How do you manage corneal ectasia after refractive surgery?

Corneal cross-linking should be the first step to halt progression. I would then typically encourage patients to try hard contacts, which help improve the vision in the most conservative way. There are a variety of surgical interventions that can be considered depending on how advanced the ectasia is (topo guided PRK or intracorneal segments are some options). The goal of these treatments is typically to improve best spectacle correction so it is important the patient understands the expectation...

Crosslinking should be performed to strengthen the cornea and prevent further progression of ectasia. Of note - one can consider ectasia after refractive surgery identical to keratoconus - just that there is a history of previous refractive surgery. Our experience with crosslinking has been very positive, with a 1-2% risk for needing a 2nd crosslinking procedure over the next 5 years (so 98-99% of patients require just one crosslinking procedure).

This is way more common in patients with pre op thin corneas or in patients where the amount of cornea 'removed' is more than a 'conservative amount' because a higher amount of myopia is trying to be corrected. Patient selection and conservative surgical goals are key.