January 2019


Crosslinking playbook

Clara Chan, MD,
Cornea editor

In the past, patients with keratoconus, post-LASIK ectasia, or pellucid marginal degeneration would experience progressive vision loss until a cornea transplant was performed. With the advent of corneal crosslinking as a treatment, these types of patients now have hope that their disease process may be halted and that a cornea transplant may not be needed. Corneal crosslinking has been approved in the United States since April 2016. In Canada where I practice, we have been performing corneal crosslinking since 2008. Internationally, trials began in the early 2000s. The standard procedure involves removal of the epithelium, riboflavin drop application to the cornea, and ultraviolet-A light illumination. Given the few years of recent experience in the United States, we wanted to explore what we have learned about corneal crosslinking in this month’s featured series.
We begin with J. Bradley Randleman, MD, and Rajesh Rajpal, MD, who discuss the preoperative considerations for the patient and surgeon prior to crosslinking such as what relevant clinical findings should be considered, diagnostic data variables, patient demographics, corneal thickness, and etiology of the patient’s ectasia.
Next, Parag Majmudar, MD, Audrey Talley Rostov, MD, and William Trattler, MD, review pearls for the intraoperative and postoperative care of patients undergoing corneal crosslinking. Epithelium-on techniques are compared to standard epithelium-off; optimal methods to measure corneal thickness, fluence settings to the light machine, theoretical benefits of a decentered light source in certain patients, ideal postoperative pain control regimens, the importance of counseling the patient to discontinue eye rubbing, and recommended methods to monitor for progression are presented.
Eric Donnenfeld, MD, Raymond Stein, MD, and George Waring IV, MD, share their preferred adjunctive treatments to corneal crosslinking. Intrastromal ring segments and topography-guided custom ablation treatment PRK are compared and contrasted with additional discussion on whether riboflavin could be placed under a LASIK flap, in a SMILE-stromal pocket or Intacs channel.
Finally, we conclude with the exciting future of what lies ahead in possible advances in the field of corneal crosslinking. Jorge Alio, MD, Jack Parker, MD, and Vance Thompson, MD, comment on refractive and corneal infection applications of crosslinking, other biochemical and nanotechnology options rather than using riboflavin, stem cells for stromal regeneration to treat keratoconus, and Bowman’s layer transplantation techniques.
Please enjoy this issue of EyeWorld, and thank you to all the physicians above for taking the time to share their expertise and their own playbooks for crosslinking.

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