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Refractive improvements and safety with topography-guided corneal crosslinking for keratoconus: 1-year results
  1. Maria Nordström,
  2. Maria Schiller,
  3. Anneli Fredriksson,
  4. Anders Behndig
  1. Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden
  1. Correspondence to Professor Anders Behndig, Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå SE-901 87, Sweden; anders.behndig{at}


Purpose To assess the refractive improvements and the corneal endothelial safety of an individualised topography-guided regimen for corneal crosslinking in progressive keratoconus.

Methods An open-label prospective randomised clinical trial was performed at the Department of Clinical Sciences, Ophthalmology, Umeå University Hospital, Umeå, Sweden. Thirty-seven patients (50 eyes) with progressive keratoconus planned for corneal crosslinking were included. The patients were randomised to topography-guided crosslinking (photorefractive intrastromal crosslinking (PiXL); n=25) or uniform 9 mm crosslinking (corneal collagen crosslinking (CXL); n=25). Visual acuity, refraction, keratometry (K1, K2 and Kmax) and corneal endothelial morphometry were assessed preoperatively and at 1, 3, 6 and 12 months postoperatively. The PiXL treatment involved an asymmetrical treatment zone centred on the area of maximum corneal steepness with treatment energies ranging from 7.2 to 15.0 J/cm2; the CXL treatment was a uniform 9 mm 5.4 J/cm2 pulsed crosslinking. The main outcome measures were changes in refractive errors and corneal endothelial cell density.

Results The spherical refractive errors decreased (p<0.05) and the visual acuity improved (p<0.01) at 3, 6 and 12 months after PiXL, but not after CXL. The between-groups differences, however, were not significant. K2 and Kmax decreased at 3, 6 and 12 months after PiXL (p<0.01), but not after CXL (p<0.01 when comparing the two treatments). No corneal endothelial cell loss was seen after either treatment.

Conclusions Individualised topography-based crosslinking treatment centred on the ectatic cone has the potential to improve the corneal shape in keratoconus with decreased spherical refractive errors and improved visual acuity, without damage to the corneal endothelium.

Trial registration number NCT02514200, Results.

  • Cornea
  • Optics and Refraction
  • Degeneration

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  • Contributors MN and MS share first authorship. All authors have made substantial contributions to the conception and design of the work, as well as the acquisition, analysis and interpretation of data for the work. All authors have contributed to drafting the work and revising it critically for important intellectual content. Finally, all authors have provided a final approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This study was funded by grants from the KMA Fund and Ögonfonden.

  • Disclaimer Neither KMA Fund nor Ögonfonden had any role in the design or conduct of the study; the collection, management, analysis or interpretation of the data; the preparation, review or approval of the manuscript; or the decision to submit the manuscript for publication.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval  The study was approved by the Regional Ethical Board in Umeå, Sweden, and was performed in accordance with the Declaration of Helsinki.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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