AIM: To study the efficacy and safety of accelerated collagen cross-linking in keratoconus.

METHODS: Medical records of keratoconic corneas underwent accelerated collagen cross-linking at King Chulalongkorn Memorial Hospital, Thailand between April 2015 and August 2018 were reviewed. Preoperative and postoperative data at 1a of visual acuity, auto-refraction, corneal topography, higher-order aberrations(HOA), topometric indices and corneal densitometry were evaluated. Age of 24 and 30 years old, maximum keratometry value(Kmax)of 55 D, and baseline best corrected visual acuity(BCVA)of 20/40(or 0.3 in LogMAR unit)were used as cut-off values to highlight the cross-linking effects. The effect of age, preoperative Kmax and BCVA were analyzed. The association between the change of corneal densitometry and other factors including preoperative Kmax, Kmean, manifest refraction spherical equivalent(MRSE), visual acuity, thinnest pachymetry, the change in Kmax, and the change of those parameters were also analyzed. P<0.05 was considered statistically significant.

RESULTS: One hundred and fifty-five patients(185 eyes)were included. One hundred and nineteen patients were male and thirty-six patients were female. According to Amsler-Krumeich classification, stages 1 and 2 were dominant(37.84% and 35.14% respectively). At 1a, mean LogMAR uncorrected visual acuity(UCVA)improved by 0.1(P<0.05). The number of eyes of which postoperative BCVA improved more than 0.2 LogMAR was higher in the worse baseline BCVA group(preoperative BCVA ≥0.3)compared to the better baseline BCVA group(preoperative BCVA < 0.3)(78.26% vs 21.74%, P<0.05). Mean Kmax decreased from baseline by 2.36 diopters(D)(P<0.05). Seventy-three percent of the eyes of which Kmax reduced more than 2.0 D had preoperative Kmax ≥55 D. Corneal HOA at 6 mm from corneal apex decreased by 0.40(P<0.05). Corneal densitometry at 0-6 mm zone increased at 1mo and persisted 1a postoperatively(P<0.05). The relationship of the increase in densitometric value and the decrease of thinnest pachymetry at 1a were in linear fashion. Index of surface variance, index of vertical asymmetry, keratoconus index, index of height decentration decreased at 1a(P<0.05). Success rate at 1a was 90.24%. Postoperative corneal haze was found 11.35%, 30.27%, 15.67%, 10.27% and 2.16% at 1wk, 1, 3, 6mo and 1a respectively. No eyes developed corneal edema. There was one case of sterile keratitis.

CONCLUSION: Accelerated collagen cross-linking in keratoconus was effective to flatten, reshape the cornea, improved visual acuity, HOA and topometric indices. Great Kmax reduction was found in advanced keratoconus. The magnitude of Kmax reduction is also greatest among previous reports.