In order to overcome the contra-indication of treating corneas with a thickness bordering on 400μm, Kymionis et al.  developed the use of pachymetry-guided epithelial debridement- a treatment modification in which the epithelium is only removed from regions of the cornea with a thickness in excess of 400μm. The safety and efficacy of the treatment has yet to be fully validated,
An alternative solution proposed by Hafezi et al.  is the replacement of the standard iso-osmolar riboflavin solution (containing dextran) with a hypo-osmolar riboflavin solution (without dextran) in order to swell the cornea to an acceptable thickness prior to cross-linking. Treatment of 20 patients with thin corneas (minimum preoperative stromal thickness of 323µm) using this method resulted in keratoconus progression being arrested in all cases . It is however advised that a minimal preoperative stromal thickness of 330μm is required for successful cross-linking using this modified protocol .
 Kymionis, G. et al. Customized pachymetric guided epithelial debridement for corneal collagen cross linking. BMC Ophthalmology. 2009;9:10.
 Hafezi, F. et al. Collagen crosslinking with ultraviolet A and hypoosmolar riboflavin solution in thin corneas. Journal of Cataract and Refractive Surgery. 2009;35:621-4.
 Hafezi, F. Limitation of collagen cross-linking with hypoosmolar riboflavin solution: failure in an extremely thin cornea. Cornea. 2011;30(8):917-9.