endothelial cell density (ECD), intraocular pressure, and complications were evaluated at 1, 3, 6, and 12 months after the procedure. RESULTS BSCVA, manifest refraction, ECD, and corneal thickness did not change significantly after both procedures. The keratometric value was significantly decreased from the preoperative value at 12 months (p < 0.001). Progression to more than 1.0 D after CXL was observed in 10 eyes (9.3%). The ΔKmax was negatively associated with preoperative Kmax (p < 0.001) and positively associated with preoperative thinnest corneal thickness (p < 0.001). Both treatment modules showed no significant difference in all parameters. CONCLUSION CXL was as effective in treating keratoconus in Japanese patients as in individuals of other ethnicities. Overall, CXL could be performed using either the conventional or accelerated approach to halt the progression of keratoconus in Japanese populations.
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Affiliation(s)
- Naoko Kato
- Department of Ophthalmology, Saitama Medical University, Morohongo 38, Moroyamamachi, Iruma, Saitama, 350-0495, Japan.
- Department of Ophthalmology, Ichikawa General Hospital, Tokyo Dental College, Chiba, Japan.
- Department of Ophthalmology, School of Medicine, Keio University, Tokyo, Japan.
| | - Kenji Konomi
- Department of Ophthalmology, Ichikawa General Hospital, Tokyo Dental College, Chiba, Japan
| | - Megumi Shinzawa
- Department of Ophthalmology, Ichikawa General Hospital, Tokyo Dental College, Chiba, Japan
| | - Kozue Kasai
- Department of Ophthalmology, Ichikawa General Hospital, Tokyo Dental College, Chiba, Japan
| | - Takeshi Ide
- Tokyo Vision Eye Clinic Asagaya, Tokyo, Japan
| | | | - Chikako Sakai
- Department of Ophthalmology, School of Medicine, Keio University, Tokyo, Japan
| | - Kazuno Negishi
- Department of Ophthalmology, School of Medicine, Keio University, Tokyo, Japan
| | - Kazuo Tsubota
- Department of Ophthalmology, School of Medicine, Keio University, Tokyo, Japan
| | - Jun Shimazaki
- Department of Ophthalmology, Ichikawa General Hospital, Tokyo Dental College, Chiba, Japan
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