EW FEATURE
48
Crosslinking playbook • January 2019
procedures with a limited treatment
primarily focused on refractive
data—that is, a limited refractive
treatment based on refractive data
and designed for vision correction
and spectacle independence.
However, Dr. Waring has per-
formed simultaneous crosslinking
with Intacs and patients can do well.
Dr. Donnenfeld generally per-
forms Intacs and CXL at the same
time.
"Once I make the Intacs pocket
with the femtosecond laser I inject
riboflavin into the pocket, which
helps achieve high tissue levels of
riboflavin, then I insert the Intacs,"
Dr. Donnenfeld said. "On the other
hand, I prefer to perform CXL 3
months or more prior to TCAT, as I
have had patients heal poorly when
both are performed at the same
time."
Pain possibility
Dr. Donnenfeld has never seen
neuropathic pain after TCAT PRK or
Intacs implantation. Although such
pain is exceedingly rare, he said it is
possible.
"The potential side effects of
TCAT PRK are the same as all PRK
procedures and include infection,
scarring, and delayed healing, and
with TCAT the results are less pre-
dictable than traditional PRK," Dr.
Donnenfeld said. "Intacs also has
the risk of acute infection and can
have late extrusion with infection.
Other side effects include lipid depo-
sition in the channels."
LASIK flap
Dr. Stein said it is possible to per-
form CXL with riboflavin injected
under a LASIK flap or into a pocket.
However, clinical studies are still
needed to definitively demonstrate
the safety and success of that tech-
nique.
"However, if the surgeon thinks
the patient is at a higher risk of cor-
neal ectasia with LASIK or SMILE, I
think it is safer to perform PRK with
limited CXL," Dr. Stein said.
Dr. Donnenfeld agreed that it
is possible to perform CXL under a
LASIK flap, into a pocket, or with
SMILE.
"But I do not personally do any
of these options other than placing
riboflavin in an Intacs pocket, as I
consider an ectatic cornea to have
increased risk of further ectasia
with a flap or SMILE and prefer to
perform PRK in these cases," Dr.
Donnenfeld said. EW
Editors' note: Dr. Donnenfeld has
financial interests with Avedro
(Waltham, Massachusetts). Dr. Waring
has financial interests with Avedro and
Oasis Medical (Glendora, California).
Dr. Stein has no financial interests
related to his comments.
Contact information
Donnenfeld: ericdonnenfeld@gmail.com
Stein: Raymondmstein@gmail.com
Waring: gwaring@waringvision.com
Preop and postop scans of a TCAT PRK and CXL patient
Source: Eric Donnenfeld MD
Adjunctive continued from page 47
