DEC 2013

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

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December 2013 antibiotics; in cases of severe infections, systemic antibiotics or further surgical procedures, possibly under general anaesthesia, may become necessary to rescue the eye. However, these interventions can harm the fetus. Therefore, pregnant women with keratoconus should be well counselled about the possibility of keratoconus progression during pregnancy and the risk of prolonged epithelial healing, infection, and stromal melting following crosslinking and perhaps be advised to undergo surgery after delivery. Another potential complication that can occur in some patients is a deep corneal scar. Again this tends to occur more commonly in patients with a predisposition, such as those with thin corneas and high keratometry readings. We have found that treating these patients with hypoosmolar riboflavin solution instead of iso-osmolar riboflavin solution can reduce the risk of developing corneal scars. I have seen sterile infiltrates as a sign of an immunological reaction in some of my patients. They are usually found subepithelially in the corneal periphery, separated from the limbus by a clear zone of the cornea. However, they often disappear within a few weeks of topical steroid treatment. Haze has been reported as a minor side effect of crosslinking. However, this haze needs to be differentiated from the haze that is seen after refractive excimer laser surface ablation. Haze after corneal crosslinking is very faint and usually disappears with topical steroid treatment. Yet in some patients, even several months after surgery, fine haze can persist but usually only affects the crosslinked area. Such haze does not interfere with visual acuity and most likely occurs as a result of structural changes in the crosslinked tissue. Ensuring good outcomes after crosslinking We have found that the new optimized beam profile in the latest UV-X 2000 device achieves better outcomes and more efficient flattening than other UV illumination systems. Whereas with the previous top-hat beam profile most of the effect of crosslinking is seen at the center of the treated corneal tissue, with the new optimized beam profile we are able to achieve a greater volume of crosslinked tissue at the periphery of the irradiated area, and thus more uniform flattening across the cornea. We have verified with anterior segment optical coherence tomography that the demarcation line is parallel to the epithelial surface of the crosslinked area even in the periphery when using this new optimized beam profile. Patient counseling is essential for successful treatment An essential factor in helping patients follow their postoperative regimen is patient counseling, both before and after surgery. The majority of my patients do not have much difficulty following their postoperative regimen. However, this is because I spend time with them both before and after surgery to ensure that they have reasonable expectations from the procedure. It is important to inform patients that they will likely experience some pain, photophobia, tearing, and red eye after the procedure and that they will have to follow a course of antibiotics, ocular surface lubricants, and steroids so that they are not taken by surprise after surgery. Recommendations as simple as wearing sunglasses for the few days following surgery to counter photophobia can also go a long way in the postoperative management of crosslinking patients. Good postoperative patient care and management are indispensable for achieving good treatment outcomes and patient satisfaction after corneal crosslinking. Awareness of the potential side effects and complications of corneal crosslinking, a strong focus on re-establishing ocular surface health, and patient counseling both before and after surgery are key strategies for improving visual outcomes, patient recovery, satisfaction, and comfort after crosslinking. EW Editors' note: Dr. Raiskup is a senior consultant, cornea, external diseases and refractive surgery unit, Department of Ophthalmology, Carl Gustav Carus University Hospital, Dresden, Germany, and associate professor of ophthalmology, Department of Ophthalmology, Faculty of Medicine, Hradec Králové, Charles University, Prague, Czech Republic. He has no financial interests related to this article. 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