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Updated: Oct 26, 2026
Three Different Protocols of Corneal Collagen Crosslinking in Keratoconus: Conventional, Accelerated and Iontophoresis
Published on: November 12, 2015
Long-Term Visual, Refractive, and Patient-Reported Satisfaction of the Tel-Aviv Protocol (ePRK-CXL) for Progressive
Asaf Friehmann1,2,3, Adir Sommer3,4,5, Tzahi Sela3
1Department of Ophthalmology, Sheba Medical Center, Ramat Gan, Israel.
Purpose:
To evaluate the long-term visual, refractive, and patient-reported satisfaction of epithelial photorefractive keratectomy (ePRK) combined with corneal cross-linking (CXL) - the Tel-Aviv Protocol - in patients with progressive keratoconus.
Setting:
Care-Vision Laser Center, Tel Aviv, Israel.
Design:
Retrospective, single-center case series.
Methods:
Consecutive patients with progressive keratoconus who underwent ePRK-CXL were included. Preoperative and last-available postoperative pachymetry, keratometry (Kmean, Kmin, Kmax), spherical equivalent (SEQ), manifest refraction, uncorrected distance visual acuity (UDVA), and corrected distance visual acuity (CDVA) were recorded; safety and efficacy indices were calculated. Patient-reported outcomes regarding spectacle/contact lens dependence, satisfaction, and visual symptoms were assessed with a structured questionnaire.
Results:
Fifty eyes of 38 patients (mean age 25.9±6.8 years) were followed for a mean of 2,910±605 days (∼8 years; range 5-12). UDVA improved from 1.04±0.70 to 0.36±0.37 logMAR and CDVA from 0.23±0.16 to 0.11±0.10 logMAR (both P < 0.001); safety and efficacy indices were 1.42±0.55 and 0.93±0.51. K-max decreased from 47.51±2.96 to 45.95±2.99 D and SEQ from -2.42±2.29 to -0.82±1.57 D (both P < 0.001). Pachymetry decreased from 448.65±38.95 to 418.93±55.77 μm. Overall satisfaction was high (81.6% satisfied/very satisfied), 76.3% reported subjective visual improvement, 52.6% achieved spectacle independence, and 92.1% required no contact lenses. No progression was observed in the examined eyes.
Conclusions:
At a mean follow-up of ∼8 years, the Tel-Aviv Protocol provided durable visual and refractive improvement, stabilized keratometry without progression, and yielded high patient satisfaction with low symptom burden. These results support ePRK-CXL as a tissue-sparing option for progressive keratoconus.