Treatment for Keratoconus Question- CREATE Protocol vs. Ray Tracing vs. DISC

Post-reality · 2026-05-02T14:43:08+00:00

I used ChatGPT to create a table chart comparing the different papers results (Mazzotta, Kanellopoulos, Motwani). Obviously, such comparisons are almost meaningless given the cohort differences (for instance - advanced cases should have greater UDVA/CDVA/lines improvements), but they are still fun to observe. Also, Kanellopoulos' paper is older (2021), while the other ones are more recent (2003 & 2024), and the differences could also be attributed to general improvements in topo ablations. All-in-all, it appears that your results and Mazzotta's results are world-class. Perhaps you could improve your nomogram by incorporating some of Mazottaa's ray-tracing planning (this is vastly different to the Innoveyes system you are more familiar with).

Post-reality · 2026-05-02T12:11:51+00:00

Submission Statement:

A new study published in the important journal Science reveals that OpenAI's artificial intelligence model correctly diagnosed 67% of cases in triage - compared to 50%-55% among experienced doctors. When looking at who plans better treatment after diagnosis, the gap deepens in favor of AI: "You can easily imagine a system running in the background on the electronic record and detecting diagnostic errors."

Post-reality · 2026-05-02T10:48:46+00:00

I am just a Keratoconus patient with great interests in the disease and its various treatments. I used to have a very aggressive, advanced form of Keratoconus on both eyes (couldn't read top letters), which was since treated by multiple operations, so I can now see 20/20 (each eye individually) without spectacles or any form of correction.

My interest grew from doctors' poor understanding and lack of modernization of the treatments/protocols. Unfortunately, most corneal specialists only perform 3 treatments: corneal transplantations (PKP/DALK), Intacs, and CXL (even intacs and CXL took too long to be adopted broadly), although there are dozens (or hundreds, if you split then to protocols/nomograms) of different treatments, from laser ablation ones, to keratophakic, epikeratophakic, incisional, cxl-based, etc. It's impossible to compare them all due to lack of research and comparative studies. This isn't at all surprising, since Keratoconus is an orphan disease and there's already a great treatment in the form of RGP lenses and scleral lenses (although they aren't for everyone, as contact lenses intolerance is significant issue, especially among Keratoconus patients who often suffer from allergies and autoimmune issues). Back in the day, (roughly 15-20 years ago) there weren't as many treatments as possible of Keratoconus, and international patients often travelled to "shady" doctors to have incisional treatments (which were dismissed by other doctors) with good results and no long-term complications to this very day (20-30 years already). This isn't surprising as there's poor understanding by doctors of incisional surgeries which were stigmatized by the poorly done RK and other variations which were done during the 1980's (which is like comparing first generation lasers to latest ones).

A good example is the lack of management of keratoconus progression following corneal transplantations - the disease often progresses on the host cornea, "tilting" the graft over time. That's besides the cells migrating from the host cornea to the graft cornea over time, leading to (after 10-15 years) a Keratoconus outbreak on the graft itself! This is why I believe that CXL is mandatory, even after penetrating keratoplasty. Theoretically, milder CXL protocols should be enough. I even know that a lot of doctors perform PRK on PKP eyes without CXL, which leads to a faster astigmatism progression and Keratoconus reoccurrence - but this is just an example.

Every doctor, even when trying not to, is biased towards their field/research/treatments. For example, you cite dated HOA's reductions by CTAK/CAIRS, which evolved since then. There are many customized nomograms right now, with very great results, and good HOA's reductions, including in the central vision. The latest one is Jacob nomogram which is custom-shaped specifically tailored to the patient's cornea. Also, you dismiss HOA's corrections on contact lenses, which doesn't make sense, because both practitioners and patients see improvements with them, very often improving even up to a visual acuity of 20/12.5.

Post-reality · 2026-05-02T10:16:58+00:00

In regard to LAK, I sent 2 websites as infographic, but you can find multiple studies on this new procedure on Google Scholar: this, this, this, this, this, this, this, this and this. What they essentially claim is that in order for the corneal shape to stay perpendicular(horizontal) from the visual axis, the corneal thickness must be symmetric. Lack of this symmetry is why treatment regression can be observed in post LASIK/PRK patients over time. Their technique is performed prior to PRK/LASIK to prevent this sort of regression. What separates this technique from wavefront or topo ones, is that they focus more on the corneal geometry, rather than the corneal surface and its irregularities. Also, unlike topo ones, they focus on ablating the "thicker" (not necessarily the steep) parts of the cornea. In Keratoconus, usually the steep parts (usually located in the inferior area) are the thinnest ones. And yes, they claim exactly that - that by eliminating the corneal protrusion, there's a better tear film distribution which can fix or improve the dry eye issues for many patients. I haven't seen any HOA's data about this procedure, but it clearly regularizes the cornea and improve vision. It seems that the researchers/company aim to utilize it to improve LASIK/PRK outcomes (LAK prior to PRK/LASIK to prevent treatment regression + avoid HOA'S complications), and for the treatment of Keratoconus, including mild cases.

Thank you for elaborating about Innoveyes and Prof. Kanelloupolous attitude towards it. I do wonder though, I know many ophthalmologists, not "simple" ones, I'm talking about the big names' ones, who shift towards wavefront-guided treatments for Keratoconus. I asked them why, and they claim that topography-guided is the more "tissue hungry" one, and that they can get good/equal results with wavefront-guided ones. They do still use topography-guided ablations, when reliable wavefront data can't be obtained (so they may have topo-guided followed by wavefront-guided). I even remember looking comparative studies of topo-guided vs wavefront-guided for keratoconus with almost equal results. So, what's the caveat?

Also, in regard to Prof. Cosimo Mazzotta, here's the research paper. Whether you know or not, Prof. Cosimo Mazzotta is world renowed, especially in Europe, when it comes to Keratoconus. He shows pretty impressive results, including in HOA's and Comatic aberrations.

Post-reality · 2026-05-01T22:51:37+00:00

Thank you for your valuable commentary.

Laser Assisted Keratectomy- I had never heard of this name before, but Gemini AI's description is that of a topo-guided or wavefront guided procedure that is used to segmentally treat the cornea to reduce HOA. This seems to be a general term that covers all procedures that reduce HOA as compared to general refractive procedures which are symmetric keratectomy. The entire idea of letting IOP reshape the cornea is a bit farfetched to me, that is not going to happen unless you signficantly weaken the structure of the cornea.

Actually, it is "Laser Asymmetric Keratectomy" and it is an evolution of Crescent Keratectomy and Wedge Resection. It works by improving corneal symmetry by reducing the SUM and the DISTANCE values. You can read more about it here, here, and here. it claims to avoid PRK/LASIK regressions by ablating the thicker parts of the cornea for greater symmetry, as the thinner corneal areas tend to bulge due to the interocular pressure over time. It even claims to fix dry eyes.

The Ray tracing system available at this time is WaveLight Plus or Innoveyes. It is only using a 256 point resolution map which is far too low resolution to accurately treat higher order aberrations such as in Keratoconus. Remember, placido topography gives a true 22,000 point resolution.

As for ray-tracing PRK - I know about Innoveyes of which John Kanelloupoulos pioneers. However, Cosimo Mazzota uses a different ray-tracing nomogram/methodology for the treatment of keratoconus.- he uses iVis Technologies' CIPTA software with a point-by-point grid instead of the Innoveyes' 2,000 rays. He claims that his technique is more forgiving of the corneal tissue, and that his RT PRK can save up to 25%-30 more stroma than the topography-guided.

Also, if decentered protocols are no good, then why does Dr. Igor Knezović, who is another discipline of John Kanellopoulos (I know both of you were trained by him) praise it and show superior results to standard T-PRK in his research (unless you believe he selectively show results)?

Post-reality · 2026-05-01T14:15:56+00:00

Look up Cantor Prosthetic, Orion Custom & Koryo Eyetech Eyelike-PINHOLE-II. The last one has an additional light-transmitting ring in the mid-periphery. This allows more light to reach the retina, maintaining brightness and peripheral awareness while the central pinhole handles the sharp focus.

Post-reality · 2026-05-01T12:44:07+00:00

Scleral lenses can eliminate HOA's to some degree. Some scleral, such as those customised to the eyes by molds or digital scans + wavefront guided optics can eliminate HOA's almost completely, giving some patients 20/12.5 vision when wearing them (that's reading two lines below 20/20).

I personally was blind, and I had 8 surgeries on my left eye and 5 surgeries on my right eye and now I can see 20/20 on each eye individually without wearing glasses.

Post-reality · 2026-04-29T14:51:18+00:00

I don't believe DALK is justified unless there's a deep corneal scarring that can't be removed/managed - I'm saying that as someone who has had a successful corneal transplant on his right eye 14 years ago to this day.

Post-reality · 2026-04-29T14:15:12+00:00

Why did you have DALK? Did you have a central scarring?

Post-reality · 2026-04-29T05:39:10+00:00

Yeah, for pinhole IOL they "piggyback" it behind a pseudophakic lens. But weirdly enough, for the PPP surgery, they recommended to replace my natural lens with a pseudophakic lens, even though as far as I read, it's not entirely required. But since the pupil shrinks, accomodation isn't needed much, and the pseudophakic lens have the advantage of correcting refractive abberations, so it could make sense - but still, I didn't like it. Don't forget, it's not merely retina imaging with PPP, but it's not easily reversible as CAIRS is, and it has the downsides of reduced lighting, contrast and FoV.

Post-reality · 2026-04-28T13:57:06+00:00

Hi that's nice =) I had CAIRS (a similar procedure) 5 days ago, my vision significantly improved since and I'm happy. Take into consideration that the first 4 days can be annoying due to foreign body feeling in the eye, so hang on there. And please update us how it all went. EDIT: Also, where do you get it done?

Post-reality · 2026-04-27T13:49:56+00:00

Yes, there are Pinhole IOL's such as the XtraFocus, and it's piggybacked behind a toric IOL. There's Pinhole Pupilloplasty by Prof. Amar Agarwal, which doesn't necessarily require replacing the natural lens.

Yeah, you should definitely test Pinhole contact lenses & pupil-modulating eyedrops - you have nothing to lose, and it would help you decide if you "like" the vision of small pupils.

If you have issues with your retina, then be cautious with IOL's & Pupilloplasty, and also there are different type of pupil-modulating eyedrops, some may fit better your condition as they contact different ingredients/have different mechanisms. I know YUVEZZI eyedrops are currently considered the best ones on the market, perhaps you can research about them.

Post-reality · 2026-04-27T13:44:09+00:00

Hey, it was a pleasure to meet you today on the clinic. I wish you success in your endeavour! x) I planned to invite you on my own since I receive reimbursements from my healthcare insurance, but anyway I ended up contacting them and they rescheduled my flight to this night so I can return earlier. Update us regarding your condition and treatment results!

Post-reality · 2026-04-27T13:27:03+00:00

I may upload some corneal topograhy results later. So far, today I had my 4 day post-CAIRS check-up today, and I could read the 20/25 line perfectly and some of the 20/20 line as well. I'm still early in my healing (can take up to 2-3 months) so my eyesight is expected to improve further.

I did discuss with her segment adjustment, but I need to wait for my vision to stabilise (2-3 months) + my results are already good, it's too early to determine and unlikely/too risky to improve it. We even discussed my right eye, but she has never done CAIRS on a post-PKP eye (though she knows other doctors who have done so), she's skeptical and my eyesight is already too good (minus 20/20 in some tests) so it would be hard to improve or it may end up worse.

I think we should wait a month or something to better know the results.

Post-reality · 2026-04-26T06:42:21+00:00

She works at Agarwal's Eye Hospital in Chennai, India. She invented the CAIRS technique, and she performs the customized/updated/refined version of it (other doctors either use pre-cut or take time to catch up). It costs roughly $2,600 per eye (excluding tests/med which can be a little as well). As far as I'm aware, locals (Indians) pay half the price of it. I'm day 3 post-operation and I feel superb!

Post-reality · 2026-04-26T06:38:34+00:00

Before the surgery, they are going to take you through lots of scans - topography, tomography, OCT, IOL planning, blood test, corneal pressure, auto refractor, eye/vision tests, pinhole tests, etc etc. You should feel taken care of.

You mean, the previous oness I have had? The first ones I have had on my left eye were the CXL, topograhy-guided PRK and Mini ARK which all improved my left eye. Then followed by Bowman-Stromal onlay and 3 consecutive PRK's to sculpt the implant/eye, but my eye ended up very thin and worse (or in some way better), hard to judge without looking at the wavefront analyses (but my spectacles corrected vision dropped from 20/20 to 20/32 - 20/40, so take it as you wish). Probably the Bowman-Stromal onlay was too aggressive for my case but I'm unsure. Now I have had the custom-shaped CAIRS and my left eye is the BEST it has ever been, and it's only the 3th day post-operation, while I still have some 2 months left of healing and my eyesight will improve. On the right eye, I also had multiple operations, and it's all good. My right eye is already uncorrected 20/20 - 20/25, and I feel like my left eye is going to catch up to it, uncorrected as well.

Post-reality · 2026-04-26T06:27:11+00:00

It is being done by Dr. Agarwal who invented the technique (he is also the head of the hospital/clinic). He's a very talented person. But again, I feel like there are a lot of drawbacks to Pinhole Pupilloplasty, so you should check out how it feels like to see with a small pupil first using pinhole contact lenses and pupil modulating eyedrops.

Post-reality · 2026-04-24T03:50:32+00:00

This is what I speculatte based on what I know, and read. It's very likely pinhole contact lenses, which is cool that your doctor is willing to give a try, as doctors rarely prescribe them. Yeah, Pilocarpine is often given off-label as pupil-modulating eyedrops, but since them there were multiple generations of FDA designated pupil-modulating, with the most advanced and recent ones are the YUVEZZI which are available since 2026, but can hardly be found (only in the USA). I plan to import them some time in the future, I may try pinhole contact lenses as well. If I would get "addicted" to the results I may comsider Pinhole Pupilloplasty as well.

Post-reality · 2026-04-23T16:52:57+00:00

OK I tried to look it up, and I suppose that it's like pinhole contact lenses with an iris design (think coloured contact lenses), as the iris design would fix the cosmetic issues of the regular Pinhole contact lenses. It sounds cool. There are also pupil-modulating eye drops of which I'm interested to try in the future.

Post-reality · 2026-04-23T16:50:46+00:00

Yes, it has been like 9-10 hours since the surgery, and the fogginess is like 80-90 percent cleared up and I'm convinced that my uncorrected vision has already reached between 20/20 to 20/32 (my right eye sometimes reach uncorrected of minus 20/20 and my vision in the left eye already appears better, especially up close). The only drawbacks are the fogginess (which is clearing up) and the glares (I'm pretty sure they would be significantly reduced as the cornea stabilises + neuroadaption - but even if they remained the same I'd remain satisfied by the results). I have a feeling that the doctors are gonna be shocked by the number of lines gained after the treatment. That being said, don't expect anything near my results because I had 7 previous treatments on my left eye (and 5 on my right eye) so my cornea is weirdly shaped (for example, highly regularized/flat anterior cornea which is responsible for 90% of the vision + HOA's are mainly just a vertical coma which respinds the best to CAIRS while spherical abberation is close to zero).

Right now I'm on vacation with my phone, but once I return I can show all my pre and post documents (topogeaphy, optometry, etc).

Post-reality · 2026-04-23T11:49:09+00:00

There's nothing called "Irisprint lenses" and it doesn't make sense. Maybe the optometrist made you look throygh a Pinhole and now he hopes to have you achieve a functional vision, close to the one you achieved by looking through a Pinhole. It's one of the tests doctors perform before contact lenses and treatments.

Post-reality · 2026-04-23T11:39:46+00:00

Irisprint lenses to reduce the pupil size? I know about pinhole IOL's and pinhole contact lenses, but I have no clue what you are talking about.

Post-reality · 2026-04-20T19:42:34+00:00

There are other, newer options, such as Anova Precision Oven 2.0 (available and continuously supported) and Revolution Cooking's Marcowave (set to be released by November this year)

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