Simultaneous photorefractive keratectomy and accelerated collagen cross-linking in high-risk refractive surgery (Tehran protocol): 3-year outcomes



To evaluate safety and efficacy of performing simultaneous photorefractive keratectomy (PRK) and collagen cross-linking (CXL) in myopic patients with preoperative risk factors for developing keratectasia.


Seventeen eyes of 15 patients with at least one of the following risk factors were recruited: central keratometry (Kmax) between 48 and 50, difference between inferior, superior corneal power (I–S value) between 1.4 and 1.9 and corneal thickness between 450 and 480 µm. Upon final stage of standard PRK, 0.02% mitomycin was applied for 30–50 s, and then, accelerated CXL was performed for 5 min. Pre- and postoperative Oculus Pentacam® imaging for keratometry values, measurement of uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were done for all patients.


Mean follow-up time was 32.08 ± 7.79 months (range 25–49 months). Mean age of patients was 28.78 ± 3.80 years. Mean postoperative spherical equivalent was + 0.19 ± 0.42 (− 0.5 to + 1.0 [D]). Mean UDVA and CDVA improved from 0.9062 ± 0.485 log MAR and 0.0148 ± 0.043 log MAR to 0.0173 ± 0.040 log MAR and 0.0057 ± 0.023 log MAR, respectively (P = 0.011, P = 0.735). Mild degree of early postoperative stromal haze was seen which did not persist more than 6 months. There was no late stromal haze, corneal ectasia or other major postoperative complication in the follow-up period.


Combined PRK and accelerated CXL is an efficient and safe procedure for high-risk refractive surgery candidates, with no increased risk of persistent corneal haze.

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This study was funded by Tehran University of Medical Sciences.

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All authors made a significant contribution to this study.

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Correspondence to Ahmad Masoumi.

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Review board and ethics committee of Tehran University of Medical Sciences (IR.TUMS.REC1394.984).

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Mohammadpour, M., Farhadi, B., Mirshahi, R. et al. Simultaneous photorefractive keratectomy and accelerated collagen cross-linking in high-risk refractive surgery (Tehran protocol): 3-year outcomes. Int Ophthalmol (2020).

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  • PRK
  • CXL
  • High-risk patients
  • PRK Xtra