Tel-Aviv Protocol for Postrefractive Surgery Corneal Ectasia: A Case Series

Abstract

Purpose: The aim of this study was to describe the safety and efficacy of the Tel-Aviv Protocol (epithelial photorefractive keratectomy and corneal cross-linking) as a treatment for postrefractive surgery corneal ectasia. Methods: This study includes 8 eyes from 7 patients, each diagnosed with postrefractive surgery ectasia years after refractive surgery and treated with the Tel-Aviv Protocol. The procedure included transepithelial PRK using the EX500 excimer laser, a 50-μm laser ablation of the epithelium and anterior stroma, delivered on the visual axis with cyclotorsion correction, treating up to 50% of refractive astigmatism. After the epithelial photorefractive keratectomy, all patients underwent corneal cross-linking. Results: The mean keratometry (K) and maximal K both decreased [from 43.37 ± 2.23 to 41.84 ± 2.01 (P = 0.03) and from 44.95 ± 3.08 to 42.78 ± 2.19 (P = 0.03), respectively]. Astigmatism was significantly reduced (from 3.53 ± 2.36 to 0.88 ± 0.89 diopter; P = 0.02). Uncorrected visual acuity improved significantly in all patients from a mean of 0.56 ± 0.32 to 0.15 ± 0.14 logMAR (P = 0.01). Best-corrected visual acuity improved from 0.22 ± 0.24 to 0.06 ± 0.06 logMAR (P = 0.07; 1-tail P = 0.04). All patients maintained visual acuity during the follow-up period, up to 25 months, mean = 329 days. The Tel-Aviv Protocol was found to be safe [mean safety index: 1.63 ± 1.03 (range: 1.00–4)] and effective [mean efficacy index: 1.29 ± 0.66 (range: 0.71–2.1)]. Conclusions: The Tel-Aviv Protocol, developed initially for keratoconus treatment, is a safe and promising procedure to stop postrefractive surgery ectasia progression while significantly improving vision, thereby avoiding keratoplasty.