EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW NEWS & OPINION 12 September 2016 World view Considering corneal crosslinking K eratoconus is the most common corneal dystrophy in the U.S. Corneal collagen crosslinking with riboflavin has revolutionized the management of keratoconus. But before that, the options for patients were contact lenses until they no longer fit properly and to suffer with progressive vision loss until a cornea transplant was performed. The patients 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 cor- neas utilizing sugars activated by ultraviolet light. International trials in the 2000s showed stabilization of keratoconus after crosslinking treatment using a standard technique of epithelium removal, riboflavin drops to the cornea until the stroma was fully saturated, followed by ultraviolet-A light illumina- tion, whereby bonds forming across adjacent corneal stromal collagen fibers would strengthen the cornea. The procedure received FDA approval in the U.S. in April 2016. In this issue, leading experts Francis Price, MD, and William Trattler, MD, 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. They also detail what equipment is required, the associated capital costs, reimbursement issues, and logistics of patient flow. Uri Elbaz, MD, Sumit Garg, MD, and Enrique Graue-Hernandez, MD, present the pros and cons of crosslinking protocols using traditional epi- thelial-on versus epithelial-off treatments. Either method requires sufficient riboflavin to be absorbed into the corneal stroma for good efficacy. While there may be 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 refrac- tive treatments to crosslinking have been studied such as intrastromal ring segments, topography-guided photorefractive keratectomy, and LASIK with concomitant crosslinking. Small patient series looking at the effect of cross- linking on fluctuations in vision after radial keratotomy seem to have unpre- dictable results. Peter Hersh, MD, Simon Holland, MD, Raymond Stein, MD, and John Kanellopoulos, MD, discuss the implications and outcomes of using refractive adjunctive measures with corneal crosslinking. There are a variety of factors to consider when deciding to use cross- linking to treat a patient. J. Bradley Randleman, MD, Leejee Suh, MD, and Karolinne Maia Rocha, MD, comment on their experiences offering crosslinking to patients with keratoconus, post-LASIK ectasia, pellucid mar- ginal degeneration, and radial keratotomy. Discussion with patients is key to properly address their expectations in a reasonable and realistic fashion. Finally, Dr. Hersh, Barry Lee, MD, Dr. Trattler, and Elmer Tu, MD, expound on the evidence for the expanded indications of crosslinking such as for cases of infections, Terrien's marginal degeneration, post-RK, and even post-penetrating keratoplasty ectasia. I hope you enjoy this issue of EyeWorld, and many thanks to all of the physicians for taking the time to share their expertise on the important topic of corneal crosslinking. EW Clara Chan, MD, FRCSC, FACS, Cornea editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S September 2016 Volume 21 • No. 9 Publisher Donald R. Long don@eyeworld.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Berlin, Germany Vanessa Caceres Bradenton, Florida Michelle Dalton Reading, Pennsylvania Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. 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