Implantation of biological corneal
inlays, derived from small incision lenticule extraction, may be a feasible method for surgical management of refractive and
corneal diseases. However, the refractive outcome is dependent on stromal remodelling of both the
inlay and recipient stroma. This study aimed to investigate the refractive changes and tissue responses following implantation of 2.5-mm biological
inlays with or without corneal
collagen crosslinking (CXL) in a rabbit model. Prior to implantation, rotational rheometry demonstrated an almost two-fold increase in corneal stiffness after CXL. After implantation, haze gradually subsided in the CXL-treated
inlays (p = 0.001), whereas the untreated
inlays preserved their clarity (p = 0.75). In-vivo confocal microscopy revealed reduced keratocyte cell count at the interface of the CXL
inlays at week 8. Following initial steepening, regression was observed in anterior mean curvature from week 1 to 12, being most prominent for the non-CXL subgroups (non-CXL: -12.3 ± 2.6D vs CXL: -2.3 ± 4.4D at 90 μm depth, p = 0.03; non-CXL: -12.4 ± 8.0D vs CXL: -5.0 ± 4.0D at 120 μm depth, p = 0.22). Immunohistochemical analysis revealed comparable tissue responses in CXL and untreated subgroups. Our findings suggest that CXL of biological
inlays may reduce the time before refractive stabilization, but longer postoperative
steroid treatment is necessary in order to reduce postoperative haze.