The Expanding Role of Corneal Cross-linking

European Society of Cataract & Refractive Surgeons (ESCRS) 2013

Roger F. Steinert, MD


November 01, 2013

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Hello. I'm Dr. Roger Steinert. I'd like to share my thoughts about one of the most exciting and most common of the topics presented at the European Society of Cataract & Refractive Surgeons (ESCRS) meeting, which is collagen cross-linking.

If you are not a cornea specialist, you may not think that this applies to you. But trust me, it does. The excitement is over 2 things. The one that applies to all comprehensive ophthalmologists is the potential for cross-linking technology to have a major impact on how we manage infectious corneal infiltrates. There were a handful of presentations[1,2] showing that cross-linking technology -- namely, the soaking of riboflavin as a chromophore into the cornea followed by exposure to ultraviolet light -- may speed up the eradication of organisms. In fact, it may potentially completely replace the need for antibiotics or antifungals and leave the cornea clearer. This is something that would be a game changer in how we manage infectious keratitis. Can you imagine a patient coming in with a fungal infection, Acanthamoeba, or Pseudomonas, and instead of the prolonged pain and treatment that they are currently subjected to, they are able to undergo 1 or 2 treatments and end up with an intact cornea, not even needing restorative penetrating or lamellar keratoplasty? That would be truly remarkable.

For those of you who are not that familiar with cross-linking, this has been around for over a decade. It was first done experimentally, and then extensive treatments were done in Europe. There is no evidence of any significant safety factor. There are some haze issues, which do potentially relate to the removal of the epithelium to allow penetration of the riboflavin. Ways of pharmacologically altering the riboflavin to get better penetration through the epithelium, locally disrupting the epithelium with devices that create puncture spots with intact epithelium between, and the potential for using laser to break down some of the epithelial barriers without completely removing the epithelium were all addressed.[3] These are all works in progress. I did not see any consistent evidence that this was as effective as complete epithelium-off cross-linking, and some argued that it was not as good as full epithelial removal.

There is also a much more concerted effort to develop some way of measuring the penetration of riboflavin into the cornea[4] -- how deep it is and how dense it is -- and then using that as a guide for whether there has been adequate preparation before ultraviolet exposure.

And, finally, there is some work going on to find alternative chromophores to riboflavin,[5] which is just a vitamin, and to come up with something else that will be equally or potentially more effective, penetrate through the epithelium, and avoid the necessity of removing the epithelium, which can trigger haze as well as several days of pain for the patient.

This is Roger Steinert, Chair of Ophthalmology at the University of California-Irvine and Director of the Gavin Herbert Eye Institute. On behalf of Medscape, so long.


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