Eyeworld

EW FEATURE 70 Update on crosslinking • September 2017 AT A GLANCE • Many surgeons agree crosslinking is particularly effective for younger patients because of the ability to halt progressive keratoconus early on. • Thin corneas may pose a challenge in crosslinking. Though not an absolute contraindication, these patients should be aware that the procedure may not be ideal for their condition. • Crosslinking could potentially have an impact on corneal transplantation in the future by decreasing the need for transplants because of the ability to prevent progression of keratoconus. by Ellen Stodola EyeWorld Senior Staff Writer to do it right away on patients who have keratoconus," he said. These young patients likely didn't have an abnormal cornea when they were born, and now they have an abnor- mal cornea, so by definition they're progressing. Dr. Berdahl compared keratoconus treatment to treating glaucoma. "When you do an evalu- ation for glaucoma, you don't [wait until they] get worse before initiat- ing treatment because you can't get that vision back," and he feels the same way about keratoconus. "You don't want the cornea to become more misshapen." "As physicians, our calling is to do what's right for the patient," Dr. Berdahl said. "The question I ask myself is what I would want for myself or my child." He will have a straightforward discussion with patients about risks and benefits and come to a mutual decision. "I think this is best for a young patient who has mild keratoconus," he said, because you're able to freeze the cornea in position and shape before it becomes more misshap- en, and you can avoid decades of challenges, as well as a cornea transplant. the point of needing keratoplasty, I would recommend finding a way to accomplish crosslinking as soon as possible once progression has been documented," he said. Dr. Raizman said he reserves crosslinking for progressive kerato- conus, but he added that there are some situations where keratoconus is severe and you wouldn't want to wait to document progression. He added that crosslinking can be combined with PRK for certain cor- neas with relatively small refractive errors and Intacs (Addition Technol- ogy, Lombard, Illinois). "I have not achieved much benefit in crosslink- ing older patients whose keratoco- nus has been stable for many years," he said. The protocol that was ap- proved in the U.S. has been studied for years, and there's a large database that physicians can access and use to make reasonable assumptions based on European data, Dr. Raizman said. Dr. Berdahl said that the cross- linking labeling is for progressive keratoconus, but he thinks that most young patients who have ker- atoconus are progressive by nature. "As I've gotten more experience with crosslinking, I'm more inclined Experts discuss ideal patients and factors to consider with crosslinking W ith crosslinking approved in the U.S. for more than a year now, more physicians are using the proce- Patient selection for crosslinking Getting into crosslinking Young eye surgeon learned crosslinking, seeing it as a 'paradigm shift' B ennett Walton, MD, first gained experience in crosslinking while in fellowship at Slade & Baker Vision, Houston, which was a site for clinical trials and where he now practices. "It's certainly a paradigm shift for keratoconus and ectasia options. We can finally stop a progressive disease that we could not previously," Dr. Walton said. "We owe it to our patients to give them the best chance to avoid the significant loss of vision and visual quality that can occur with keratoconus. I either needed to provide the procedure myself or refer to someone else." Dr. Walton said he thinks crosslinking is the new standard, and those in anterior segment or cornea practice who do not offer it might be at a disadvantage. One doesn't need to have cornea fellowship training to bring crosslinking into their practice though, he added. "If someone is comfortable taking care of healing corneas and is comfortable with topography and tomography, then I think crosslinking may be a reasonable extension of that expertise," Dr. Walton said. The main learning curve when it comes to crosslinking, according to Dr. Walton, is in the pre- and postop stages. "The preop counseling for crosslinking is a little more like glaucoma counseling than cataract or refractive counseling in that the goal is to stop progression, not to make improvements to their vision. I tell patients that we do occasionally see some normalization of the corneal curvature, but this is considered a bonus if it happens," he said. When it comes to postop healing, Dr. Walton suggested surgeons starting epithelium-off crosslinking make sure they are comfortable caring for exposure and delayed epithelial healing in the case of the occasional slow epithelialization that can be seen. Offering further advice for those getting into crosslinking, Dr. Walton pointed out the importance of being aware of other crosslinking methods beyond the standard, FDA-approved Dresden protocol, which patients might come in asking about. Other pearls Dr. Walton offered included using a soft contact lens soaked in riboflavin on corneas less than 400 µm to increase "effective corneal thickness" and making sure that if a patient is pseudophakic, he or she has a UV light-blocking IOL. EW Editors' note: Dr. Walton has no financial interests related to his comments. Contact information Walton: drwalton@visiontexas.com dure for their patients. Sumit "Sam" Garg, MD, Gavin Herbert Eye Institute, Irvine, California, John Berdahl, MD, Vance Thompson Vi- sion, Sioux Falls, South Dakota, and Michael Raizman, MD, Ophthalmic Consultants of Boston, discussed patient selection, ideal patients, con- traindications, and other crosslink- ing considerations. Lessons learned from early phases of FDA approval The FDA has approved the cross- linking procedure for patients age 14 and older, Dr. Raizman said. In the clinical trials, he treated patients as young as 12 who did extremely well with the procedure. "I would recommend treating patients with progressive keratoconus even under age 14," he said, adding that there probably weren't enough patients under age 14 for the FDA to feel comfortable approving it for younger patients, but the worldwide experience on younger patients is excellent. "They tolerate the proce- dure quite well," he said. "Because the patients with pro- gressive keratoconus at a very young age are most likely to advance to

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