Kankariya Vardhaman P, Dube Ankita B, Grentzelos Michael A, Kontadakis George A, Diakonis Vasilios F, Petrelli Myrsini, Kymionis George D
Asian Eye Hospital and Laser Institute, Pune, Maharashtra, India.
Asian Eye Hospital and Laser Institute, Pune, Maharashtra, India; Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, Lausanne, Switzerland.
Indian J Ophthalmol. 2020 Dec;68(12):2757-2772. doi: 10.4103/ijo.IJO_1841_20.
The past two decades have witnessed an unprecedented evolution in the management of keratoconus that demands a holistic approach comprising of inhibiting the ectatic progression as well as visual rehabilitation. The advent of corneal cross-linking (CXL) in the late 1990s resulted in long-term stabilization of the ectatic cornea along with limited reduction in corneal steepening and regularization of corneal curvature. However, CXL as a standalone procedure does not suffice in rehabilitating the functional vision especially in patients who are unwilling or intolerant towards contact lenses. The concept of "CXL plus" was proposed which incorporates adjunctive use of refractive procedures with CXL in order to overcome the optical inefficiency due to corneal irregularity, decrease the irregular astigmatism, correct the residual refractive error and improve functional visual outcome in keratoconus. Several refractive procedures such as conductive keratoplasty (CK), photorefractive keratectomy (PRK), transepithelial phototherapeutic keratectomy (t-PTK), intrastromal corneal ring segments (ICRS) implantation, phakic intraocular lens (PIOL) implantation and multiple other techniques have been combined with CXL to optimize and enhance the CXL outcome. This review aimed to summarize the different protocols of CXL plus, provide guidelines for selection of the optimum CXL plus technique and aid in decision-making for the comprehensive management of cases with primary keratoconus in addition to discussing the future and scope for innovations in the existing treatment protocols.
在过去的二十年里，圆锥角膜的治疗发生了前所未有的演变，这需要一种整体的方法，包括抑制扩张进展以及视觉康复。20世纪90年代末角膜交联（CXL）的出现，使扩张性角膜得到了长期稳定，同时角膜变陡程度有限降低，角膜曲率也得到了规整。然而，单纯的CXL手术不足以恢复功能性视力，尤其是对于那些不愿意或不耐受隐形眼镜的患者。于是提出了“CXL联合”的概念，即将屈光手术与CXL联合使用，以克服角膜不规则导致的光学效率低下，减少不规则散光，矫正残余屈光不正，改善圆锥角膜患者的功能性视觉结果。几种屈光手术，如传导性角膜成形术（CK）、准分子激光角膜切削术（PRK）、经上皮光性角膜切削术（t-PTK）、角膜基质内环植入术（ICRS）、有晶状体眼人工晶状体（PIOL）植入术以及多种其他技术，已与CXL联合使用，以优化和提高CXL的效果。本综述旨在总结不同的CXL联合方案，为选择最佳的CXL联合技术提供指导，并辅助原发性圆锥角膜病例的综合管理决策，此外还将讨论现有治疗方案的未来发展和创新空间。
