Journal of Ophthalmology

Journal of Ophthalmology / 2019 / Article

Letter to the Editor | Open Access

Volume 2019 |Article ID 4986597 |

Avi Wallerstein, Mathieu Gauvin, Mark Cohen, "Comment on “Under-the-Flap Crosslinking and LASIK in Early Ectasia with Hyperopic Refractive Error”", Journal of Ophthalmology, vol. 2019, Article ID 4986597, 2 pages, 2019.

Comment on “Under-the-Flap Crosslinking and LASIK in Early Ectasia with Hyperopic Refractive Error”

Academic Editor: Suphi Taneri
Received06 Feb 2019
Accepted29 May 2019
Published01 Jul 2019

We read with great interest the article by el-Khoury et al. “Under-the-Flap Crosslinking and LASIK in Early Ectasia with Hyperopic Refractive Error” [1]. It is encouraging to see clinical work with the goal of stabilizing the progression of early post-LASIK ectasia and improving visual outcomes. In their article, a combination of excimer laser ablation and corneal collagen crosslinking (CXL) was performed under an existing LASIK flap.

Sequential excimer laser ablation with CXL has been previously described for the management of cornea ectasia after LASIK [24]. The novelty of el-Khoury’s article is applying this combination “under-flap” instead of performing a corneal surface treatment with epithelial removal.

While el-Khoury and colleagues included key references on CXL combined with excimer laser ablation in their article, we noted an important omission of the source reference that first introduced and described the “under-flap” approach to CXL in patients with early ectasia. The article “Under-flap stromal bed CXL for early post-LASIK ectasia: a novel treatment technique” was published in Clinical Ophthalmology in December 2016 [5]. This article is the first to describe and report on outcomes of performing CXL performed under a previous LASIK flap.

The unintentional omission of this reference might lead the readers to wrongfully believe that Dr. el-Khoury and colleagues were the first to describe an under-flap approach to CXL in the management of early post-LASIK ectasia. We would kindly ask Dr. el-Khoury to update his reference list so that the readers can be better informed of the origins of the under-flap method for CXL.

We would like to congratulate the authors for their contribution to the field.

Conflicts of Interest

The authors declare that there are no conflicts of interest and no financial interest in the subject matter or materials presented herein.


  1. S. el-Khoury, Y. Abdelmassih, M. Amro, E. Chelala, and E. Jarade, “Under-the-Flap crosslinking and LASIK in early ectasia with hyperopic refractive error,” Journal of Ophthalmology, vol. 2018, Article ID 4342984, 10 pages, 2018. View at: Publisher Site | Google Scholar
  2. A. J. Kanellopoulos and P. S. Binder, “Management of corneal ectasia after LASIK with combined, same-day, topography-guided partial transepithelial PRK and collagen cross-linking: the athens protocol,” Journal of Refractive Surgery, vol. 27, no. 5, pp. 323–331, 2011. View at: Publisher Site | Google Scholar
  3. G. D. Kymionis, D. M. Portaliou, V. F. Diakonis et al., “Management of post laser in situ keratomileusis ectasia with simultaneous topography guided photorefractive keratectomy and collagen cross-linking,” Open Ophthalmology Journal, vol. 5, pp. 11–13, 2011. View at: Google Scholar
  4. G. Tamayo, C. Castell, P. Vargas, E. Polania, and J. Tamayo, “High-resolution wavefront-guided surface ablation with corneal cross-linking in ectatic corneas: a pilot study,” Clinical Ophthalmology, vol. 11, pp. 1777–1783, 2017. View at: Publisher Site | Google Scholar
  5. A. Wallerstein, E. Adiguzel, M. Gauvin, N. Mohammad-Shahi, and M. Cohen, “Under-flap stromal bed CXL for early post-LASIK ectasia: a novel treatment technique,” Clinical Ophthalmology, vol. 11, pp. 1–8, 2017. View at: Publisher Site | Google Scholar

Copyright © 2019 Avi Wallerstein et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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