Higher Order Aberrations Following the Tel-Aviv Protocol for Keratoconus

Purpose: To evaluate changes in higher order aberrations (HOAs) in patients with keratoconus following treatment with the Tel-Aviv protocol. Methods: A retrospective comparative analysis. Medical records of patients who underwent the Tel-Aviv protocol, consisting of epithelial photorefractive keratectomy using a 50 to 60 µm epithelial ablation with a myopic spherical and astigmatic component, followed by corneal cross-linking between 2021 and 2024, were reviewed. Data on keratometry, refractive error, corrected distance visual acuity (CDVA), epithelial thickness, and HOAs were collected and compared before and 6 months after the procedure. Results: Fifty-five eyes of 50 patients met the inclusion criteria. The mean age was 29.45 ± 10.5 years (range: 14 to 53 years), with 18 patients (32.7%) being women. The mean follow-up time was 262.73 ± 232.1 days. CDVA improved significantly from 0.23 ± 0.14 to 0.13 ± 0.125 logarithm of the minimum angle of resolution ( P < .001). Significant reductions were observed in vertical coma, vertical trefoil, spherical aberration, residual aberrations, and root mean square for total HOAs ( P < .05 for all). Epithelial thickness demonstrated stability, and improvement was noted in corneal symmetry indices and the ectasia index. A significant positive correlation was found between the reduction in vertical coma and the improvement in CDVA ( r = 0.34, P = .01). Conclusions: The Tel-Aviv protocol significantly reduces most HOAs in keratoconus, particularly vertical coma. The reduction in vertical coma was positively correlated with improvement in CDVA, underscoring its dominant role in visual degradation in keratoconus. Visual outcomes and corneal symmetry indices also improved.