PURPOSE: To assess the safety and efficacy of a novel pulsed-light enhanced-fluence iontophoresis corneal cross-linking (EF I-CXL) procedure in patients with progressive keratoconus. METHODS: This prospective interventional pilot study included 12 eyes of 10 patients. Iontophoresis with Ricrolin+ solution (Sooft, Montegiorgio, Italy) was used for stromal imbibition. The treatment energy dose (fluence) was optimized at 30% (from 5.4 J to 7 J/cm ² ) and ultraviolet-A (UV-A) power set at 18 mW/cm ² × 6.28 minutes of exposure time, pulsing the light 1 second on/1 second off with a total irradiation time of 12.56 minutes. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), Scheimpflug corneal tomography data, and corneal optical coherence tomography (OCT) at baseline and 1, 3, 6, and 12 months postoperatively were evaluated. RESULTS: Twelve-month statistically significant average data ( P < .05) showed UDVA decreased from 0.50 ± 0.10 to 0.36 ± 0.08 logMAR, maximum keratometry decreased from 52.86 ± 1.50 to 51.49 ± 0.90 diopters (D), surface asymmetry index decreased from 2.34 ± 0.36 to 2.13 ± 1.12 D, symmetry index decreased from 4.22 ± 1.01 to 3.56 ± 0.90 D, and coma decreased from 0.25 ± 0.05 to 0.14 ± 0.06 μ m. Corneal OCT showed greater than 80% demarcation line detection at 295.8 ± 20.2 μ m depth on average in the first postoperative month. CONCLUSIONS: The preliminary results of the EF I-CXL protocol demonstrate its capability to increase I-CXL efficacy closer to standard CXL. [ J Refract Surg. 2018;34(7):438–444.]

Purpose: The aim of this study was to report the 12 to 96 months results of a tissue-preservation algorithm based on ray-tracing-guided transepithelial excimer laser central corneal ablation (RT t-PRK) combined with individualized pachymetry-guided accelerated crosslinking (M nomogram ACXL) in young adult patients with stable keratoconus (KC). Methods: This was a prospective interventional study including 38 eyes of 38 young adult patients (stage II KC) with a mean age of 35 years (range 26–46 years) who underwent simultaneous RT with t-PRK plus pachymetry-based ACXL in the worst eye. The treatments were performed using the iViS Suite iRES Excimer Laser (Ligi, Taranto, Italy). Ray-tracing–guided treatments were planned using the customized interactive programmed transepithelial ablation (CIPTA) 2 web software and diagnostic data were assessed by the Precisio 2 tomographer (Ligi, Taranto, Italy) and Sirius tomographer (C.S.O., Florence, Italy). The main outcome measures included uncorrected distance visual acuity, best spectacle–corrected visual acuity, Kmax, high-order aberrations, minimum corneal thickness, and posterior elevation, with a mean follow-up of 52 months (range 12–96 m). Results: The mean UDVA improved + 3.5 ±1.28 Snellen lines (SL); 38% gained ≥ 4 ±1.34 SLs, 35% ≥ 3 ±1.21 SLs, 22% ≥ 2 ±1.12 SLs, and 5% ≥ 1 ±0.75 SLs. The mean best spectacle–corrected visual acuity increased by + 4.3 ±1.3 SL. Sixty-eight percent gained ≥ 4 ±0.88 SLs and 30% ≥ 3 ±0.78 SL. No SLs were lost. Conclusions: RT t-PRK plus ACXL significantly improved the quality of vision in patients with KC, preventing overcorrection and minimizing tissue consumption.

Purpose: To assess the 3-year clinical results of the 18 mW 7 J/cm² transepithelial enhanced fluence pulsed light M accelerated crosslinking in the treatment of progressive keratoconus (KC) with chemically enhanced hyper-concentrated riboflavin solutions without iontophoresis and with air-room oxygenation. Setting: Siena Crosslinking Center, Siena, Italy. Methods: Prospective pilot, open non-randomized interventional study including 40 eyes of 30 young adult patients over 21 years old (10 simultaneous bilateral) with early (Stage I and II) progressive KC undergoing TE-EFPL 18 mW/7 J/cm² ACXL (EFPL M TECXL). The 12 min and 58 s pulsed light (1 s on/1 s off) UV-A exposure treatments were performed with a biphasic corneal soaking using Paracel I 0.25% for 4 min and Paracel II 0.22% for 6 min riboflavin solutions and New KXL I UV-A emitter (Glaukos-Avedro, Waltham, USA) at an air room of 21% oxygenation. All patients completed the 3-year follow-up. Results: CDVA showed a statistically significant improvement in the third postoperative month (Δ + 0.17 d. e.) with a final gain of +0.22 d. eq. AK showed a statistically significant decrease in the sixth postoperative month (Δ − 1.15 diopters). K itmax showed a statistically significant decrease at 1-year follow-up (Δ − 1.3 diopters). The coma value improved significantly by the sixth month (Δ − 0.54 µm). MCT remained stable during the entire follow-up. No adverse events were recorded. Corneal OCT revealed a mean demarcation line depth at 282.6 ± 23.6 μm. Conclusions: Transepithelial enhanced fluence pulsed light M accelerated crosslinking with chemically enhanced riboflavin solution halted KC progression in young adult patients without iontophoresis and no intraoperative oxygen supplementation addressing the importance of increased fluence.

We describe the use of a simple tool to evaluate the postoperative alignment of toric intraocular lenses (IOLs). The entire anterior segment is scanned using anterior segment optical coherence tomography and analyzed with an internal dedicated tool. A topographic map is displayed along with an anterior segment image, including a linear axis marker centered on the corneal apex. The marker can be rotated until it is aligned with the line connecting the IOL marking dots, precisely reproducing the IOL astigmatic axis, which is measured in angle degrees. The value of the IOL astigmatic axis is compared with the value of the astigmatic axis shown in real time on the same screen in the topographic map. Evaluating the alignment of a toric IOL axis simultaneously with the topographic astigmatic axis eliminates the potential errors that result from head tilting and strictly correlates with the astigmatic correction achieved.

To evaluate the efficacy of a low-cost preparation of platelet-rich plasma (PRP) eye drops in the treatment of persistent non-infectious corneal ulcer. A 67-year-old female presented to our clinic with a wide corneal ulcer and severe paracentral corneal thinning refractory to medical therapy with antibiotics, lubricant and contact lens bandage. The patient received a novel preparation of PRP solution. After 15 days of therapy, we observed complete resolution of the corneal ulcer with regrowth of the epithelium and a reduction in corneal opacity. Although the low-cost PRP preparation gives a lower platelet concentration than standard procedures, our work shows this preparation to be effective in the treatment of refractory non-infectious corneal ulcer.

The purpose of this study was to evaluate the effectiveness and safety of a novel buffered riboflavin solution approved for corneal cross-linking (CXL) in progressive keratoconus and secondary corneal ectasia. Following the in vivo preclinical study performed on New Zealand rabbits comparing the novel 0.25% riboflavin solution (Safecross^®) containing 1% hydroxypropyl methylcellulose (HPMC) with a 0.1% riboflavin solution containing 0.10% EDTA, accelerated epithelium-off CXL was performed on 10 patients (10 eyes treated, with the contralateral eye used as control) through UV-A at a power setting of 9 mW/cm² with a total dose of 5.4 J/cm². Re-epithelialization was evaluated in the postoperative 7 days by fluorescein dye test at biomicroscopy; endothelial cell count and morphology (ECD) were analyzed by specular microscopy at the 1st and 6th month of follow-up and demarcation line depth (DLD) measured by anterior segment optical coherence tomography (AS-OCT) one month after the treatment. We observed complete re-epithelization in all eyes between 72 and 96 h after surgery (88 h on average). ECD and morphology remained unchanged in all eyes. DLD was detected at a mean depth of 362 ± 50 µm, 20% over solutions with equivalent dosage. SafeCross^® riboflavin solution chemically-boosted corneal cross-linking seems to optimize CXL oxidative reaction by higher superoxide anion release, improving DLD by a factor of 20%, without adverse events for corneal endothelium.