Keratoconus Hybrid Treatment: Personalized Surface Laser and Cross-Linking
This is a patient-friendly summary of the keratoconus case I discussed at the Interactive Refractive Surgery Meeting. In this keratoconus hybrid treatment, we combined a topography and wavefront-guided surface laser with cross-linking in one patient. Two-year results are included.
Keratoconus hybrid treatment smooths the irregular corneal surface with a personalized surface laser profile. In the same session, cross-linking (CXL) strengthens the cornea. The goal is not only to stop the disease from progressing, but also to improve vision quality. In the patient from the presentation, a 36-year-old, uncorrected vision in the right eye rose from 0.05 to 0.7. Vision with glasses rose from 0.3 to 1.0. At the two-year check, the cornea was clear. We use this treatment in selected patients whose corneal thickness and measurements are suitable.
About the presentation
This article summarizes my case presentation for doctors, titled "Keratoconus: treatment recommendations", at the Interactive Refractive Surgery Meeting. In the session, we reviewed a keratoconus patient's measurements together with the participants. We then discussed the treatment options. Finally, I shared the two-year results of the hybrid treatment we performed.
Transparency note
I have no financial relationship with any product or company mentioned in the presentation. The results below belong to a single patient. Therefore, every patient may not achieve the same result.
Keratoconus and the goal of treatment
Keratoconus is a progressive corneal disease. It usually affects the two eyes to different degrees. The cornea thins, becomes irregular and takes a cone shape. It is mostly seen in young patients, and without treatment it can lead to vision loss.
Today, the basis of treatment is cross-linking (CXL), which strengthens the cornea to stop progression. However, CXL often does not improve vision noticeably. To improve vision quality, doctors use corneal rings, surface laser (PRK) and special keratoconus contact lenses. In advanced cases, a corneal transplant may be needed. For patients who cannot wear contact lenses and have low vision, a topography or wavefront-guided surface laser together with CXL can be an option.
"Our aim is to bring the steepened areas closer to normal as far as the cornea allows. We also smooth the surface to reduce irregular refraction. At the same time, cross-linking lowers the risk of progression."
— Prof. Dr. Fırat Helvacıoğlu, from the presentation
Case: options and the treatment we chose
Our patient was a 36-year-old man. His right eye had about −1.25 myopia and 3 diopters of astigmatism. Uncorrected vision was 0.05 in both eyes. Vision with glasses was 0.3 in the right eye and 0.8 in the left. The corneal maps showed clear signs of keratoconus in the right eye.
In the presentation, we asked the participants to choose among these options:
- Follow-up with topography only, without waiting for progression at this age
- CXL with or without removing the epithelium
- Intracorneal ring and/or CXL
- Surface treatment (PTK) + CXL
- Personalized (corneal wavefront-guided) surface laser + CXL
In this patient, the measurements were within safe limits. Therefore, we chose the last option, which is the hybrid treatment. It combines a corneal wavefront-guided surface laser with CXL in the same session.
Keratoconus hybrid treatment case: 36 years old, right eye
We smoothed the corneal surface with a personalized laser profile and performed cross-linking in the same session. At the two-year check, vision had improved markedly and the cornea stayed clear.
- Before treatmentClear steepening in the lower area and irregular astigmatism. Uncorrected vision 0.05, with glasses 0.3.
- Two-year checkThe surface is more regular and the steep area has decreased. The cornea is clear, with no haze.
- Visual acuityUncorrected vision rose from 0.05 to 0.7, and vision with glasses rose from 0.3 to 1.0 (Snellen).
Keratoconus hybrid treatment step by step
- Calculating the adjusted prescription: In a keratoconus eye, the glasses prescription alone is not reliable. Therefore, we combine the corneal map and wavefront measurements. From these, we recalculate the value to correct.
- Personalized treatment plan: We plan the laser profile to remove as little corneal tissue as possible. We then decide, for each patient, how much of the prescription to correct.
- Surface laser: We treat from the surface, including the epithelium. We make no incision and no flap.
- Cross-linking: In the same session, riboflavin drops and ultraviolet light strengthen the cornea. During the treatment, we keep the corneal surface moist and cool. This is important to prevent haze.
Recovery is similar to surface laser. In the first days, we place a protective lens, and you may feel a stinging sensation. I explain the details on the combined CXL + No Touch page.
Who is suitable for keratoconus hybrid treatment?
Hybrid treatment does not suit every keratoconus patient. When deciding, we look at the following:
- Corneal thickness: after treatment, the cornea must keep the thickness at which CXL can be done safely (about 400 microns)
- The amount of tissue removed by the laser must stay within safe limits (in the presentation, below about 110 microns including the epithelium)
- No deep scar in the cornea
- Reliable prescription and corneal measurements
For a very thin cornea, an advanced stage or a deep scar, we choose different treatments. With our team, we presented the short-term, 2-year, 3-year and long-term results of this approach at ESCRS congresses. The approach combines corneal wavefront-guided normalization with CXL in keratoconus. To notice keratoconus early, you can read the article "Does your glasses prescription change often?".
Technical notes for doctors on keratoconus hybrid treatment
Practical recommendations from the presentation
- For corneal wavefront (CW) treatment, use the adjusted manifest refraction. Otherwise, you correct the higher-order aberrations (HOA) twice.
- For CW treatment planning, you must obtain the corneal measurements (SCC and DCC).
- The acceptable CW ablation difference between treatments is about 11–15 microns.
- For the astigmatism value in the adjusted refraction, use the 3 mm zone on topography.
- Scheimpflug + Placido systems give corneal wavefront. Placido + aberrometry systems give corneal or ocular wavefront.
- Example CXL protocol: 1 drop of riboflavin per minute for 10 minutes, then 3 minutes of 30 mW UVA (total energy 5.4 J/cm²). Depending on the device, you can choose a different duration and energy.
Frequently asked questions
We do not perform classic laser eye surgeries (LASIK, SMILE) in keratoconus. However, in selected patients, we can combine a special surface laser that smooths the corneal surface with cross-linking.
Keratoconus does not disappear completely. The aim is to stop progression with cross-linking. In addition, we smooth the surface to improve vision quality.
Some patients keep a small prescription, so they may need glasses or contact lenses. However, vision quality, with or without glasses, often improves markedly.
We numb the eye with drops before the procedure. As with surface laser, you may feel stinging, watering and light sensitivity in the first few days. A protective lens and drops relieve these symptoms.
People with a very thin cornea, advanced keratoconus or a deep corneal scar are usually not suitable. For these patients, we consider options such as corneal rings, special lenses or corneal transplant.
Related pages
References
- Gomes JAP, Tan D, Rapuano CJ, et al. Global consensus on keratoconus and ectatic diseases. Cornea. 2015;34(4):359-369. doi:10.1097/ICO.0000000000000408
- Sunay E, Helvacıoğlu F. Outcomes of corneal wavefront guided surface ablation for treatment of keratoconus. Schwind User Meeting, Istanbul, March 2016 (presentation).
- Sunay E, Helvacıoğlu F, Kavalcıoğlu Ö, Akyurt A, Akın T. Short term outcomes of keratoconus management with corneal wavefront-guided normalization combined with corneal cross-linking stabilization. 34th ESCRS Congress, Copenhagen, 2016 (paper).
- Sunay E, Helvacıoğlu F, Kavalcıoğlu Ö, Akyurt A, Kaya Ünsal S, Akın T. Two year outcomes of keratoconus management with corneal wavefront-guided normalization combined with corneal cross-linking stabilization. 35th ESCRS Congress, Lisbon, October 2017 (paper).
- Sunay E, Helvacıoğlu F, Kavalcıoğlu Ö, Akyurt A, Kaya Ünsal S, Akın T. Three years’ outcomes of keratoconus management with corneal wavefront-guided normalization combined with corneal cross-linking stabilization. 36th ESCRS Congress, Vienna, September 2018 (paper).
- Sunay E, Helvacıoğlu F, Kaya Ünsal S, Kavalcıoğlu Ö, Bulut E. Long-term outcomes of keratoconus management with corneal wavefront-guided normalisation combined with corneal cross-linking stabilisation. 37th ESCRS Congress, Paris, September 2019 (paper).
This article is for patient information only. It does not replace an examination or medical evaluation. We decide the treatment that suits you after an eye examination and measurements. Publication date: September 25, 2026.
Contact Prof. Dr. Fırat Helvacıoğlu with your questions
Prof. Dr. Fırat Helvacıoğlu · Veni Vidi Eye Clinic, Bağdat Cad. No: 257, Caddebostan – Kadıköy / Istanbul