Table 5.
Summary of Outcomes with Combinations of Multiple Techniques and CXL
| Author | Study Design | Combined procedures (number of Eyes) | Order of the procedures (Duration of follow-up) | Outcomes |
|---|---|---|---|---|
| Kremer et al.[91] | Case series | ICRS, PRK, and CXL (45) | ICRS implantation followed by (6 months later) simultaneous wavefront-guided PRK and CXL (12 months) | Significant improvement in UDVA, CDVA, and keratometry values; no patient lost any line of CDVA; no ECD changes; Epithelial hyperplasia in 4 of 45 eyes |
| Coskunseven et al.[92] | Prospective | ICRS, CXL and PRK (16) | ICRS implantation followed by CXL followed by transepithelial topography-guided PRK with an interval of 6 months between each procedure (6 months) | UDVA, CDVA, SE, and keratometry values showed significant improvement; no eye lost any line of CDVA; no complications observed |
| Dirani et al.[93] | Retrospective | ICRS, CXL and PRK (17) | ICRS implantation followed by CXL with a 4-week interval followed by non-topography-guided PRK 6 months later (6 months) | UDVA, CDVA, SE, and keratometry values showed significant improvement; no complications observed |
| Al-Tuwairqi et al.[94] | Prospective | ICRS, CXL and PRK (41) | ICRS implantation followed by (6 months later) simultaneous topography-guided PRK and CXL (12 months) | Significant improvement in UDVA, SE and keratometry values, 85% of eyes maintained or gained multiple lines of CDVA; no complications observed |
| Lee et al.[95] | Retrospective | ICRS, PRK, and CXL (23) | ICRS implantation followed by combined corneal WFG-PRK (transepithelial) and high-fluence accelerated CXL 1 month later (6 months) | Significant improvement in UDVA, CDVA, SE, keratometry values and HOAs; no complications observed |
| Koh et al.[96] | Prospective | ICRS, PRK, and CXL (30) | ICRS implantation followed by (3 months later) simultaneous wavefront-guided PRK and CXL (12 months) | UDVA, CDVA, SE, and keratometry values improved with reduction in HOAs; no complications observed |
| Assaf et al.[97] | Prospective non-randomized | CXL, PRK, PIOL (22) | Topography-guided PRK followed by same day CXL (Athens protocol), followed by iris claw or angle-supported PIOL implantation 2-4 months later (6 months) | Significant improvement in CDVA, SE and keratometry values; no complications observed |
| Coskunseven et al.[98] | Case series | ICRS, CXL and PIOL (14) | ICRS implantation followed by CXL (>6 months) and then toric PIOL implantation (>6 months) (12 months) | Significant improvement in UDVA and CDVA in keratoconic eyes with high refractive error; no complications observed |
| Dirani et al.[99] | Retrospective | ICRS, CXL and PIOL (11) | ICRS implantation followed by CXL (4-week interval) and then toric PIOL implantation 6 months later (12 months) | Significant improvement in UDVA, CDVA, SE and keratometry; no complications observed |
| Abdelmassih et al.[100] | Consecutive case series | ICRS, CXL and PIOL (16) | ICRS implantation followed by CXL (4-week interval) and then toric PIOL implantation 6 months later (24 months) | Significant improvement in UDVA, CDVA, SE and keratometry; no complications observed |
| Yeung et al.[101] | Retrospective case series | t-PTK, ICRS and CXL (16) | Same-day t-PTK followed by single ICRS implantation and CXL (6.9±4.6 months) | Significant improvement in UDVA, CDVA and mean and steep keratometry values; no complications observed |
| Rocha et al.[102] | Prospective case series | t-PTK, ICRS and CXL (55) | ICRS implantation, followed by CXL and PTK (6 months) | Significant improvement in UDVA, CDVA sphere and cylinder; no complications observed |
| Coskunseven et al.[103] | Retrospective interventional case series | ICRS, CXL, PIOL, PRK (11) | ICRS implantation, followed by CXL followed by PIOL followed by topography-guided PRK with interval of 6 months between each procedure (12 months) | Significant improvement in UDVA, CDVA, SE and astigmatism; no complications observed |
CXL=Corneal cross-linking; ICRS=Intrastromal corneal ring segments; PRK=Photorefractive keratectomy; UDVA=Uncorrected distance visual acuity; CDVA=Corrected distance visual acuity; PIOL=Phakic intraocular lens; SE=Spherical equivalent; ECD=Endothelial cell density; t-PTK=Transepithelial phototherapeutic keratectomy; HOAs=Higher order aberrations, WFG=Wavefront-guided