{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T13:15:36Z","timestamp":1783430136538,"version":"3.54.6"},"reference-count":36,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T00:00:00Z","timestamp":1783296000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vision"],"abstract":"<jats:p>Combined intrastromal corneal ring segment implantation with corneal collagen cross-linking (CXL) aims to improve optical regularity and reduce the risk of ectatic progression in selected eyes with keratoconus. In this retrospective, single-center, complete-case longitudinal series, 58 eyes from 40 patients treated at OCULENS Ophthalmology Clinic between 2019 and 2022 were analyzed after same-session KeraRing implantation and conventional epithelium-off CXL, with baseline and 6-, 12-, 24-, and 36-month follow-up data. Outcomes included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), thinnest pachymetry, maximum keratometry (Kmax), the Belin\/Ambrosio enhanced ectasia total deviation index (BAD-D), the C and D components of the ABCD classification, and Corvis ST-derived dynamic deformation parameters. Longitudinal continuous outcomes were analyzed as eye-level repeated-measures estimates with Holm-adjusted paired comparisons, and stage distributions were analyzed with the Friedman test. At 36 months, UDVA improved from 0.560 \u00b1 0.151 to 0.469 \u00b1 0.136 logMAR and CDVA from 0.350 \u00b1 0.109 to 0.287 \u00b1 0.092 logMAR (both p &lt; 0.001). Kmax decreased from 56.11 \u00b1 3.17 D to 54.87 \u00b1 2.86 D, BAD-D improved from 5.62 \u00b1 1.89 to 4.70 \u00b1 1.75, and thinnest pachymetry measured 440.7 \u00b1 21.9 \u00b5m at 36 months, corresponding to 97.0% of baseline thickness. Corvis ST-derived deformation behavior shifted toward lower deformation amplitude and higher stiffness parameter at first applanation (SP-A1), but these device-derived parameters should be interpreted as indirect deformation response metrics rather than as direct tissue stiffness measurements. Two clinically significant complications were recorded (2\/58 eyes, 3.4%): one sterile corneal infiltrate requiring ring explantation and one case of corneal melting requiring ring explantation and referral for keratoplasty. The findings support sustained 36-month visual, tomographic, and Corvis ST-derived changes after combined treatment, while interpretation remains limited by the retrospective complete-case design, unavailable denominator for cases excluded because of incomplete follow-up, eye-level analysis with bilateral cases, lack of a control group, and indirect nature of Corvis ST-derived biomechanical assessment.<\/jats:p>","DOI":"10.3390\/vision10030042","type":"journal-article","created":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T12:01:37Z","timestamp":1783339297000},"page":"42","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Three-Year Visual, Tomographic, and Corvis ST-Derived Biomechanical Outcomes After Combined Intrastromal Ring Implantation and Corneal Collagen Cross-Linking for Keratoconus"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3473-2141","authenticated-orcid":false,"given":"Radu-Nicolae","family":"Pop","sequence":"first","affiliation":[{"name":"OCULENS Ophthalmology Clinic, 400347 Cluj-Napoca, Romania"},{"name":"Faculty of Medicine, \u201cLucian Blaga\u201d University, 550169 Sibiu, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia Ariadna","family":"Nicula","sequence":"additional","affiliation":[{"name":"OCULENS Ophthalmology Clinic, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3222-6448","authenticated-orcid":false,"given":"Cristina Ariadna","family":"Nicula","sequence":"additional","affiliation":[{"name":"OCULENS Ophthalmology Clinic, 400347 Cluj-Napoca, Romania"},{"name":"Department of Oral and Maxillofacial Surgery and Radiology, Faculty of Dentistry, \u201cIuliu Ha\u021bieganu\u201d University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorin Vasile","family":"Nicula","sequence":"additional","affiliation":[{"name":"OCULENS Ophthalmology Clinic, 400347 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bianca","family":"Pop","sequence":"additional","affiliation":[{"name":"Surgical Department, University of Agricultural Sciences and Veterinary Medicine, 400372 Cluj-Napoca, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1016\/S0039-6257(97)00119-7","article-title":"Keratoconus","volume":"42","author":"Rabinowitz","year":"1998","journal-title":"Surv. Ophthalmol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1097\/ICO.0000000000000408","article-title":"Global consensus on keratoconus and ectatic diseases","volume":"34","author":"Gomes","year":"2015","journal-title":"Cornea"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1117","DOI":"10.1016\/S0886-3350(00)00451-X","article-title":"Correcting keratoconus with intracorneal rings","volume":"26","author":"Colin","year":"2000","journal-title":"J. Cataract Refract Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"5","DOI":"10.1007\/s40123-019-00211-2","article-title":"Intracorneal Ring Segment Implantation in the Management of Keratoconus: An Evidence-Based Approach","volume":"8","author":"Sakellaris","year":"2019","journal-title":"Ophthalmol. Ther."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1016\/S0002-9394(02)02220-1","article-title":"Riboflavin\/ultraviolet-A-induced collagen crosslinking for the treatment of keratoconus","volume":"135","author":"Wollensak","year":"2003","journal-title":"Am. J. Ophthalmol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"585","DOI":"10.1016\/j.ajo.2009.10.021","article-title":"Long-term results of riboflavin ultraviolet A corneal collagen cross-linking for keratoconus in Italy: The Siena Eye Cross Study","volume":"149","author":"Caporossi","year":"2010","journal-title":"Am. J. Ophthalmol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1016\/j.jcrs.2014.09.033","article-title":"Corneal collagen crosslinking with riboflavin and ultraviolet-A light in progressive keratoconus: Ten-year results","volume":"41","author":"Raiskup","year":"2015","journal-title":"J. Cataract Refract Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"228","DOI":"10.18240\/ijo.2021.02.08","article-title":"Evaluation of corneal topographic, tomographic and biomechanical indices for detecting clinical and subclinical keratoconus: A comprehensive three-device study","volume":"14","author":"Heidari","year":"2021","journal-title":"Int. J. Ophthalmol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"147516","DOI":"10.1155\/2014\/147516","article-title":"Corneal biomechanical assessment using corneal visualization Scheimpflug technology in keratoconic and normal eyes","volume":"2014","author":"Tian","year":"2014","journal-title":"J. Ophthalmol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"579190","DOI":"10.1155\/2014\/579190","article-title":"Corneal biomechanical changes after crosslinking for progressive keratoconus with the corneal visualization Scheimpflug technology","volume":"2014","author":"Steinberg","year":"2014","journal-title":"J. Ophthalmol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"840","DOI":"10.3928\/1081597X-20181012-01","article-title":"Tomographic and biomechanical Scheimpflug imaging for keratoconus characterization: A validation of current indices","volume":"34","author":"Steinberg","year":"2018","journal-title":"J. Refract Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1055","DOI":"10.1007\/s00417-022-05881-6","article-title":"Reliability analysis of successive Corvis ST measurements in keratoconus 2 years after accelerated corneal crosslinking compared to untreated keratoconus corneas","volume":"261","author":"Xanthopoulou","year":"2023","journal-title":"Graefes Arch. Clin. Exp. Ophthalmol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2084","DOI":"10.1016\/j.jcrs.2009.07.008","article-title":"Effect of treatment sequence in combined intrastromal corneal rings and corneal collagen crosslinking for keratoconus","volume":"35","author":"Coskunseven","year":"2009","journal-title":"J. Cataract Refract Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1136\/bjo.2010.179580","article-title":"Sequential versus concurrent KERARINGS insertion and corneal collagen cross-linking for keratoconus","volume":"95","year":"2011","journal-title":"Br. J. Ophthalmol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1016\/j.jcrs.2011.11.041","article-title":"Riboflavin injection into the corneal channel for combined collagen crosslinking and intrastromal corneal ring segment implantation","volume":"38","year":"2012","journal-title":"J. Cataract Refract Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1146","DOI":"10.1016\/j.jcrs.2013.03.022","article-title":"Efficacy of single or paired intrastromal corneal ring segment implantation combined with collagen crosslinking in keratoconus","volume":"39","author":"Yeung","year":"2013","journal-title":"J. Cataract Refract Surg."},{"key":"ref_17","first-page":"703","article-title":"Investigation of the efficiency of intrastromal ring segments with cross-linking using different sequence and timing for keratoconus","volume":"8","author":"Liu","year":"2015","journal-title":"Int. J. Ophthalmol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"830","DOI":"10.1016\/j.jcrs.2019.01.020","article-title":"Corneal crosslinking and intracorneal ring segments for keratoconus: A randomized study of concurrent versus sequential surgery","volume":"45","author":"Hersh","year":"2019","journal-title":"J. Cataract Refract Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2441","DOI":"10.1007\/s00417-020-04827-0","article-title":"Combined corneal cross-linking and 320\u00b0 intrastromal corneal ring segments in progressive keratoconus: One-year results","volume":"258","author":"Zaky","year":"2020","journal-title":"Graefes Arch. Clin. Exp. Ophthalmol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"4447","DOI":"10.2147\/OPTH.S333832","article-title":"One-Year outcomes of intracorneal ring-segment insertion assisted by femtosecond laser simultaneously performed with corneal collagen cross-linking for treatment of keratoconus","volume":"15","author":"Rashid","year":"2021","journal-title":"Clin. Ophthalmol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"2831","DOI":"10.4103\/ijo.IJO_2078_20","article-title":"ABCD: A new classification for keratoconus","volume":"68","author":"Belin","year":"2020","journal-title":"Indian J. Ophthalmol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1069","DOI":"10.1136\/bjophthalmol-2020-316789","article-title":"Keratoconus staging by decades: A baseline ABCD classification of 1000 patients in the Homburg Keratoconus Center","volume":"105","author":"Flockerzi","year":"2021","journal-title":"Br. J. Ophthalmol."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"de Sanctis, U., Caselgrandi, P., Gennaro, C., Tosi, C., Borrelli, E., Marolo, P., and Reibaldi, M. (2025). Topographic Pattern-Based Nomogram to Guide Keraring Implantation in Eyes with Mild to Moderate Keratoconus: Visual and Refractive Outcome. J. Clin. Med., 14.","DOI":"10.3390\/jcm14030870"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1186\/s40662-021-00234-6","article-title":"The number of intracorneal ring segments in asymmetric and central cones","volume":"8","author":"Utine","year":"2021","journal-title":"Eye Vis."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"23","DOI":"10.4103\/0301-4738.126170","article-title":"Decision making nomogram for intrastromal corneal ring segments in keratoconus","volume":"62","author":"Shetty","year":"2014","journal-title":"Indian J. Ophthalmol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/s40662-016-0040-z","article-title":"The use of intracorneal ring segments in keratoconus","volume":"3","author":"Alio","year":"2016","journal-title":"Eye Vis."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Benlarbi, A., Kallel, S., David, C., Barugel, R., Hays, Q., Goemaere, I., Cuyaubere, R., Borderie, M., Borderie, V., and Bouheraoua, N. (2023). Asymmetric Intrastromal Corneal Ring Segments with Progressive Base Width and Thickness for Keratoconus: Evaluation of Efficacy and Analysis of Epithelial Remodeling. J. Clin. Med., 12.","DOI":"10.3390\/jcm12041673"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"740","DOI":"10.3928\/1081597X-20191010-02","article-title":"Complications and Explantation Reasons in Intracorneal Ring Segments (ICRS) Implantation: A Systematic Review","volume":"35","year":"2019","journal-title":"J. Refract Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"153","DOI":"10.1016\/j.jcrs.2018.09.021","article-title":"Incidence and associations of intracorneal ring segment explantation","volume":"45","author":"Nguyen","year":"2019","journal-title":"J. Cataract Refract Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"378","DOI":"10.1097\/j.jcrs.0000000000001369","article-title":"Comparison of long-term outcomes of simultaneous accelerated corneal crosslinking combined with intracorneal ring segment or topography-guided PRK","volume":"50","author":"Cohen","year":"2024","journal-title":"J. Cataract Refract Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1167\/tvst.8.3.38","article-title":"Efficacy of Different Procedures of Intra-Corneal Ring Segment Implantation in Keratoconus: A Systematic Review and Meta-Analysis","volume":"8","author":"Pereira","year":"2019","journal-title":"Transl. Vis. Sci. Technol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1097\/j.jcrs.0000000000000500","article-title":"Five-year long-term outcomes of intrastromal corneal ring segment implantation using the manual technique for keratoconus management","volume":"47","author":"Costa","year":"2021","journal-title":"J. Cataract Refract Surg."},{"key":"ref_33","first-page":"CD010621","article-title":"Corneal collagen cross-linking for treating keratoconus","volume":"3","author":"Sykakis","year":"2015","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1016\/j.jtos.2014.05.002","article-title":"Epithelium-off photochemical corneal collagen cross-linkage using riboflavin and ultraviolet A for keratoconus and keratectasia: A systematic review and meta-analysis","volume":"12","author":"Craig","year":"2014","journal-title":"Ocul. Surf."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1136\/bjo.2010.196493","article-title":"A randomised, prospective study to investigate the efficacy of riboflavin\/ultraviolet A (370 nm) corneal collagen cross-linkage to halt the progression of keratoconus","volume":"95","author":"Chan","year":"2011","journal-title":"Br. J. Ophthalmol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"812","DOI":"10.1016\/j.ophtha.2013.10.028","article-title":"A randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: Three-year results","volume":"121","author":"Chan","year":"2014","journal-title":"Ophthalmology"}],"container-title":["Vision"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2411-5150\/10\/3\/42\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T12:31:46Z","timestamp":1783427506000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2411-5150\/10\/3\/42"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,6]]},"references-count":36,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["vision10030042"],"URL":"https:\/\/doi.org\/10.3390\/vision10030042","relation":{},"ISSN":["2411-5150"],"issn-type":[{"value":"2411-5150","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,6]]}}}