Is the Athens Protocol the Next Step in Keratoconus Treatment?

Originally published in NKCF Update (November 2023).

Consider advances in treatment of KC over the past decade. Ten years ago, doctors in the US could only monitor their patients’ corneas as they changed shape. In 2016, the FDA approved corneal cross linking (CXL), a simple surgical procedure to stop disease progression. In short order, CXL became the standard of care for individuals with unstable keratoconus.

Another European innovation, combining CXL with modest corneal reshaping has made its way to the US. Soon this may be the customary treatment of keratoconus.

More than two decades ago, Dr. John Kanellopoulos MD, a Boston and New York City trained ophthalmologist established a surgical cornea practice in Athens, Greece. An early innovator in crosslinking, he looked for ways to improve visual outcomes for his patients.

While CXL stops progression, depending on how advanced the disease is, or the condition of the cornea, some patients are left with poor vision after successful crosslinking. Kanellopoulos sought to ‘normalize’ the corsslinked cornea surface, using an excimer laser to remove minimal amounts of tissue.

Dr. Kanellopoulos has said, “I realize surface ablation in a keratoconic eye may sound unorthodox, but the goal of our treatment is to normalize the corneal surface and improve best corrected visual acuity.”

He warns performing topographic-guided photo refractive keratectomy (PRK) in this case is not vision correction surgery, “This is a therapeutic procedure, not a refractive one.” The goal is not to achieve LASIK-like perfect vision, but to get individuals with moderate to severer keratoconus to function better with glasses or contact lenses.

Some surgeons combine the laser refinement and CXL in a single session, others perform the procedures sequentially. IN a recent article published in the journal Cornea, Kanellopoulos cited more than 20 scientific papers documenting results and follow-up of the combined procedure, referred to as the Athens Protocol. Today, a handful of surgeons in the US have introduced the Athens Protocol into their practice.

The combined CXL/topographic-guided PRK is not advantageous or necessary for all patients with keratoconus. It is recommended when reshaping of the cornea would improve functional vision and reduce refractive error. Crosslinking is still the essential cmponented to the effective treatment of progressive KC.

Reference: Combined Photorefractive Keratectomy and Corneal Cross-Linking for Keratoconus and Ectasia: The Athens Protocol, Kanellopoulos AJ, Cornea, 42:1199-1205, 2023.