Progressive Keratoconus Treatment with Transepithelial Two-Step Phototherapeutic Keratectomy Combined with Corneal Crosslinking (CXL): Clinical Outcomes and Postoperative Management Including Potential Complications of the Modified Athens Protocol De

<b>Objectives:</b> To report a novel application within the USA of excimer ablation for the normalization of central corneal refractive irregularity, combined with higher fluence CXL in the effective management and visual rehabilitation of progressive keratoconus. <b>Methods:</b> 17 consecutive cases with progressive keratoconus were treated with corneal surface excimer laser ablation normalization using topography-guided (Contura) myopic ablation for customized corneal re-shaping with a 6 mm optical zone. The epithelial removal was accounted for by adding a -2.75 diopter correction to this topography-guided normalizing surface ablation followed by a second wavefront-optimized hyperopic excimer treatment of +2.75 diopters also with a 6 mm optical zone. The two sequential excimer ablations applied on the intact epithelium were followed by corneal crosslinking (CXL). Visual acuity, refraction, and keratoconus documentation via keratometry, topography, and pachymetry, as well as endothelial cell density were evaluated over 36 months. <b>Results:</b> Keratoconus stabilized in all cases. The severity and stage of keratoconus determined by the Amsler-Krumeich criteria improved for the OD from an average of 2.2 to 1. The median UDVA showed marked improvement at one-year follow-up (all values in LogMAR), from 0.8 preoperative to 0.3 at 12 months, and was stable through the 3 years at 0.3. The median CDVA increased from 0.5 to 0.1 at 1 year and was stable at 0.1 at 3 years. The average minimal corneal thickness decreased from 466 μm to 396 μm, as recorded the first year postoperatively, and then slightly increased to 405 μm at the 3-year follow-up. <b>Conclusions:</b> We introduce herein the initial clinical data for the use of a novel, off-label therapeutic excimer laser surface ablation application. It was designed to perform both epithelial removal and anterior corneal stroma reshaping and combined with CXL to apply the Athens Protocol CXL with US excimer laser-approved specifications.