Eyeworld

EW FEATURE 72 Update on crosslinking • September 2017 AT A GLANCE • There are advantages and disad- vantages to both epi-on and epi-off corneal collagen crosslinking. • In the less invasive epi-on method, the cornea's epithelial layer is left intact. Patients experience less pain and faster recovery. • With the epi-off approach, the epithelium is removed to get quicker, deeper saturation of the riboflavin. by Michelle Stephenson EyeWorld Contributing Writer the efficacy of the epi-off approach," Dr. Elling said. A recent European review noted that almost all published long-term data and comparative studies have been performed with the epi-off technique. 1 Epi-on studies suggest some efficacy, but less than with epi- off treatments, and long-term data are unavailable. "Although the epi-on approach has seen spikes in popularity over the years as new riboflavin formu- lations have been released, these approaches have not been validated in the peer-reviewed literature. 2 What we see in the scientific liter- ature is that riboflavin is only one part of the equation and that the epithelium also acts as a barrier to sufficient availability of UVA light and oxygen," Dr. Elling said. "Re- cently, we have been evaluating new technology from Avedro [Waltham, Massachusetts] aimed at addressing these limitations, which includes specialized riboflavin formulations saturation of the riboflavin, which may be more effective, but there is the risk of infection. Epi-off Epi-off is the traditional method for corneal collagen crosslinking, and Matthias Elling, MD, Bochum, Germany, thinks it is the best, most effective choice for patients. "In Germany, we have had access to both the epi-off and epi-on ap- proaches for many years. Today, we use an epi-off approach for most of our keratoconus patients because we are confident that it will be effective in stabilizing progression. There is much interest in the epi-on treat- ment as a gentler method, but for a patient with keratoconus, progres- sion means worsening vision, and we want to offer our patients the best chance to preserve visual func- tion. Epi-off is the established stan- dard of care, and both our personal experience and the peer-reviewed literature provide strong support for ing as the gold standard, and epi-off crosslinking was approved by the U.S. Food and Drug Administration in April 2016. Using this method, the epithelium is removed prior to soaking the cornea in a riboflavin solution and exposing it to ultra- violet light. The results have been good, but the technique is not ideal. Because part of the epithelium is scraped off, there is a risk of infec- tion and side effects, such as corneal haze. More recently, ophthalmologists have begun to consider whether the epithelium needs to be removed. Leaving the epithelium intact would make the procedure less invasive and less time consuming. There are advantages and disadvantages to both methods. In the less invasive epi-on method, patients experience less pain and faster recovery, but there is the risk of progression. In contrast, with the epi-off approach, the epithelium is removed to get quicker, deeper Surgeons continue to debate this issue because there are pros and cons to both techniques I n recent years, there has been much debate over the protocol for corneal collagen crosslink- ing. In 2003, the Dresden proto- col established epi-off crosslink- Corneal collagen crosslinking: Is epi-off or epi-on best for patients? Getting into crosslinking Crosslinking was something he 'wanted to bring to the table' E van Schoenberg, MD, Georgia Eye Partners, Atlanta, sees crosslinking as a vital tool and a landmark achievement for the ophthalmic community to be able to halt progression of keratoconus, post-LASIK ectasia, and similar conditions that before had, as he put it, "absolutely nothing." Dr. Schoenberg first began performing crosslinking in 2013 while in fellowship at Price Vision Group, Indianapolis, which was conducting clinical trials at the time. He then went on to launch the crosslinking program at Georgia Eye Partners where he is currently the only crosslinking provider. Given his fellowship experience, "it was something I wanted to bring to the table," he said. "Choosing to launch it from a clinical perspective I found to be easy. I felt strongly that I wanted to offer it to my patients. Figuring out where it fit on the business side was a little more challenging with the current insurance landscape," Dr. Schoenberg said. From a reimbursement standpoint, though FDA approved, crosslinking is not yet covered by all insurance providers. As such, Dr. Schoenberg said his practice has been proactive with local insurance companies. "The experience with insurance has been variable, but on the whole, it has been positive," Dr. Schoenberg said. In terms of volume, Dr. Schoenberg said one needs to have the clinic flow or referral base to support launching this procedure. "If you look back at your last year and you've seen three patients with keratoconus and one or two were candidates for crosslinking, this is not a technology you want to launch in your practice because you don't have the volume to support it. On the other hand, I think that if you see a fair number of keratoconus patients, that volume comes when you offer the procedure both from internal and external word of mouth," he said. In general, Dr. Schoenberg thinks any clinician treating keratoconus patients should have crosslinking available in his or her practice or have a physician who does offer it on speed dial. "I think this is a core procedure for refractive surgeons. I see no reason that a comprehensive ophthalmologist who is willing to stay up to date on patient selection, advances in the procedure, and feels comfortable managing smooth as well as potentially complicated cases couldn't successfully provide crosslinking to the community. The procedure itself doesn't require any magic." EW Editors' note: Dr. Schoenberg has no financial interests related to his comments. Contact information Schoenberg: drschoenberg@gaeyepartners.com

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