Is Corneal Cross Linking experimental?

or Does It really work?

We pose this question as many medical insurances deny patients reimbursement for cornea cross linking to treat keratoconus. Many parents also pose this question as their own optometrists were unaware of the benefits of cross linking the cornea.

We are going to turn to Australia for a peer review objective answer to this question. Our Australian colleagues performed a study which has been vetted by our peers. The Australian keratoconus experts selected 100 eyes with progressive keratoconus eye disease. They divided them into 2 groups. One would receive Conventional cornea cross linking while the other would have no intervention ( like your insurance company would want). They measured various data like vision, cornea thickness, and curvature of the cornea at various intervals over a period of 3 years.

Are you ready for the results? Can you guess what they showed?

Yes Conventional Cross Linking with UV-A applied on riboflavin soaked eyes was able to prevent steepening  of the cornea. It preserved vision both uncorrected and best corrected. It also improved the shape and vision in many instances. We are so convinced by the results we would not be able to repeat it here in the United States. For we would not condemn any kid with keratoconus to be in the control group. The benefits are so obvious. Like society eradicated Polio it is time to wipe away keratoconus eye disease.

Feel Free to print the abstract from the respected Journal Ophthalmology which is attached as an image to show your doubting doc, illogical insurance rep or obstinate optometrist.

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Autobahn of Cornea cross linking to treat Keratoconus

BMW on the autobahn is a hair rising experience. Now our German friends want to bring that concept to cxl or corneal cross linking. You may have heard of accelerated cornea cross linking? This is cxl with 10 minutes of UV radiation treatment, In the newest version they propose treatment of only 5 minutes utilizing 18 mw/cm2 of UV radiation.

This would of great benefit to patients. The amount of time they have to stare at the blue light would decrease. Exposure of the cornea to the elements  would be less.

We would like to quote the results of the study here ” The mean follow-up time was 21.7 ± 7.2 months (range, 12-34 months). No statistically significant changes were found in the mean corrected distance visual acuity, corneal astigmatism, Kmean, Kflat, Ksteep, corneal pachymetry (at the apex and at the thinnest point), and corneal densitometry at follow-up. A significant reduction of Kmax, index of surface variance, index of vertical asymmetry, and Km of the posterior corneal surface (Km(B)) was observed (Kmax: P = 0.018; index of surface variance: P = 0.016; index of vertical asymmetry: P = 0.038; Km(B): P = 0.008). No complications were reported during the postoperative follow-up period in this study.”

Our question for the authors are. 1) How deep was the demarcation line?

2) was any comparison made to conventional cross linking?

Other papers or followup studies should be address the questions.

Dr.Khanna is a Keratoconus Expert. These informative blog posts are for information purposes. They should not replace a careful discussion with you Keratoconus Eye surgeon.

Conventional cross linking is still King Kong – say surgeons from Hong Kong

Keratoconus eye disease is no laughing matter. It afflicts teens and can destroy careers. We need to accelerate our fight against this vicious disease. At the same time we have to study scientifically the newer protocols. Accelerated cross linking speeds the treatment by decreasing the time of exposure of UV light. This has recently been studied in pediatric keratoconus.

This landmark study from Hong Kong By Surgeons of Royal college is a landmark one. It shows that accelerated cornea cross linking slows the progress of the bulging eye disease. it is the first one to document that only conventional cornea cross linking with its deep demarcation line can actually flatten the cornea. In essence it means that the 30 min api off intervention can halt the progression as well as reverse some of the effects.

The deeper the demarcation line the more the cornea flattening .

Keratoconus Experts in Los Angles thank the authors to bring new meaningful data for mutual benefit.

Accelerated Cross linking effective in Children for treatment of Keratoconus

Accelerated Cross linking has been in use to treat Keratoconus. The traditional time of cross linking at 3 mw of UV energy has been 30 minutes. In accelerated protocols the energy is increased to 9 mw and the time decreased to 10 minutes. It is more comfortable for patients especially teens.

In this recently published study we find that accelerated cross linking is as effective as conventional cross linking. This is good news for Keratoconus Experts seeking to cure and halt the progression of the disease. The doctors of this study done at Zurich compared the results in patients where keratoconus had been documented by corneal topography. The corneal thickness had to be greater than 400 microns.

They compared the shape or topography and vision 12 months later. They found the accelerated treatment had similar outcomes.The failure rate in accelerated were 9/39 whereas in conventional they were 6/39.

So statistically accelerated crosslinking may be as good as conventional. Still it is not superior.

 

Epi on or Epi off Crosslinking- that is the question

Keratoconus progression can be halted by corneal collagen cross linking has been established. We thank all our patients who believed and participated in the trials. Now the hot question is which is better- to remove epithelium or to leave it alone.The debate has recently become intense. Various specialists have filed trade marks, patents or invested in a particular technology. Sometimes their opinions seem biased. So where do we turn to if we want to know the true answer?

Riboflavin cornea cross linking
How about the FDA? They are experts at looking at the data and known for they unbiased opinion. They have the interest of American patients in mind.

They analyzed lot of safety data. Here is what they have approved in USA 

Epi off cornea cross linking 

So that means so far Epi off is better than epi on or it’s variations like c3R

The epithelium interferes in the seepage of riboflavin i the cornea. It also hinders the uniform transmission of uvA . Therefore it a good idea to remove it

Some may disagree and say FDA process is tedious and hence Epi on is still stuck somewhere. We can than turn to peer reviewed journals. No published study has ever shown that Epi on crosslinking is better than Epi off.

Multiple studies have shown that Epi on Cross linking is the current Gold Stsndard.

So we rest our case

Epi off cross linking is the procedure Keratoconus specialists recommend 

FDA approves epi off Cornea cross linking

Yes what we had been waiting for finally happened. Another arrow in fight against keratoconus . FDA looked at the safety and efficacy of riboflavin activated by uv A radiation in detail. They looked at the data submitted by Avedro. FDA said epithelium removed or epi off is a good option. 

This means if you have been waiting to make your cornea stronger the time has arrived. It may also mean your insurance may cover part of the cost. So send your insurance card to our keratoconus center. You may also qualify for no interest 36 monthly payment plan.

Unfortunately they have not approved epi on or c3r and other variants. So invest your money in the technique FDA considers more safe and result oriented. 

Come to our Beverley Hills center for keratoconus treatment and get an unbiased opinion.

Epi on cross linking and corneal sensitivity

A new study in journal of cataract and refractive surgery increases our knowledge of cross linking in keratoconus patients. Cross linking, as you may recall is a newer treatment for bulging cornea. The strength of the cornea is increased by adding riboflavin and activation it by UV radiation. This affects the nerves in the cornea.

This study on keratoconus patients undergoing cross linking compared the return of corneal sensation. It divided the patients into two groups. One group had epi off cross linkage and the other had epi on cross linkage.The Keratoconus experts analyzed the results. They came to the conclusion that the nerve sensation recovered in both methods. The recovery was faster in pi on or transepithelial corneal cross linking.

Currently the most efficous method for corneal collagen cross linking is the epithelium off Dresden protocol. Research in cross linking is further needed to make epithelium on more beneficial as it has quicker recovery and less patient discomfort.

Each individual eye is different. A keratoconus surgeon can discuss with you which treatment protocol would be best for your eye.