Eyeworld

NOV 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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A S C R S World view Exploring corneal crosslinking T he prevalence of keratoconus is estimated to be 1 in 500 to 1 in 2,000, making it the most common corneal dystrophy in the U.S. Prior to corneal collagen crosslinking with riboflavin, which has revolutionized the management of keratoconus, the options for patients were to use contact lenses until they no longer fit properly and for patients to suffer with their progressive Clara Chan, MD, FRCSC, FACS, vision loss until a cornea transplant was percornea editor formed. The patients who were most greatly affected were often young, productive members of society. The concept behind crosslinking came about during the 1990s when researchers noted that diabetic patients rarely developed keratoconus because of a glycosylation-mediated process that naturally strengthened the stromal tissue. Their goal was to induce a similar effect in non-diabetic corneas utilizing sugars activated by ultraviolet light. International trials in the 2000s showed stabilization of keratoconus after crosslinking treatment performed using a standard technique of epithelium removal, application of riboflavin drops to the cornea until the stroma was fully saturated, followed by ultraviolet-A light illumination, whereby bonds forming across adjacent corneal stromal collagen fibers would strengthen the cornea. While the procedure is awaiting FDA approval in the U.S., there are many patients being treated in various U.S. clinical trials, and our international colleagues have a great deal to share from their experiences. In this issue, Drs. Donnenfeld and Trattler explain how to set up a crosslinking program to offer your patients access to treatment and describe the role of the ophthalmic technician in the process. A list of crosslinking clinical trials in the U.S. is also provided for your reference. Drs. Cummings, Seiler, Stulting, and Trattler discuss which patients are the best candidates for corneal crosslinking treatments, contraindications that surgeons should be aware of, and how to set appropriate patient expectations. This is especially important for those in the early stages of using this technology. While there is some vision improvement on occasion after corneal crosslinking, this should not be an expectation of the keratoconus patient. In the attempt to improve visual acuity for these patients, adjunctive treatments to crosslinking have been studied such as intrastromal ring segments, topography-guided photorefractive keratectomy, or phototherapeutic keratectomy. Drs. Daya, Holland, and Ku discuss the implications and outcomes of using these adjunctive measures. Drs. Garg, Pinelli, Raizman, and Rootman answer questions that patients may ask about crosslinking including: When can I wear contact lenses or glasses again? When will my vision fully stabilize? How do I know if my disease is progressing again? What technique used for crosslinking is the best? Drs. Donnenfeld, Moshirfar, and Stulting expound on the evidence for the expanded indications of crosslinking such as for cases of infections, post-LASIK ectasia, and even corneal melts or corneal edema. I hope you enjoy this issue of EyeWorld, and thank you to all the physicians above for taking the time to share their expertise on the topic of corneal crosslinking. Clara Chan, MD, FRCSC, FACS, cornea editor The official publication of the American Society of Cataract & Refractive Surgery November 2013 Volume 18 • No. 11 P U B L I S H I N G   S TA F F Publisher Matt Young don@eyeworld.org Enette Ngoei Donald R. 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