CORNEAL CROSS-LINKING (CXL) - Light For Sight
Transcript of CORNEAL CROSS-LINKING (CXL) - Light For Sight
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J. Bradley Randleman, M.D.CXL Experts Meeting
Zurich Switzerland December 2, 2016
CORNEAL CROSS-LINKING (CXL)
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Presenter Introduction• J. Bradley Randleman, MD • Professor of Ophthalmology,
Keck School of Medicine of USC
• Director, Cornea & Refractive Surgery USC Roski Eye Institute
• Editor-in-Chief, Journal of Refractive Surgery
No Financial Disclosures
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OVERVIEW
• CXL Basic principles
• Primary Indications: Ectatic corneal disorders
• CXL Protocols
• Complications & Controversies
• Patient Selection: Beginning & Advanced
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Crosslinking*for*keratoconus*(KC)*
• Non5enzyma9c*collagen*s9ffening*with*riboflavin*and*UVA*light*
Wollensak et al, AJO, 2003 Wollensak, Spoerl, Seiler Am J Ophthalmol 2003
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CX: CLINICAL RESULTS
Wittig-Silva JRS 2008
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Goals for CXL in Ectasias
• Stabilize ectatic process • Reduce corneal steepening • Improve CTL fitting • Provide alternatives for visual rehabilitation
o Intracorneal ring segments o PRK
Avoid corneal transplantation!
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CXL: STEP BY STEP
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Procedure: Standard Dresden Technique
• 9 mm epithelial removal
• Riboflavin 0.1% drops x 30 min
• Riboflavin 0.1% drops x 30 min with 30 minutes 365 nm UVA (3mW/cm2)
• UV-X , Peschke Meditrade, Zurich
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CXL IN THE US
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CXL IN THE US
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CXL FOR CORNEAL ECTASIAS
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Emory University data (unpublished)
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Emory University data (unpublished)
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Emory University data (unpublished)
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Emory University data (unpublished)
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Emory University data (unpublished)
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Eyes Achieving UDVA 20/40 or Better
Emory University data (unpublished)
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Eyes Achieving BSCVA 20/40 or Better
Emory University data (unpublished)
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MEASURING CXL CHANGES: CHALLENGES
Difference Maps
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ORA$changes$with$crosslinking$in$$post4LASIK$ectasia$
Delay in peak 1
Increase in Pmax
Earlier/shallower recovery from concavity
Hallahan KM, Rocha KM, Roy AS, Randleman JB, Stulting RD, Dupps WJ. Effects of corneal crosslinking on ocular response analyzer waveform-derived variables in keratoconus and post-refractive surgery ectasia. Eye Contact Lens 2014 Nov;40:339-44
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CXL COMPLICATIONS
• Corneal Damage
• Infectious Keratitis
• Lack of efficacy
• Failed remodeling
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COMPLICATIONS
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DELAYED HEALING
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CORNEAL MELT
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PERIPHERAL INFILTRATES
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PERIPHERAL INFILTRATES
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ENDOTHELIAL DAMAGE
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0
100
200
300
400
500
600
Dep
th (
mic
ron
s)
UVA Corneal Absorption in Presence of Riboflavin
3.00 mW/cm²
1.49 mW/cm²
0.74 mW/cm²
0.36 mW/cm²
0.18 mW/cm²
0.09 mW/cm²
0.06 mW/cm²
Damage Threshold
Keratocytes: 0.5 mW/cm2
Endothelium: 0.3 mW/cm2
Irradiance
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COMPLICATIONS
Failed Remodeling
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EPI-OFF CXL
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Epithelium MUST be removed for efficacy
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EPITHELIUM ON OR OFF?● Epithelium must be removed for efficacy
Epi Off
Epi On
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Standard
Iontophoresis
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CXL PROTOCOLS
• Epi-Off
• Standard (30 min x 3mW/cm2)
• Accelerated
• 10 min x 5mW/cm2
• 5 min x 18 mW/cm2
• 3-4 min x 30mW/cm2
• Epi-on
• “regular”
• iontophoresis
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PATIENT SELECTION
• Progressive keratoconus/ectasia
• high risk for progression
• adolescents
• signs of progression
• history of changing vision
• Issues with current visual correction
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PROTOCOL
• Follow the evidence:
• Epithelium-off
• Standard protocol
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CONCLUSIONS
• Complications can arise after CXL
• Requires diligence early postoperative
• Affects screening for CXL
• Affects patient and surgeon acceptance of protocols
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CONCLUSIONS
• Variations in clinical protocols occurring faster than research into these protocol variations
• Variability in comparative results depending on the metric followed
• Best metrics to follow still undetermined