Korean J Ophthalmol.  2019 Apr;33(2):189-195. 10.3341/kjo.2018.0028.

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

  • 1Abbondanza Eye Centers, Rome and Milan, Italy. info@abbondanza.org
  • 2Centre for International Security Studies, The University of Sydney, Sydney, Australia.
  • 3Graduate School of Public Health, St. Luke's International University, Tokyo, Japan.


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.
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.
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.
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.


Corneal cross-linking; Keratoconus; Mini asymmetric radial keratotomy; Rome protocol

MeSH Terms

Cohort Studies
Follow-Up Studies
Keratotomy, Radial*
Postoperative Complications
Retrospective Studies
Visual Acuity


  • Fig. 1 Diagram of mini asymmetric radial keratotomy mini-incisions.

  • Fig. 2 The Abbondanza markers.

  • Fig. 3 Mean keratometry changes (with confidence intervals) before and after surgery. A Kruskal-Wallis non-parametric test showed that mean keratometry values do not have identical data distributions in the follow-up period (p = 0.175). A Wilcoxon signed-rank test indicates that postoperative Kavg values after 7 years are significantly lower than preoperative values (p < 0.05).

  • Fig. 4 Mean pachymetry (with 95% confidence intervals) before and after surgery. A Wilcoxon signed-rank test showed that postoperative pachymetry is significantly higher than preoperative pachymetry (p < 0.005).

  • Fig. 5 Pachymetric map (A) before and (B) after surgery, showing a general improvement in corneal thickness.

  • Fig. 6 Mean best spectacle-corrected visual acuity (BSCVA) (on a decimal scale with 95% confidence intervals) before and after surgery. A Wilcoxon signed-rank test shows that postoperative BSCVA is significantly higher than preoperative BSCVA (p < 0.005).


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