January 19, 2016
3 min read
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Benefits of cross-linking go beyond stopping progression of keratoconus

Older patients with keratoconus may also experience improved vision and corneal shape.

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Corneal cross-linking may provide more benefits than just stopping the progression of keratoconus, according to a speaker at OSN New York 2015.

While the technique prevents keratoconus progression, it also can improve uncorrected visual acuity and best corrected visual acuity in patients of any age, while also improving corneal shape and reducing corneal astigmatism, OSN Technology Section Editor William B. Trattler, MD, told colleagues.

“I really want you to understand that cross-linking can help with far more than just stopping the progression of keratoconus. It helps by improving the corneal shape, which can result in improvement in quality of vision,” Trattler said. “Patients with keratoconus, when they are in their 50s or 60s, can experience improved vision and corneal shape with CXL. The procedure helps keratoconus patients more than by just stopping progression.”

William B. Trattler

Cross-linking questions

According to Trattler, the main questions he is asked about cross-linking include whether the epithelium-on technique is as effective as the epithelium-off technique, whether re-treatments are effective if progression occurs after the procedure, and whether FDA approval will occur.

Cross-linking is not currently approved by the FDA, although it is available throughout the U.S. for patients with keratoconus as part of clinical trials, Trattler said. Despite the lack of approval, Trattler recommended that children should be treated promptly via referral to one of the clinical trials in the U.S. because progression can be rapid.

“As far as waiting for progression, I have evaluated many patients referred to me who have keratoconus in their 40s, 50s and 60s who have experienced documented progression of their disease, resulting in worsened vision. It can be very frustrating for these patients because they are wondering why they were not given the opportunity to have CXL as part of one of the many clinical trial sites across the U.S.,” Trattler said. “If they are treated with CXL, their vision as well as corneal shape has a chance of improvement.”

Avedro has resubmitted a new drug application for its cross-linking system to treat progressive keratoconus and corneal ectasia after refractive surgery, according to Trattler’s presentation. The Prescription Drug User Fee Act date is in April.

The procedure

The Dresden epi-off cross-linking technique is a relatively simple procedure, Trattler said, involving anesthetic drops before surgery, preparation of the cornea, removal of the epithelium, administration of riboflavin drops for 30 minutes followed by UV light application for 30 minutes, and then a bandage contact lens.

“It is important to properly set patient expectations. You can advise your patients that they can expect some improvement in corneal shape and vision at 6 months, and often at 1 year and 3 years, they can experience further improvement,” Trattler said. “That’s important to understand — patients should be advised to expect slow improvement over a number of years.”

However, a small percentage of patients who have cross-linking, whether epi-on or epi-off, can still experience progression in keratoconus. Studies published in the medical literature suggest the risk of experiencing progression is 3%, Trattler said. The good news, he said, is that a second cross-linking procedure has a high rate of being successful. – by Kate Sherrer

Disclosure: Trattler reports he is a consultant for CXLO.