A Systematic Review and Meta-Analysis Comparing Epithelium-On and Epithelium-Off Corneal Collagen Cross-Linking in Keratoconus Management: Integrating New Evidence
Purpose:
Keratoconus is a progressive corneal ectasia leading to visual impairment. Corneal collagen cross-linking (CXL) is a widely used intervention to halt progression, with 2 main approaches: epithelium-on (Epi-On) and epithelium-off (Epi-Off). This study presents a meta-analysis integrating findings from existing literature and newly analyzed data.
Methods:
A systematic search was performed to compare Epi-On and Epi-Off CXL outcomes from 2014 to 2024. Meta-analysis techniques were employed to evaluate the changes in visual and imaging outcomes based on the differences between baseline to available 6-month, 1-year, 2-year, and 3-year follow-up. In addition, subgroup analyses were conducted based on study design (randomized controlled trials vs. non-RCT and observational studies) and risk of bias (high vs. low), using standardized risk assessment tools.
Results:
This meta-analysis included 28 studies, covering 1764 eyes including 875 (49.6%) Epi-Off and 889 (50.4%) Epi-On treated eyes. Maximum keratometry flattening was observed at 6 months (ES = 0.183,
Conclusions:
Epi-Off CXL demonstrates superior topographic and tomographic improvements compared with Epi-On, although visual acuity outcomes remain equivalent. These findings support a personalized approach in selecting CXL technique based on patient profile and treatment goals.
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Journal of Medical Economics
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Journal of Refractive Surgery
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Taylor & Francis
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SLACK
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