title: Corneal collagen cross-linking (CXL) combined with refractive procedures for the treatment of corneal ectatic disorders: CXL plus.
abstract: OBJECTIVE
  To discuss current combined corneal collagen cross-linking (CXL) and refractive surgical techniques (herein termed "CXL plus") for the treatment of corneal ectatic disorders to improve functional visual acuity in addition to corneal stability from CXL alone.
  
  
  METHODS
  Literature review.
  
  
  RESULTS
  Efficacious combined treatments with CXL include: photorefractive keratectomy, transepithelial phototherapeutic keratectomy, intrastromal corneal ring segments implantation, phakic intraocular lens implantation, and multiple combined procedures. Some uncertainty remains as to the optimal strategies for each patient. A decision tree is proposed to facilitate optimal patient management.
  
  
  CONCLUSIONS
  With multiple adjuvant techniques, CXL plus is likely to benefit many patients with corneal ectatic disorders. The appropriate combined procedure will depend on multiple factors, such as refraction, corneal thickness, and degree of irregular astigmatism.
authors.forename: George D
authors.initials: GD
authors.lastname: Kymionis
authors.forename: Michael A
authors.initials: MA
authors.lastname: Grentzelos
authors.forename: Dimitra M
authors.initials: DM
authors.lastname: Portaliou
authors.forename: Vardhaman P
authors.initials: VP
authors.lastname: Kankariya
authors.forename: J Bradley
authors.initials: JB
authors.lastname: Randleman
mesh_terms: D003094:Collagen / Q000378:metabolism*; D003131:Combined Modality Therapy; D003319:Corneal Stroma / Q000378:metabolism; D003432:Cross-Linking Reagents / Q000627:therapeutic use*; D006801:Humans; D007640:Keratoconus / Q000188:drug therapy* / Q000378:metabolism / Q000601:surgery*; D017319:Photosensitizing Agents / Q000627:therapeutic use*; D054140:Refractive Surgical Procedures; D012256:Riboflavin / Q000627:therapeutic use; D014466:Ultraviolet Rays
chemical_list: D003432:Cross-Linking Reagents; D017319:Photosensitizing Agents; D003094:Collagen; D012256:Riboflavin