Eyeworld

World view Crosslinking playbook I n 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 cross- linking 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 Cana- da 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, ri- boflavin 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 pri- or to crosslinking such as what relevant clinical findings should be consid- ered, 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 rub- bing, 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. In- trastromal 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 possi- ble advances in the field of corneal crosslinking. Jorge Alio, MD, Jack Park- er, MD, and Vance Thompson, MD, comment on refractive and corneal infection applications of crosslinking, other biochemical and nanotechnol- ogy 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. EW The news magazine of the American Society of Cataract & Refractive Surgery A S C R S January 2019 Volume 24, number 1 ASCRS Executive Director Steve Speares sspeares@ascrs.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Senior Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Designer Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Editorial Production Assistant/ Social Media Coordinator Taylor Wise taylor@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Berlin, Germany Vanessa Caceres Bradenton, Florida Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. Chiles Aedam R. Samaniego Muntinlupa, Philippines Michelle Stephenson Roanoke, Virginia Senior Contributing Writer Maxine Lipner Nyack, New York Sales, Sponsorships, and Special Events ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 703-591-2220 Jessica Donohoe jessica@eyeworld.org Shelly Dixon shelly@eyeworld.org Joe Dooley joe@eyeworld.org Molly Phillips molly@eyeworld.org Cathy Stern cathy@eyeworld.org Anne Le anne@eyeworld.org ASCRS Publisher: EyeWorld (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; telephone: 703-591-2220; fax: 703-591-0614. 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Postmaster: Send change of address to EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EyeWorld do not necessarily reflect those of the editors, publisher, or its advertisers. P U B L I S H I N G S T A F F Clara Chan, MD, Cornea editor ASCRS•ASOA Annual Meeting MAY 3 —7 • 2019 SAN DIEGO

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