Purpose. To analyze the results of three-year outcomes of combined epithelium-on cross-linking with femtosecond laser ICRS
(cross-linking PLUS) for keratoconus management. Design. A retrospective multicenter clinical study. Methods. 43 eyes of 38
patients were subjected to preoperative and postoperative UCVA, BCVA, refraction, Pentacam pachymetry, and keratometry
examinations at 3-, 6-, 12-, 24-, and 36-month follow-up period. Results. The preoperative and postoperative mean UCVA was
1.30 ± 0.48 (logMAR ± SD) and 0.82 ± 0.22 respectively. The preoperative and postoperative mean BCVA was 0.90 ± 0.40 and
0.60 ± 0.30, respectively. The preoperative and postoperative mean K average was 50.63 ± 0.87 (D ± SD) and 45.56 ± 0.98,
respectively. The preoperative and postoperative mean pachymetry was 471 ± 92.36 (μm± SD) and 423 ± 39.58, respectively.
The preoperative and postoperative mean astigmatism was 7.55 ± 1.75 and 3.39 ± 1.26, respectively. One eye showed ICRS
edge exposure while 6 eyes showed progression of keratoconus. Conclusion. CXL PLUS was proved to be a successful
procedure to halt progression (mainly by CXL) and to correct the refractive status of the keratoconic eye (mainly by ICRS).
CXL PLUS performed a synergistic action correcting and maintaining the correction of both myopic and astigmatic components
of keratoconus.