Table 1.
Oxford CEBM-based grading of main clinical recommendations.
| Clinical recommendation | Main evidence base | Supporting references | Oxford CEBM level | Recommendation strength |
|---|---|---|---|---|
| Progressive keratoconus should be stabilized before refractive optimization, most commonly with CXL. | Systematic reviews, contemporary reviews, and comparative/cohort evidence supporting CXL for progression control. | (3, 7–9) | Level 1–2 | Strong |
| Customized PRK + CXL may be considered in selected mild-to-moderate keratoconus with sufficient stromal reserve and adequate topographic/wavefront data quality. | Meta-analysis of nonrandomized studies, prospective comparative cohorts, and representative clinical series. | (1, 8, 15–29) | Level 2 | Moderate |
| ICRS may be considered in contact-lens-intolerant eyes or eyes with poor spectacle function when cone morphology, corneal clarity, and stromal thickness are suitable. | Systematic review/meta-analysis, indication-focused review, and observational cohort studies. | (10, 30–45) | Level 2–3 | Moderate |
| CAIRS may be considered an emerging corneal regularization option, but current evidence remains heterogeneous and less standardized. | Systematic reviews based mainly on retrospective or prospective case series, technical reports, and short-term observational cohorts. | (11, 46–72) | Level 3–4 | Weak-to-moderate |
| Toric pIOLs may be considered in stable keratoconus with reproducible regular refractive astigmatism and adequate anterior segment anatomy. | Systematic review/meta-analysis and observational cohorts of iris-fixated and posterior chamber toric pIOLs. | (12, 73–106) | Level 2–3 | Moderate |
| Toric IOLs may be considered in cataract patients with stable mild-to-moderate keratoconus and sufficiently regular astigmatism. | Contemporary review, IOL-calculation evidence, and systematic review/meta-analysis of toric IOL implantation in keratoconus. | (13, 107–110) | Level 3 | Weak-to-moderate |
The Oxford CEBM level reflects the hierarchy of the principal supporting evidence. Recommendation strength represents a qualitative synthesis of the overall evidence base and should not be interpreted as a formal GRADE assessment.
CEBM, Centre for Evidence-Based Medicine; KC, keratoconus; CXL, corneal collagen cross-linking; PRK, photorefractive keratectomy; ICRS, intracorneal ring segments; CAIRS, corneal allogeneic intrastromal ring segments; pIOL, phakic intraocular lens; IOL, intraocular lens.