Efficacy and Safety of Epi-on versus Epi-off Corneal Cross-Linking for Keratoconus

AI Generated Summary*

Thirteen randomized controlled trials (872 patients, 1041 eyes; 478 epithelium-on, 563 epithelium-off) from a six-database search to July 2024 compared transepithelial and epithelium-off corneal collagen cross-linking for corneal ectasia, including keratoconus, with four to ten trials pooled per outcome. At 12 months, maximal keratometry did not differ significantly (mean difference 0.06 D, 95% CI -0.30 to 0.42), and steep and flat keratometry, best-corrected acuity (0.03 logMAR) and uncorrected acuity (0.05 logMAR) were also nonsignificant, though visual outcomes showed high heterogeneity. Endothelial cell counts differed significantly, by 84.71 cells/mm² favoring epithelium-off. Qualitatively, epithelium-off treatment carried more complications, including stromal haze, corneal scarring and delayed epithelial healing, whereas epithelium-on eyes experienced less pain. Ten trials had low risk of bias.

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