Long-term Results of Mini Asymmetric Radial Keratotomy and Corneal Cross-linking for the Treatment of Keratoconus

Purpose: To investigate the long-term results (at least 5 years of follow-up) of the mini asymmetric radial keratotomy (MARK) and corneal cross-linking (CXL) combined intervention, also known as the ‘Rome protocol,’ for patients with progressive stage I and II keratoconus and contact lens intolerance. Methods: This was a retrospective observational case series. Fifteen eyes of 12 patients were evaluated, with a mean follow-up of 6.9 years. To assess the efficacy and stability of the MARK + CXL combined protocol, best spectacle-corrected visual acuity, mean pachymetry, and mean keratometry were recorded preoperatively and at least 1, 3, and 5 years postoperatively. Statistical analysis was performed using the R platform and involved the Wilcoxon signed-rank and Kruskal-Wallis non-parametric tests. Results: Best spectacle-corrected visual acuity improved for all patients, from 0.46 ± 0.69 logarithm of the minimum angle of resolution (20 / 60) to 0.15 ± 0.69 logarithm of the minimum angle of resolution (20 / 30, p = 0.0006), while mean pachymetry increased in 93% of patients, from 442.80 ± 61.02 to 464.50 ± 62.72 μm (p = 0.003). Lastly, mean keratometry improved in 87% of patients after 6.9 years of observation from 48.82 ± 5.00 to 43.25 ± 3.58 diopters (p = 0.008). No intraoperative or postoperative complications were observed. Conclusions: The MARK + CXL combined protocol was effective in treating keratoconus by halting corneal thinning and bulging. In addition, this procedure significantly improved visual acuity based on long-term follow- up data. Analysis of data from a larger cohort of patients would be useful to support these findings.