Corneal Cross-Linking Periprocedural Care

A standard patient education web and video (animation) session is completed. A corneal cross-linking surgery consent form is read to and signed by the patient and the surgeon.

A detailed history and comprehensive eye examination is performed on each patient. Best potential visual acuity is taken. Ancillary diagnostic eye tests to determine corneal curvature, astigmatism and thickness are performed. The examination includes:

See the list below:

• Detailed medical and ophthalmic history, including weight, allergies, sleep patterns, medical conditions, eye rubbing, eye trauma, contact lens use, prior eye surgeries, changes in visual acuity, changes in prescription eyeglasses.
• Detailed family eye history, heritable disease
• Assessment of ability to lay still flat-on-back for an hour, while staring at a focusing light.
• Uncorrected visual acuity for both distance and near, including pinhole testing.
• Best corrected visual acuity (with current eyeglasses, current contact lenses, manifest refraction) for both distance and near, including pinhole testing.
• External eye examination
• Ocular alignment and motility
• Pupillary function
• Intraocular pressure (IOP) measurement using a Goldmann Applanation Tonometer
• Slit lamp biomicroscopy of the anterior segment (conjunctiva cornea, anterior chamber, iris, lens)
• Dilated eye examination of the posterior segment (lens, vitreous, retina, macula, optic nerve)
• Refraction
• Keratometry
• Corneal Topography
• Optical Coherence Tomography (anterior segment, macula, optic nerve)
• Specular microscopy
• Ultrasonic pachymetry
• Higher order aberrometry

Ultraviolet Light Source

There are numerous ultraviolet light source providers, ranging from the very basic to the highly customizable advanced versions. Here is a list of popular devices:

See list below:

• Avedro  http://avedro.com/medical-professionals/products/mosaic/
• IROC  http://avedro.com/medical-professionals/products/iroc-innocross/uv-x-2000/
• Peschke  http://www.peschketrade.com/products/peschke-cxl/

Riboflavin solutions

There are countless Riboflavin preparations by different manufacturers. Here is a list of the most common preparations by Peschke http://www.skymed.co.il/upload/document/crosslinking/Ribo%20Fact%20Sheet_new.pdf:

See list below:

• Standard Riboflavin Solution with Dextran for epithelium-off procedure: The Dresden Original preparation; 0.1% Riboflavin (Vitamin B2), 20% dextran 500
• Standard Riboflavin Solution without Dextran for epithelium-off procedure: doesn't reduce corneal thickness; 0.1% Riboflavin (Vitamin B2), 1.1% HPMC
• Hypotonic Riboflavin Solution for corneal swelling: to swell thin corneas (< 400 μm) by means of osmotic effect; 0.1% Riboflavin (Vitamin B2)
• Transepithelial Solution for epithelium-on procedure: no removal of the corneal epithelium necessary; significant reduction of pain and danger of postoperative infections; 0.25% Riboflavin (Vitamin B2), 1.2% HPMC, 0.01% Benzalkoniumcloride
• Riboflavin Solution for use with LASIK procedures: for use in connection with LASIK procedures on thin corneas; recommended usage after flap preparation and excimer treatment put 3-5 drops on stroma, put flap back, wait for 3-4 minutes, open flap and rinse off Riboflavin, put flap back and radiate with 1/2 of the recommended energy (1/2 of the time); >=0.23% Riboflavin (Vitamin B2)

Following corneal cross-linking, patients need to be followed to complete visual rehabilitation.

Since we do Epi-Off procedures exclusively, we follow up all patients on:

• Day 1 | to check if the bandage contact lens is still on
• Day 5 to 7 | to remove the bandage contact lens (patient is requested to return to the clinic, when ocular discomfort is at a minimum)
• Months 1, 3, 6 | fluctuating visual acuity is initially large, loss in best corrected visual acuity of 2-3 lines
• Months 9, 12 | best corrected visual acuity returns to pre-corneal cross-linking levels, and may improve to 2-3 lines, may return to rigid gas permeable lenses
• Months 15, 18, 21, 24 | maximum flattening is achieved at 24 months, may have new rigid gas permeable lenses