title: Toric topographically customized transepithelial, pulsed, very high-fluence, higher energy and higher riboflavin concentration collagen cross-linking in keratoconus.
abstract: OBJECTIVE
  To report a novel application of toric topographically customized transepithelial collagen cross-linking (CXL) aiming to achieve refractive astigmatic changes in a keratoconic cornea.
  
  
  METHODS
  Specially formulated riboflavin transepithelial administration and delivery of high-fluence UVA in a topographically customized pattern was applied in an eye with progressive keratoconus. Visual acuity, cornea clarity, keratometry, topography, and pachymetry with a multitude of modalities, as well as endothelial cell counts were evaluated for >6 months.
  
  
  RESULTS
  Uncorrected distance visual acuity changed from preoperative 20/40 to 20/25 at 6 months. A mean astigmatic reduction of 0.8 D, and significant cornea surface normalization was achieved 6 months postoperatively. There was some mild change in the epithelial distribution, with the treated area having a slight normalization in the average epithelial thickness.
  
  
  CONCLUSIONS
  We introduce herein the novel application of a topographically customizable transepithelial CXL in progressive keratoconus in order to achieve an astigmatic refractive effect and ectasia stabilization. This novel technique offers a nonablative and nonincisional approach to treat irregular astigmatism in ectatic cornea with rapid visual rehabilitation.
authors: Laservision.gr Eye Institute, Athens, Greece ; Department of Ophthalmology, NYU Medical School, New York, N.Y., USA.
authors: Anastasios John
authors: AJ
authors: Kanellopoulos
authors: Department of Ophthalmology, Cleveland State University, Cleveland, Ohio, USA ; Department of Biomedical Engineering, Cleveland Clinic, Cleveland State University, Cleveland, Ohio, USA.
authors: William J
authors: WJ
authors: Dupps
authors: Department of Cole Eye Institute, Cleveland Clinic, Cleveland State University, Cleveland, Ohio, USA ; Department of Chemical and Biomedical Engineering, Cleveland State University, Cleveland, Ohio, USA.
authors: Ibrahim
authors: I
authors: Seven
authors: Laservision.gr Eye Institute, Athens, Greece.
authors: George
authors: G
authors: Asimellis
keywords: High-fluence cross-linking; KXL II; Keratoconus; Photorefractive intrastromal cross-linking; Topography customizable cross-linking; Toric cross-linking; Transepithelial cross-linking