Corneal crosslinking without epithelial removal

Stulting, R. Doyle; Trattler, William; Woolfson, Jonathan M.; Rubinfeld, Roy S.

doi:10.1016/j.jcrs.2018.07.029

Cited by 47 publications

(72 citation statements)

References 38 publications

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“…Two, TE-CXL can successfully treat ongoing postsurgical ectasia after epi-off CXL. We also suggest that effective TE-CXL 8 may, by avoiding surgical removal or disruption of the corneal epithelium, reduce the risk of DLK, infection, scarring and extended recovery that can occur as a result of epi-off CXL 6 , 9 in this situation.…”

Section: Discussionmentioning

confidence: 94%

“…Repeat CXL was recommended as salvage therapy prior to consideration of keratoplasty. The thinnest corneal pachymetry by Pentacam was 340 μm when the patient underwent thermokeratoplasty to regularize the cornea by conductive keratoplasty (CK; Refractec, Bloomington, MN) followed by a novel, transepithelial CXL (TE-CXL) procedure (CXLO; CXL Ophthalmics, Encinitas, California) 24 hours later 7 , 8 …”

Section: Case Reportmentioning

confidence: 99%

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Diffuse lamellar keratitis after epi-off corneal crosslinking: An under-recognized complication?

Mannschreck

Rubinfeld

Soiberman

et al. 2019

American Journal of Ophthalmology Case Reports

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PurposeTo report diffuse lamellar keratitis (DLK) occurring in an eye that underwent epithelium-off (epi-off) corneal cross-linking (CXL) as a treatment for post-surgical ectasia and the successful treatment of progressive ectasia with a novel epi-on CXL and conductive keratoplasty (CK) treatment.ObservationsA 42-year-old man presented with corneal ectasia in his right eye 3 years after laser in situ keratomileusis (LASIK) surgery. He underwent epi-off corneal CXL using the Dresden protocol. Grade II DLK was diagnosed within days of CXL. Despite successful treatment of DLK, best-corrected visual acuity in the right eye deteriorated over the next 4 months due to progression of ectasia and remained worse than the patient's pre-operative baseline 1 year after epi-off CXL. Because of apparent disease progression, despite his CXL treatment, the patient underwent a novel, transepithelial CXL (TE-CXL) treatment combined with conductive keratoplasty (CK). This treatment improved his vision and stabilized his ectasia without subsequent DLK. Approximately 3 years after CK and TE-CXL, his eye remains stable with 4 Snellen lines of improved vision and no progression of ectasia.Conclusion and importanceEpithelium-off CXL is used increasingly to treat post-LASIK ectasia. First, in this case, DLK occurred after epi-off CXL. We suggest careful scrutiny of such cases as DLK is difficult to identify after epi-off CXL. Second, the epi-off CXL was unsuccessful in stopping the post-LASIK ectasia. Transepithelial CXL successfully treated the ongoing ectasia after resolution of the DLK with no subsequent re-occurrence of DLK. We suggest that TE-CXL may provide a successful initial treatment for post-LASIK ectasia that also minimizes the epithelial disruption that can lead to DLK.

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Section: Discussionmentioning

confidence: 94%

Section: Case Reportmentioning

confidence: 99%

Diffuse lamellar keratitis after epi-off corneal crosslinking: An under-recognized complication?

Mannschreck

Rubinfeld

Soiberman

et al. 2019

American Journal of Ophthalmology Case Reports

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“…In turn, this could allow for transepithelial CXL (epi‐on treatment), which may decrease the initial ocular irritation, increase safety and open up for bilateral same‐day treatments (Stulting et al. ).…”

Section: Introductionmentioning

confidence: 99%

“…Increasing the oxygen concentration in the ambient air during treatment might thereby potentially increase the cross-linking effect. In turn, this could allow for transepithelial CXL (epi-on treatment), which may decrease the initial ocular irritation, increase safety and open up for bilateral same-day treatments (Stulting et al 2018).…”

Section: Introductionmentioning

confidence: 99%

A prospective evaluation of photorefractive intrastromal cross‐linking for the treatment of low‐grade myopia

Fredriksson

Näslund

Behndig

2019

Acta Ophthalmologica

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Purpose To evaluate photorefractive intrastromal cross‐linking (PiXL) treatment for low‐grade myopia, comparing three treatment protocols. Methods Healthy individuals, 25.6 ± 3.6 years of age, with low‐grade myopia underwent epi‐on PiXL with either: 4‐mm zone treated in high oxygen environment (4 mm‐HIGH; n = 15), 4‐mm/room air (4‐mm LOW; n = 6), or 6‐mm/high oxygen (6‐mm HIGH; n = 6). Efficacy was determined by change in uncorrected visual acuity (UCVA), manifest refractive spherical equivalent (MRSE) and corneal curvature (Kmean) over a 12‐month follow‐up. Safety was determined by best spectacle corrected visual acuity (BSCVA), corneal endothelial cell loss and registration of side‐effects. Results Twenty‐seven subjects were included. Due to insufficient effect with the 4‐mm LOW treatment and an unacceptable degree of initial light sensitivity/ocular irritation in the 6‐mm HIGH group, the inclusions to these treatments were stopped after inclusion of 6 patients in each group. The 4‐mm HIGH treatment showed a significantly larger improvement in UCVA (−0.45 ± 0.27 LogMAR) and MRSE (+0.99 ± 0.44 D) at 1, 6 and 12 months compared with the 4‐mm LOW treatment (p < 0.05). At 12 months posttreatment, endothelial cell count and BSCVA were unaltered. More initial side‐effects were noted with the 6‐mm HIGH treatment, compared with the 4‐mm HIGH treatment (p < 0.05). Conclusion Epi‐on PiXL may become a safe and effective non‐ablative treatment for low‐grade myopia. The effect is augmented by high oxygen environment and remains stable for 12 months. The initial ocular irritation is acceptable with a 4‐mm treatment zone. The present results justify further clinical studies on PiXL, including refinements of the technique and long‐term results.

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“…A multicenter study in the USA conducted by the physician sponsored CXL-USA study group, made up of 17 centers across the country, evaluated Epi-On CXL. 7 Forme fruste keratoconus, post LASIK ectasia, pellucid marginal degeneration (PMD), forme fruste PMD, keratoconus or fluctuating vision after radial keratotomy all inclusion criteria for the study. In a single-center analysis 7 patients followed for 3-6 months showed approximately 50% of eyes treated with the epi-on CXL technique had gained 1 or more lines from baseline CDVA at both followup intervals or showed improved corneal topographic changes including reduction in K max (approximately 1-1.5 D of flattening) and regularization of irregular astigmatism while 90% of eyes maintained their shape and did not progress.…”

Section: Discussionmentioning

confidence: 99%

Epithelium-on Corneal Cross-linking for Progressive Keratoconus: Two-year Outcomes

Cummings¹,

Shaw²,

Kelly³

2018

International Journal of Keratoconus and Ectatic Corneal Diseases

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Corneal cross-linking (CXL) has been established as a successful treatment tool for the treatment of progressive keratoconus in terms of slowing or halting progressive corneal steepening and thinning and even on some occasions, reversing the steepening. To date the Dresden epithelium-off protocol is regarded as the gold standard and the epithelium-on (epi-on) approaches have met with less success. Both doctors and patients would welcome an epi-on CXL procedure that provided good outcomes as the morbidity with epi-on CXL is so much less and the safety is enhanced. Patient comfort is greater with the epi-on techniques when compared to epi-off. This study looked at 82 eyes that had documented progression of keratoconus and then underwent epi-on CXL using the CXLO system. The results show that corneal steepening can be halted and even reversed over a 2-year follow-up period with no complications noted. Over the 24 months post treatment on average there was a decrease in all keratometry values, BAD and ISV when compared to before treatment with IHD being marginally increased.Further studies over a longer follow-up period are required but recent publications using the same approach are validating the findings seen in this study.

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Corneal crosslinking without epithelial removal

Abstract: Epithelium-on CXL using this new protocol halted the progression of keratoconus and ectasia after LASIK. It was safer and provided more rapid visual recovery than CXL with epithelial removal, allowing routine bilateral, simultaneous treatment.

Cited by 47 publications

References 38 publications

Diffuse lamellar keratitis after epi-off corneal crosslinking: An under-recognized complication?

Diffuse lamellar keratitis after epi-off corneal crosslinking: An under-recognized complication?

A prospective evaluation of photorefractive intrastromal cross‐linking for the treatment of low‐grade myopia

Epithelium-on Corneal Cross-linking for Progressive Keratoconus: Two-year Outcomes

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