J Cataract Refractive Surg. First, it may reduce the occurrence of corneal melt and the spread of the infection within the corneal stroma by increasing the cornea’s rigidity. Wollensak G, Spoerl E, Seiler T. Riboflavin/ultraviolet-a–induced collagen crosslinking for the treatment of keratoconus. J Refract Surg 2012;28:12:890-4. J Refract Surg 2016;32:1:41-46. “A patient came in with post-LASIK ectasia, and we thought she’d be a great candidate for cross-linking. “We know it’s going to help prevent problems, so we haven’t necessarily wanted to withhold treatment until progression has been documented. Washing the riboflavin off makes the outcome more accurate and reproducible.”, Comparing the new cfCXL and CXLUSA epi-on protocols, Dr. Epstein notes several differences. However, it’s still early in the game, and much more research needs to be done. J Refract Surg 2009;25:9:S812-8. 2. The cornea is treated with riboflavin (vitamin B2), then exposed to ultraviolet-A (UVA) light. It’s also possible that the UV light itself may have a sterilizing effect. “Most of the time, we find that cross-linking gives us a significant amount of corneal flattening, but there are patients who still have to wear contacts, and they’re still unhappy. In addition, UVA exposure carried a risk to the corneal endothelium particularly when the corneal thickness dipped below 400 microns, a finding not uncommon in this keratoconus population.5, Based on these findings, many investigators began exploring “epithelium-on” CXL (Table 1). This uses a different riboflavin formulation, and the way it’s applied is unique. Centrifuge and aspirate/discard the supernatant as before. Corneal crosslinking without epithelial removal. I tested DSP cross-linking reagent and could not detect my proteins of interest in protein extract by WB anymore after cross-linking. “The cross-linking treatment didn’t work, which was most likely due to the fact that the crosslinking therapy couldn’t reach the deeper portions of the cornea.” ​, Dr. Majmudar says that he hasn’t tried using cross-linking to treat problems such as fungal or bacterial postinfectious keratitis, but he believes it may have value. Aspirate out the PBS supernatant. If the patient had undergone cross-linking within a few weeks, progression could have been avoided. “Instead, I do a more limited debridement over the area of the cone. The resultant corneas were shown to be stiffer and more resistant to enzymatic digestion. Then he cultured the endothelial cells and looked for toxicity. En France, les CHU de Toulouse et de Bordeaux ont débuté des essais cliniques depuis la rentrée 2006. But I still believe that most ‘normal’ corneas are not going to get a significant refractive shift—certainly not more than 2 or 3 D at the most. If you administer the riboflavin through the corneal surface, the riboflavin left in the surface of the cornea will then act like an umbrella, blocking some of the UV light. You can find more information about that online at ClinicalTrials.gov, identifier: NCT03442751. Question. 2011;27(5):323-31. To the protein solution (0.25 to 1 mg/ml containing protein X and the crude extract) is added DSP stock solution to a final concentration of 2 mM. The family waited three months. Corneal collagen cross-linking is not FDA approved in the United States. “Furthermore, how long will the change last? Here’s how their approach works: After instillation of proparacaine at the slit lamp, the epithelium is gently brushed with a specially designed sterile sponge soaked with proparacaine to increase epithelial permeability. ​, “As the patient’s age at the time of the initial encounter increases—for instance, when treating a patient age 25 to 35—evidence of progression is probably prudent prior to performing cross-linking,” says Dr. Kanellopoulos. J Cataract Refract Surg 2003;29:9:1786-90. [3] O’Brart DPS, et al. 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It’s because the treatment area is smaller, which strengthens the effect on the curvature.”. (Dr. Hatch was an investigator in the CXLUSA study from 2011 to 2016, and says she currently treats 20 to 30 eyes a month using the FDA-approved Avedro system.) “Even so, we still had a fair amount of variability in our results, so it kind of fell out of favor in our practice. It remains to be determined whether cross-linking will change the bioavailability of topical or oral antibiotics within these corneas, which could impact their efficacy, but the preliminary data shows that cross-linking can be an effective means to address some types of corneal infection. His approach involves the use of an oral riboflavin supplement and taking advantage of the UV light that’s readily available in sunlight. Kanellopoulos AJ, Asimellis G. Hyperopic correction: Clinical validation with epithelium-on and epithelium-off protocols, using variable fluence and topographically customized collagen corneal crosslinking. Insurance companies rarely reimbursed us for the Intacs; a lot of times it was out of pocket for the patient. At this point the cornea is rinsed with BSS to remove excess riboflavin. “The cross-linking procedure also reshapes the cornea over time,” he explains. “For one thing, they rub the cornea for 15 seconds with a sponge soaked with their solution,” he says. Clin Ophthalmol Auckl NZ 2012;6:97–101. 2. Klin Monbl Augenheilkd 2012;229:4:411-5.7. Dr. Epstein explains that several factors set this treatment apart. (A paper in Cornea explains the mathematics of this.6), “Keep in mind that our protocol washes the riboflavin off the corneal surface before UV exposure,” he adds. Prepare a 50 mM solution of DSS, by dissolving 10 mg DSS in 540 µL of dry DMSO or dry DMF. Transepithelial versus epithelium-off corneal cross-linking for the treatment of progressive keratoconus: A randomized controlled trial. Rarely this thinning causes the cornea to bulge forwards and become distorted (ectasia). Corneal cross-linking has gained widespread popularity, originating in Europe and now practiced in Asia, South America, and across the globe. Ultraviolet A/riboflavin corneal cross-linking for infectious keratitis associated with corneal melts. American Journal of Ophthalmology. “I’ve done a fair amount of that,” he says. 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. Introduction. Ophthalmologists in the US were anticipating possible approval of the procedure pending the results of a multi-center phase 3 clinical trial in 2011, but the completed study has still not been published in its entirety. I think the next phase of treatment will be to take these irregular corneas and make them more regular by doing topography-guided PRK and combining that with cross-linking.


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