Corneal Wavefront–Guided Transepithelial PRK Aligned to Comatic Axis After Corneal Cross-linking for Keratoconus

Purpose: To evaluate the clinical outcomes of a comatic axis–adjusted corneal wavefront–guided transepithelial photorefractive keratectomy (TransPRK) protocol for visual rehabilitation in patients with keratoconus previously treated with corneal cross-linking (CXL). Methods: In this prospective, non-randomized, consecutive case series, 24 eyes from 17 patients with stable stage I to III keratoconus after CXL underwent anterior wavefront-guided TransPRK centered on the comatic axis, using large optical zones and a tissue-saving ablation algorithm (⩽90 µm total, ⩽50 µm stromal). Main outcome measures included changes in corrected (CDVA) and uncorrected distance visual acuity, corneal higher order aberrations (HOAs), keratometric indices, and pachymetric parameters. Follow-up evaluations were performed at 1, 3, and 6 months. Results: At 6 months, mean uncorrected distance visual acuity improved significantly from 0.83 ± 0.55 to 0.39 ± 0.20 logarithm of the minimum angle of resolution (logMAR) ( P = .003), whereas CDVA improved from 0.21 ± 0.17 to 0.10 ± 0.08 logMAR ( P = .002). Corneal HOAs decreased from 2.69 ± 1.18 to 1.95 ± 1.07 µm ( P = .0002), with vertical coma showing the most significant reduction ( P < .0001). Maximum keratometry values decreased from 54.32 ± 5.79 to 51.52 ± 4.93 diopters ( P = .001). No eyes lost lines of CDVA or developed ectasia progression or clinically significant haze during follow-up. Conclusions: Comatic axis–aligned anterior corneal wavefront–guided TransPRK in stable post-CXL keratoconus showed favorable short-term visual, aberrometric, and topographic outcomes while preserving corneal integrity, and may represent a feasible tissue-sparing strategy for optical regularization in irregular corneas.