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Corneal Cross-Linking (CXL)

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What is Keratoconus and Corneal Collagen Cross-Linking?

Corneal Collagen Cross-Linking (CXL) is an in-office procedure that treats patients suffering with keratoconus. Keratoconus is a progressive eye disease where the typically round cornea (the front clear window of the eye) thins, beginning to bulge and steepen, creating more of an irregular cone shape. The change in shape disables light from entering the eye properly. The cone shape deflects light as it enters the eye, causing distorted vision. As the shape of the cornea becomes more irregular due to the keratoconus, your vision will continue to worsen, resulting in frequent changes in your prescription. Typically, keratoconus begins during teenage years and early 20s and often these patients require a new prescription for their contacts and glasses at each yearly exam. Keratoconus can occur in one or both eyes. 

Until recently, the only treatment for keratoconus was custom contact lenses. While custom contact lenses correct vision for keratoconus patients, they do not treat the disease itself. Until recently, most keratoconus patients in the United States had to have a corneal transplant to correct their keratoconus. In April 2016, Avedro, a pharmaceutical and medical device company, announced that it received FDA approval for their KXL System. Their KXL System is used in corneal collagen cross-linking for treatment of progressive keratoconus. Neel R. Desai, MD, Cornea, Cataract, Refractive and LASIK Surgeon at The Eye Institute of West Florida was a Principal Investigator during Avedro's clinical trial for FDA approval of their KXL System. 

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Symptoms

Keratoconus typically first appears in individuals who are in their late teens or early twenties, and may progress for 10-20 years, and then slow or stabilize. Each eye may be affected differently. In the early stages of keratoconus, people might experience:

  • Slight blurring of vision
  • Distortion of vision
  • ​Increased sensitivity to light

The cornea is responsible for focusing most of the light that comes into the eye. Therefore, abnormalities of the cornea, such as keratoconus, can have a major impact on how an individual sees the world, making simple tasks such as driving a car or reading a book very difficult.

Keratoconus:

  • Can result in significant vision loss; and
  • May lead to corneal transplant in severe cases

How Does Corneal Cross-Linking Work?

Normal, healthy corneas consist of cross-links between the collagen fibers. These crosslinks keep the cornea strong and maintain the normal, round shape of the cornea. A cornea with keratoconus is weak and the cross-links are not strong enough to keep the cornea's normal shape, thus it begins to bulge and become cone-shaped. Corneal cross-linking adds more cross-links to the cornea, stabilizing and holding its shape. The new cross-links stop the cornea from continuing to thin, thus preventing further loss of vision and decreasing or eliminating the need for a corneal transplant at some point.

Corneal Cross-Linking:

  • Creates new corneal collagen cross-links
  • Results in a shortening and thickening of the collagen fibrils
  • Leads to the stiffening of the cornea

Riboflavin

Riboflavin (vitamin B2) is important for body growth, red blood cell production and assists in releasing energy from carbohydrates. Its food sources include dairy products, eggs, green leafy vegetables, lean meats, legumes, and nuts. Breads and cereals are often fortified with riboflavin.

Under the conditions used for corneal collagen cross-linking, riboflavin 5’-phosphate, vitamin B2, functions as a photoenhancer which enables the cross-linking reaction to occur.

Ultra-Violet A (UVA)

UVA is one of the three types of invisible light rays given off by the sun (together with ultra-violet B and ultra-violet C) and is the weakest of the three. A UV light source is applied to irradiate the cornea after it has been soaked in the photoenhancing riboflavin solution. This cross-linking process stiffens the cornea by increasing the number of molecular bonds, or cross-links, in the collagen. 

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What are the Benefits of Corneal Collagen Cross-Linking?

Major advantages of corneal collagen cross-linking to treat Keratoconus are: 

  • The treatment is permanent
  • Stops the progression of keratoconus
  • It is a simple, outpatient procedure that typically takes about an hour 
  • Quick recovery 
  • Eliminates the need for a corneal transplant 
  • No injections or stitches
  • No major precautions

Is Cross-Linking Right for Me?

Patients over the age of 14 who have been diagnosed with progressive keratoconus or corneal ectasia following refractive surgery should ask their doctor about corneal cross-linking.

The Eye Institute of West Florida is proud to offer patients in our practice the first and only therapeutic products for corneal cross-linking, which have been FDA approved to treat progressive keratoconus. This approval offers an effective treatment for patients who, until recently, had no therapeutic options to limit the progression of this sight-threatening disease.

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