“We create the rings using eye-bank corneas,” he explains. “This protocol could be great for patients who are pregnant, as well as pediatric patients, who tend to regress after the commercial cross-linking,” he says. They’re using technology owned by a company called CXL Ophthalmics to perform the new procedure, and some results of their studies have already been published.3,4. “I’m not sure you can tailor it precisely enough to get the exact effect you need to correct a refractive error,” he says. “This is called refractive cross-linking,” says Dr. Kanellopoulos. While there are several variations on the procedures used to accomplish this, all entail either removing or weakening the epithelial barrier of the cornea. Cornea 2017;36:5:600-604. I did the cross-linking according to protocol from Pierce. If the patient had undergone cross-linking within a few weeks, progression could have been avoided. In addition, many ophthalmologists are aware that previous epi-on techniques failed to produce lasting results. “For patients with more advanced keratoconus, the advantage of performing cross-linking first is that the corneal shape can improve, and the cornea will have become stronger. Klin Monbl Augenheilkd 2012;229:4:411-5.7. American Journal of Ophthalmology. “If a patient is interested in undergoing laser vision correction, and during the preoperative evaluation keratoconus is identified, that patient should undergo cross-linking, not LASIK or PRK,” he says. The cornea is then exposed to 370 nm UVA with an irradiance of 3 mWcm-2 for 30 minutes, during which time riboflavin is re-applied at 5 minute intervals. 11. “We use a narrow-er beam of light,” he explains. Rubinfeld RS, Stulting RD, Gum GG, Talamo JH. Spoerl, E.; Huhle, M.; Seiler, T.: Induction of cross-links in corneal tissue, Exp. “They may not have been progressing, but after cross-linking, six months or a year later we see some corneal flattening and improvement in vision. “We have seen improvements in a certain segment of the population at that age,” he notes. Used in conjunction with epithelium-on techniques, agents such as benzalkonium chloride and hypotonic riboflavin increased penetration of riboflavin improving efficacy. The eye is then exposed to UV light (4 mW/cm2) for 30 minutes, using a proprietary light device that cycles the light on and off, allowing the cornea to re-oxygenate during the dark phase. “Our ex-vivo work comparing several higher-fluence options has shown that higher fluence is relatively effective up to 30 mW/cm2,” he says. So in that situation, we suggest waiting. “We presented that data at the international cross-linking conference in 2017 and won the award for the best research.” Since then, they’ve opened the study to sites outside of their geographic area. Ultraviolet-A (UVA) Treatment can stop the progression of Keratoconus, Presentation at ARVO 2004, Ft. Schnitzler, E.; Spoerl, E; Seiler, T.: Bestrahlung der Hornhaut bei mit UVLicht und Riboflavingabe als neuer, Behandlungsversuch bei einschlmelzenden Hornhautprozessen, erste Ergebnisse bei vier Patienten, Klin. “This protocol could be great for patients who are pregnant, as well as pediatric patients, who tend to regress after the commercial cross-linking,” he says. Centrifuge and aspirate/discard the supernatant as before. All rights reserved. There’s definitely enough there to warrant further investigation.” , Dr. Majmudar says that combining cross-linking with Intacs has been a useful option. Perhaps the most significant factor was problems with reimbursement. 3. R. Doyle Stulting, MD, PhD, director of the Stulting Research Center at Woolfson Eye Institute and professor of ophthalmology, emeritus at Emory University in Atlanta, is a member of the CXLUSA group. Reduction in pain, risk of infection and melting, and endothelial toxicity, although unclear long term efficacy versus standard epithelium-off protocol. J Cataract Refract Surg 2013;39:8:1157-1163. “The idea is to deliver a similar amount of total cross-linking energy in less time. J Refract Surg 2016;32:1:41-46. 1. Beshtawi IM, O’Donnell C, Radhakrishnan H. Biomechanical properties of corneal tissue after ultraviolet-A–riboflavin crosslinking. That’s where we’re going to try to find a synergy between these two modalities.” , Dr. Kanellopoulos says his group has reported extensively on this type of work. 2003, 29:1780–1785. These ectatic changes are typically marked by corneal thinning and an increase in the anterior and/or posterior curvatures of the cornea, and often lead to high levels of myopia and astigmatism. This uses a different riboflavin formulation, and the way it’s applied is unique. Question. 1. Since the epithelium is not removed the riboflavin absorption requires more time than with epi-off procedure. Here, surgeons with extensive cross-linking experience share the latest ideas and data relating to a host of cross-linking issues.