title: Epithelium-on corneal cross-linking treatment of progressive keratoconus: a prospective, consecutive study.
abstract: OBJECTIVE
  To evaluate the outcome of collagen cross-linking (CXL) without corneal epithelial debridement in patients treated for progressive keratoconus for whom the standard epithelium-off treatment cannot be applied, as their central corneal thickness (CCT) is less than 400 μm.
  
  
  METHODS
  This was a prospective, uncontrolled, interventional study involving 32 eyes of 30 patients with progressive keratoconus and CCT of less than 400 μm. All patients received CXL treatment with application of riboflavin and exposure to ultraviolet light A for 30 minutes without corneal epithelial debridement. Patients were followed up to 12 months postoperatively. The main outcomes were changes in maximum-K reading, manifest refractive spherical equivalent, CCT, and best-corrected visual acuity (logarithm of minimum angle of resolution). Patients were also asked to report any pain or discomfort during the procedure.
  
  
  RESULTS
  At the end of the 12-month follow-up, CCT showed no significant change: from 392±5.17 μm preoperatively to 390±4.45 μm (P=0.102). Maximum-K reading decreased significantly, from 49.19±2.30 D preoperatively to 46.96±6.03 D postoperatively (P<0.05). The mean manifest spherical equivalent showed no significant change: from 4.04±1.51 D preoperatively to 4.17±1.63 D postoperatively (P=0.110). Mean best-corrected visual acuity showed no significant change: from 0.29±0.12 preoperatively to 0.31±0.11 postoperatively (P=0.110).
  
  
  CONCLUSIONS
  Epithelium-on CXL exhibits potential as a method for treating patients with progressive keratoconus and CCT of less than 400 μm, in which the standard epithelium-off CXL cannot be applied. Over 12 months of follow-up, the epithelium-on CXL was safe and effective, with results comparable to that achieved with the epithelium-off technique in thicker corneas, and reduced rates of operative and postoperative discomfort.
authors.affiliation: Ophthalmology Department, Menoufia University Hospitals, Menofia, Egypt.
authors.forename: Hany A
authors.initials: HA
authors.lastname: Khairy
authors.affiliation: Ophthalmology Department, Menoufia University Hospitals, Menofia, Egypt.
authors.forename: Hatem M
authors.initials: HM
authors.lastname: Marey
authors.affiliation: Ophthalmology Department, Menoufia University Hospitals, Menofia, Egypt.
authors.forename: Amin Faisal
authors.initials: AF
authors.lastname: Ellakwa
keywords: cross-linking; epithelium; keratoconus; refractive surgery