Eyeworld

JUNE/JULY 2020 | EYEWORLD | 33 R Contact Ciolino: Joseph_Ciolino@meei.harvard.edu Dupps: bjdupps@outlook.com Raizman: mraizman@tuftsmedicalcenter.org steepening of the cornea at 1 month. It's also true that nearly all of them are back to baseline by 2–3 months, but from there on, some pa- tients stay right where they are, but others have progressive flattening." Crosslinking additions, targeting treatment Supplemental oxygen is one of the most widely discussed factors that could improve the re- actions in a crosslinking treatment to enhance efficacy. Dr. Raizman said there are compounds other than riboflavin that can be used to create a crosslinking reaction with UV light exposure, as well as chemical methods that don't need UV light at all for crosslinking (though not currently used). He also said outside the U.S. there are different devices that provide a customized light pattern to the cornea, putting more light energy on the cone itself, with evidence showing better efficacy with this technique. Dr. Dupps said this type of customization backs off other parts of the cornea that are more stable, allowing them to flex in a more favorable manner while the weakest part of the cornea is adequately strengthened. "I think that when we have alternative treat- ments that are FDA approved, we will decide to use different types of crosslinking for different eyes in different patients," Dr. Raizman said. long, low-dose steroid taper. He said about 75% of patients choose to pay out of pocket for the serum tears, and he hasn't had any significant scarring or complications following this regi- men. Dr. Raizman said he has performed epi-on crosslinking with other parameters adjusted (supplemental oxygen, modified riboflavin drug, intensified UV light) to enhance the treatment's effect as part of a clinical trial. "We're hoping that with these modifica- tions we can achieve an equal degree of cross- linking," he said of the currently ongoing study. The draw of epi-on, Dr. Ciolino said, is not so much pain relief, but safety. There is a higher risk of complications taking the epithelium off. "I talk to my patients about the pros and cons, and the thing is they're both painful. The pain lasts longer with epithelium off, but they're both painful," he said. Measuring biomechanical effect As of right now, there's not a ready-to-use de- vice to measure the stiffening effect in real time. But Dr. Dupps said work is being done toward this goal, using Brillouin microscopy and OCT- based methods including a non-contact meth- od in development called phase-decorrelation OCT. He said having this information would al- low physicians to turn off the treatment system when the desired effect is reached, minimizing risks and shortening procedure time. Dr. Dupps said there is an immediate stiffening effect with crosslinking that can be measured in the lab, but additional flattening happens after that, which can vary patient by patient. At 1 month, Dr. Ciolino said most patients have a drop in vision, but by 2–3 months their corneas have flattened at least back to baseline or further. Flattening can occur beyond this timeframe as well. "One thing that is universally true is that the amount of flattening is not predicable with the typical Dresden protocol," he said. "It's true that the vast majority of patients have increased Relevant disclosures Ciolino: None Dupps: Glaukos, Cleveland Clinic patents Raizman: Glaukos "I think that when we have alternative treatments that are FDA approved, we will decide to use different types of crosslinking for different eyes in different patients." —Michael Raizman, MD

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