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Purpose  To compare the safety and efficacy of standard 30 min epithelium‐off cross‐linking ( CXL ) versus photorefractive keratectomy ( PRK ) combined with accelerated epithelium‐off cross‐linking ( AXL ) for the treatment of progressive keratoconus ( CXL ‐Plus).    Methods  This study was a prospective multicentre comparative clinical study. A total of 125 eyes of 75 patients with grade 1 keratoconus and documented progression were divided into two groups. Group A included 58 eyes treated with standard  CXL . Group B included 67 eyes treated with combined  PRK  and  AXL . The recorded data included  UDVA ,  CDVA , subjective and objective refraction, keratometry and pachymetry using corneal topographies preoperatively and postoperatively at 3, 6, 12 and 24 months of follow‐up.    Results  In group A, at 24 months of  UDVA  and  CDVA  were improved from 1.12 ± 0.38 and 0.58 ± 0.42 to 0.66 ± 0.20 and 0.20 ± 0.12 (Log MAR ± SD ). The spherical equivalent was reduced from 4.03 ± 1.18 to 1.78 ± 1.04 D. The cylinder reduction was 0.32 ± 0.19 D. In group B, at 24 months of  UDVA  and  CDVA  were improved from 1.26 ± 0.52 and 0.68 ± 0.36 to 0.58 ± 0.28 and 0.20 ± 0.16 (Log MAR  ±  SD ). The spherical equivalent was reduced from 4.23 ± 0.95 to 1.92 ± 0.74 D. The cylinder reduction was ±1.76 D.    Conclusion  Surprisingly, standard  CXL  showed close results to  CXL ‐Plus at the 24th follow‐up month. Standard  CXL  acted as a stabilizing procedure associated with a late myopic component reduction.  CXL ‐Plus acted as a refractive and stabilizing procedure with an early effect on both the myopic and the astigmatic component but no later improvements. Standard  CXL  seems to be more powerful than  AXL  in its long‐term effect. Therefore, in the future, we want to test the combination of  PRK  with standard  CXL .

Standard cross‐linking versus photorefractive keratectomy combined with accelerated cross‐linking for keratoconus management: a comparative study