NEWS & OPINION EWAP SEPTEMBER 2022 59 stability defined as change in Kmax within ±1 D of baseline and progression or regression falling greater than 1 D above or below this range, respectively. Additional outcome measures included corrected distance visual acuity (CDVA), manifest refractive spherical eµuivalent (MRSE), corneal densitometry, and topographic measurements such as Kmax and simulated keratometry (SimK). Results Among the 58 eyes that met inclusion criteria, standard epi-off CXL was performed in 34 eyes, TECXL in 10 eyes, and CACXL in 14 eyes. Patients were mostly male (71%) with a mean age of 19.26 years. Baseline parameters were largely comparable between groups, with no significant difference found among CDVA, MRSE, or Kmax in the groups. Patients who underwent TECXL were significantly older than those who underwent standard epi-off CXL and CACXL. Mean thinnest pachymetry was similar between the CACXL and TECXL groups and, as eÝpected, significantly thinner when compared to those that underwent standard epioff CXL. Of note, there was a trend for eyes in the CACXL group to have a higher Kmax at baseline as compared to the two other groups (p=0.09). All three techniµues were similarly effective at halting progression of ectasia at 2 years (p=0.61). In the standard epi- off CXL group, regression was seen in 62% of eyes (n=21), stabilization in 32% (n=11), and progression in 6% (n=2). In the CACXL and TECXL groups, regression was seen in 79% (n=11) and 80% (n=8) of eyes, respectively, while the remaining eyes demonstrated stabilization. No progression was seen in any eyes in the CACXL or TECXL groups. At the 2-year follow-up, the largest reduction in Kmax was seen in the CACXL group at –3.18±2.74 D, followed by –2.83±3.35 D in the standard epi-off CXL and –2.02±1.66 D in the TECXL group. Between group comparison of reduction in Kmax as well as reduction in the yat, steep, and mean simulated keratometry at 2 years was comparable among all three groups. Assessment of CDVA at 2 years demonstrated improvement in all groups when compared to baseline, however, this reached statistical significance only in the standard epi-off CXL group (p=0.006). Between group comparison revealed that improvement in CDVA was similar among all groups (p=0.46). A statistically significant improvement in MRSE was seen within all three groups that also remained similar in all groups throughout the follow-up period. One patient in the TECXL group developed herpetic epithelial keratitis (geographic ulcer) at the 3-week follow-up and was managed successfully with topical ganciclovir. No other complications were reported. Discussion Variability in CXL protocols among studies, especially for newer techniµues, can make comparison of outcomes difficult. This is the first study that compares standard epi-off Comparison of contact lens-assisted and transepithelial corneal crosslinking with standard epithelium-off crosslinking for progressive keratoconus: 24-month clinic results Malhotra C, et al. J Cataract Refract Surg. 2022;48(2):199–207 Purpose: To compare outcomes of contact lens-assisted corneal crosslinking (CACXL) and transepithelial corneal crosslinking (TECXL) with standard “epithelium-off” (“epi-off”) crosslinking (CXL) for progressive keratoconus Setting: Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India Design:Retrospective, comparative study Methods: Patients with progressive keratoconus undergoing CXL with a minimum follow-up of 24 months were included. CACXL and TECXL was performed in patients with “epithelium-on” minimal pachymetry between 350 ùm and 4x0 ùm. Main outcome measures included change in maÝimum keratometry maÝ®, corrected distance visual acuity DVA®, and efficacy in halting progression increase in maÝ Ĉ £ diopter [D]®. Results: Standard “epi-off” CXL, CACXL, and TECXL was performed in 34, 14, and 10 eyes, respectively. Baseline maÝ and DVA were comparable for all groups. maÝ was reduced significantly by qÓ.nδÎ.Îx D, –3.18±2.74 D, and –2.02±1.66 D in the standard “epi-off” CXL (p<0.01), CACXL (p=0.001), and TECXL (p=0.004) groups, respectively; the reduction was comparable for all groups (p=0.63). CDVA improved by –0.14±0.24, –0.04±0.19, and –0.12± 0.17 logMAR units in the standard “epi-off” CXL (p=0.006), CACXL (p=0.42), and TECXL (p=0.05) groups, respectively; the reduction was comparable for all groups (p=0.46). Progression was documented in 2 eyes (6%) of the standard “epi-off” CXL group and 0% eyes of the CACXL and TECXL groups (p=0.61). Conclusions:CACXL and TECXL were comparable to standard “epi-off” CXL for progressive keratoconus.
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