November 2019


Research Highlight
New crosslinking paper highlights ‘current protocols and clinical approach’

by Ellen Stodola EyeWorld Editorial Co-Director

Patient undergoing epithelium-off corneal collagen crosslinking
Source: Sumit “Sam” Garg, MD


To correspond with the publication of a new crosslinking paper in November’s Journal of Cataract & Refractive Surgery,1 EyeWorld spoke to two surgeons involved with the paper about what it will explore.
“The idea of the paper was actually not to be encyclopedic with crosslinking and it was not to suggest what future studies might be done or what the future of crosslinking should entail,” said Francis Mah, MD, chair of the ASCRS Cornea Clinical Committee. “Essentially it was a much more basic issue.”
When crosslinking was first approved by the FDA, there was a lot of frustration and misinformation with a lot of questions about the billing and reimbursement aspects, Dr. Mah said. When practitioners were seeking advice, they were getting varied responses, depending on which consultants they were talking to, Dr. Mah continued.
So ASCRS, as well as the ASCRS Cornea Clinical Committee, felt that members could really use assistance in this matter.
First, ASCRS reached out with AAO and contacted several consultants to come to a consensus on how exactly we should be billing and what CMS is saying to do. With AAO, the Cornea Society, and ASCRS in the room, the groups came an agreement, Dr. Mah said. And then with the assistance of AAO, ASCRS hammered out an understanding with CMS for the appropriate codes.
The second step was writing a paper with all of the world’s literature on the health benefits of crosslinking, trying to support crosslinking as a means for the treatment and management of keratoconus and corneal ectasia following refractive surgery in patients who were candidates before corneal transplants. The paper, he said, focuses more on the “health economics” of crosslinking to show where it can be used in the management of keratoconus and corneal ectasia. Getting the word out and educating members were two major reasons for the paper, Dr. Mah said.
“Obviously, we’ve known about keratoconus for a long time,” said Kenneth Beckman, MD, lead author on the paper. “I don’t believe that we realized how common it is and how often it’s missed, particularly in young patients. We know that it’s progressive and, if left untreated, particularly in younger patients, it can lead to corneal transplants and a lifetime of maintenance.” If a 20-year-old needs a corneal transplant, this might mean they need two or three in their lifetime, and they could also have other complications like cataract and glaucoma. Crosslinking, a treatment plan that’s been available internationally for years, just got approved in the U.S. a few years ago, Dr. Beckman said, but one of the problems is people didn’t really understand where it fit and what it was, he said.
When crosslinking first came out, people thought of it as a rescue treatment instead of a transplant, he said, but that’s not the case. “What we now see and recognize is that it’s at its best in preventing or slowing progression rather than recovering vision,” Dr. Beckman said. “Therefore, an ideal candidate is the young person right upon diagnosis.”
In this paper, the authors sought to educate ophthalmologists and optometrists that a young patient with early signs of keratoconus can be sent for a crosslinking consultation immediately, rather than being followed for years.
Crosslinking is also useful in patients who have progressed, as it can give significant flattening and improvement in patients who are already advanced. “Myself and a number of other physicians and corneal specialists have taken on the belief that if the cornea is optically clear, and the vision is blurred from steepness and irregularity rather than a central scar, there’s a very high likelihood that they can keep good vision with a scleral lens, and the fitting techniques are so good that we recommend crosslinking to stabilize and fit with a scleral lens. And you may be able to prevent a transplant,” Dr. Beckman said.
Financial factors also play a role in crosslinking, he said. Initially, it was not covered by any insurance, its expense made it a barrier to patients. “Now that CMS has recognized this and created a code, insurance companies are starting to pay,” he added. This makes crosslinking even more accessible to patients.
We’re trying to create awareness to physicians, in general, that this is a real condition and there is a treatment now that can slow or stop progression, Dr. Beckman said. “I think most corneal specialists are aware of it, so I think this will be nice for general ophthalmologists and optometrists,” he said.
In the U.S., the only regimen that is approved currently is epi-off, which works really well but there are obvious risks of removing the epithelium, Dr. Beckman said. Those risks include pain in creating the epithelial defect, infection, delayed epithelial healing (which may lead to scarring and haziness of cornea), and it’s a longer recovery and not a comfortable procedure. Internationally, they’re doing epi-on, and that’s being investigated in U.S. in a number of protocols, he added. The advantages of epi-on is that by not removing epithelium, you don’t have discomfort, you can have quicker visual recovery, much less risk for infection, and potentially less risk for scarring and haze.

About the doctors

Kenneth Beckman, MD

Columbus Eye Surgery Center
Columbus, Ohio

Francis Mah, MD
Chair, ASCRS Cornea
Clinical Committee
Scripps Health
La Jolla, California

Relevant financial interests

: Avedro
Mah: Avedro

Contact information


1. Beckman KA, et al. ASCRS Cornea Clinical Committee. Corneal crosslinking: current protocols and clinical approach.
J Cataract Refract Surg. 2019;Epub ahead of print.

New crosslinking paper highlights ‘current protocols and clinical approach’ New crosslinking paper highlights ‘current protocols and clinical approach’
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