NOV 2013

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

Issue link: https://digital.eyeworld.org/i/220233

Contents of this Issue


Page 52 of 122

50 EW FEATURE Corneal crosslinking November 2013 Corneal crosslinking November 2013 Easing patients' concerns about CXL by Vanessa Caceres EyeWorld Contributing Writer AT A GLANCE • Patients can use their contact lenses or glasses again a few weeks after a CXL procedure. • Visual fluctuations are common after CXL but tend to stabilize after three months or slightly longer. When vision stabilizes, patients can obtain a new contact lens or glasses prescription. • Immediate postop discomfort and visual haze are common. Less common complications are infections and delayed healing. • Patients should watch out for signs of progressive keratoconus as CXL does not rid them completely of keratoconus. FAQs your patients may have C orneal collagen crosslinking (CXL) is known as a generally successful procedure for patients with corneal ectasia, but naturally, patients come to their surgeons with a host of questions. How soon can I wear contact lenses or glasses again? What complications might occur? When will my vision stabilize after crosslinking? Could my keratoconus symptoms return? EyeWorld consulted with some CXL pros to find out how they typi- cally handle patients' most common questions. 1. When can I wear contact lenses or glasses again? "I generally recommend my patients stay out of contact lenses for a few weeks postoperatively," said Sumit (Sam) Garg, MD, vice chair of clinical ophthalmology, and assistant professor, cataract, corneal and refractive surgery, Gavin Herbert Eye Institute, University of California, Irvine. "I try to have them aggressively lubricate the surface and allow for the epithelium to return to normal prior to recommending contact lenses. Aggressive lubrication helps smoothe out the epithelium, therefore stabilizing vision." Roberto Pinelli, MD, scientific director, Istituto Laser Microchirurgia Oculare (ILMO), Crystal Palace, Brescia, Italy, recommends patients wait for a month after CXL before they wear their contact lenses again. 2. When will my vision stabilize again? Can there be fluctuations? Fluctuations do indeed occur, although they generally last only a couple of months. Patients are usually able to return to work or school in a day or two, said Michael B. Raizman, MD, Ophthalmic Consultants of Boston, director, cornea and cataract service, New England Eye Center, and associate professor of ophthalmology, Tufts University School of Medicine, Boston. After Monthly Pulse T that, he finds patients may have blurry vision for a few days to one week. "At that point, the vision is usually close to baseline, and the existing spectacles will typically suffice." Over the first year, the cornea typically steepens at first and then flattens, said Dr. Raizman. "The chief purpose of crosslinking is to stabilize the cornea to prevent progression, but many patients actually have some improvement in vision," he said. "With the epithelium-off technique, visual fluctuations are very common in the initial healing period," Dr. Garg said. "Just as in photorefractive keratectomy, it takes time for the epithelium to heal and normalize over the cornea surface." 3. When should I get my prescription changed? "Patients need to understand that crosslinking can cause a change in their keratometry the first few months after treatment, and this means their prescription may also change," said Dr. Garg. Ulimately, most surgeons recommend that patients wait until a couple of months after treatment to ensure a stable refraction. "We see a stability of refraction at three to six months," said Dr. Pinelli. 4. What types of complications should I be aware of? Although it's not a complication per se, initial discomfort is common. Dr. Raizman will help ease patients' discomfort in the immediate postop period with a bandage contact lens and the use of drops and oral analgesics. However, beyond that, complications are not seen often, he said. "The cornea always has mild haze, but this affects the vision only rarely," said Dr. Raizman. "If the vision is reduced by haze, this almost always improves on its own over a few months." One rare complication is infection, said Dr. Raizman. "That can be avoided in almost all cases through the use of topical antibiotics after surgery and careful observation at postoperative visits." The CXL procedure itself is very safe, said Dr. Garg, although complications such as infectious keratitis, sterile infiltrates, reactivation of herpes simplex keratitis, and slow epithelial healing can occur. David Rootman, MD, professor of medicine, University of Toronto, and director, Yonge Eglinton Laser Eye Centre, Toronto, has used the patients' own serum tears and amniotic membrane transplantation as biologic treatments for patients with slow epithelial healing. 5. What are the symptoms of progressive keratoconus? "Crosslinking is not meant to make keratoconus go away," Dr. Rootman said. Instead, it is meant to stop or slow down disease progres- Keeping a Pulse on Ophthalmology he topic of the November Monthly Pulse survey was "Corneal collagen crosslinking." When asked if they would feel confident in determining if a keratoconus patient would be a good candidate for corneal crosslinking treatment, a majority (59.1%) of respondents said they would, while 30.8% said they would feel somewhat uncertain and 10.1% said they would feel very uncertain. For keratoconus patients who had their disease progression documented by clinical history, topography, or refraction, most respondents said they would either refer the patient to an ophthalmologist who can offer corneal crosslinking (48.1%) or perform the treatment themselves (42.3%). A small group (6.3%) said they would continue observing the patient, while even fewer (3.4%) said they would offer the patient a corneal transplant. Most respondents said they would be interested in having the technology available in their practice if and when it receives FDA approval (57.8%), while 10.7% expressed no interest. Others had mild (14.6%) to moderate (17.0%) interest in obtaining the technology. Of the options available to keratoconus patients who become contact lens intolerant, respondents said they would choose the following for themselves: corneal crosslinking only (45.9%), corneal crosslinking with intrastromal ring segment implantation (35.6%), corneal transplant (8.3%), intrastromal ring segment implantation only (4.9%), topography-guided photorefractive keratectomy (4.9%), and, finally, no treatment at all (0.5%).

Articles in this issue

Archives of this issue

view archives of Eyeworld - NOV 2013