AAOpt 2026: Combination procedures and postoperative care in keratoconus

Combining corneal cross-linking with a refractive procedure can give patients with keratoconus both corneal stability and refractive improvement, according to Clark Chang, OD, MSA, MSc, FAAO. Chang spoke with Optometry Times after his lecture to dive deeper on corneal surgery for keratoconus treatment.

Cross-linking after a refractive procedure “holds the longevity of [the] refractive treatment, as well as the stability of the cornea," according to Chang. A second procedure such as CTAK, performed the same day or afterward, provides the refractive benefit, while cross-linking maintains that benefit and the stability of the cornea. Without stability, he noted, refractive gains are short-lived.

With the epithelium intact, the risk of infection and discomfort is greatly reduced, Chang said. However, the recently FDA-approved epi-on protocol holds the eye open for 11 minutes and 6 seconds of UV irradiation, which can cause drying and mild discomfort for a couple of days. Patients use a topical antibiotic and steroid for a short period. “To me, it’s a much safer procedure now, which is great news for patients,” Chang stated.

Most patients still need contact lenses after surgery, but Chang said that should not define treatment success. Improved uncorrected vision can give patients more breaks from lens wear and improve their quality of life. He urged clinicians to rethink how surgical success is defined and to educate patients accordingly. ”If they have improvement in uncorrected vision that allows them to get more breaks from their contact lens wear, that to them is a huge improvement of the quality of their life, and also can be more compliant with the instruction that we give them, so that they can wear their lenses for much longer across their lifespan,” Chang noted.