Biomechanical, Visual, and Refractive Outcomes of Total Corneal Wavefront-Guided Transepithelial PRK With Accelerated CXL in Keratoconus Using Objective Stability Markers

Purpose: To evaluate the long-term safety and efficacy of simultaneous total corneal wavefront-guided transepithelial photorefractive keratectomy (TCWG-TransPRK) with accelerated corneal cross-linking (CXL) in mild to moderate keratoconus, incorporating corneal biomechanics as objective markers of structural stability. Methods: This prospective, interventional, single-center study included patients with mild to moderate keratoconus. All underwent TCWG-TransPRK (maximum planned stromal ablation: 55 µm) followed by accelerated CXL (30 mW/cm 2 for 3 minutes; total fluence: 5.4 J/cm 2 ). Follow-up was conducted at 24 hours, 1 week, and 1, 3, 6, and 12 months. Primary outcomes were safety and efficacy, with stress-strain index version 2 (SSI v2) proposed as a key objective marker of biomechanical stability. Additionally, refractive accuracy, tomography, and epithelial remodeling were evaluated. Results: Thirty-eight eyes from 19 patients were analyzed. At 12 months, uncorrected distance visual acuity improved from 0.80 ± 0.36 to −0.03 ± 0.10 logarithm of the minimum angle of resolution ( P < .0001), with 87% achieving 20/20 and all 20/40 or better. Corrected distance visual acuity improved ( P < .0001), with no Snellen line loss. Refractive accuracy was high (89% within ±1.00 diopter). SSI v2 increased significantly ( P < .0001), indicating enhanced intrinsic stiffness. No keratoconus progression was observed. Epithelial thickness increased nasally and temporally, correlating with changes in spherical aberration and vertical trefoil. Conclusions: Despite the use of accelerated CXL parameters, TCWG-TransPRK with CXL improved vision and enhanced biomechanical stability, as evidenced by a significant increase in SSI v2. This provides an objective structural marker for monitoring and customizing keratoconus care. These findings support the procedure as a safe and effective option for non-progressive mild to moderate keratoconus.