Photorefractive Keratectomy in Keratoconus Suspect Eyes with Borderline Topographies: One-Year Longitudinal Assessment of Visual, Refractive, and Topographic Safety

Purpose: To evaluate the one-year visual, refractive, and tomographic outcomes of photorefractive keratectomy (PRK) in patients identified as keratoconus suspects (KCS), a population traditionally considered at higher risk for postoperative ectasia. Methods: This prospective interventional case series included 62 eyes from 43 patients with KCS who underwent PRK at a tertiary academic center. Inclusion criteria were based on topographic and tomographic risk factors suggestive of early ectasia, including Belin/Ambrósio Deviation Index (BigD), posterior elevation, asymmetric bowtie patterns, and pachymetric abnormalities, confirmed by expert corneal evaluation. Preoperative and postoperative assessments included uncorrected and corrected distance visual acuity (UDVA, CDVA), refraction, central corneal thickness (CCT), keratometry, and key Pentacam indices. Follow-up continued for 12 months postoperatively. Results: UDVA improved significantly from 0.34 ± 0.23 logMAR preoperatively to 0.04 ± 0.01 at one year (p < 0.001), with stable CDVA across all follow-ups. Spherical equivalent reduced from − 2.21 ± 1.53 D to − 0.15 ± 0.36 D (p < 0.001). Although CCT and keratometric values decreased postoperatively, no eyes developed clinical or topographic signs of ectasia. Seven eyes (11%) required mild optical correction due to residual refractive error. BigD and PPI values remained within the suspicious but non-pathologic range. Conclusions: PRK may be a safe and effective refractive option in carefully selected KCS patients with stable corneal morphology and borderline topographic findings. The absence of ectatic progression over one year underscores the importance of comprehensive preoperative screening and individualized surgical planning.