Collagen cross-linking should be done separately. Canan Asli Utine, MD, MSc, FICO Yeditepe University, Istanbul, Turkey

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1 Collagen cross-linking should be done separately Canan Asli Utine, MD, MSc, FICO Yeditepe University, Istanbul, Turkey

2 Collagen cross linking 1st established tx addressing the pathophysiology of corneal ectasia Only known method to halt disease progression Simultaneous positive effects on corneal topography and refraction Wollensak G. Curr Opin Ophthalmol 2006;17:

3 Surgical Visual Revalidation + CXL Combination strategies to improve the refractive, topographic and visual results & to freeze the resultant change Great idea!! but.

4 How predictable is CXL effect? Refractive changes Topographic changes Cessation / slowing of disease process? Hafezi F, et al. JCRS 2007;33:

5 Factors that affect CXL outcome 1. Local tissue concentration of riboflavin 2. UV-A radiation fluence 3. Interaction time NOT linearly related to post-cxl change in corneal elasticity Seiler T. Current Surgical Options for Visual Rehabilitation in Keratoconus. Sept 2010, Paris. Eurotimes Supplement April 2011

6 CXL effect on corneal stroma Corneal collagen turnover 2 to 7 years Renewed collagen does NOT exhibit the same increased strength and resistance to degradation Long term F/U after CXL Dahl BJ, Spotts E, Truong JQ. Optometry 2012;83:33-42.

7 Progressive effect of CXL Longest F/U of CXL until today is 6 years Raiskup-Wolf F, et al. JCRS 2008;34:

8 Are all ectasia the same? Keratoconus Forme fruste keratoconus Keratoconus + vernal keratoconjunctivitis Kaya V, et al. Cornea 2007;26: Post-RK ectasia Pellucid marginal degeneration Iatrogenic ectasia Meghpara B, et al. Arch Ophthalmol 2008;126:

9 Differential response to CXL in KCN Roy AS & Dupps WJ. IOVS 2011;52:

10 No surgery is complication free... Melting (+/- perforation!) Labiris et al. J Med Case Reports 2011;5:152. Gokhale & Remuganti. Cornea 2010;4: Faschinger et al. Ophthalmologe 2010;107: Sterile infiltrates Angunawela et al. JCRS 2009;35: Infectious keratitis Thin corneas endothelial damage Kymionis G, et al. AJO 2012;153:24-8. Corneal haze Koller et al. JCRS 2009; 35: Peripheral CNV Blurry vision Dahl BJ, Spotts E, Truong JQ. Optometry 2012;83:33-42.

11 Risk factors for failure / complications after CXL K readings > 58 D > 35 years old BCVA 20/25 Koller T, Mrochen M, Seiler T. JCRS 2009;35: Does the incidence of complications increase with combined treatments?

12 CK + CXL Significant improvement of topographic findings but effect regressed after 3 months Not effective in long term! Kymionis G, et al. Cornea 2010;29:

13 CXL + ICRS Chan CC, Sharma M, Wachler BS. JCRS 2007;33: El-Raggal TM. Br J Ophthalmol 2011;95: Saelens IEY, Bartels MC, Bleyen I, Van Rij G. Cornea 2011;30: No significant differences with respect to BCVA, UCVA, MRSE, K outcomes in the ICRS + CXL group compared to ICRS alone group. Colin J. Current Surgical Options for Visual Rehabilitation in Keratoconus. Sept 2010, Paris. Eurotimes Supplement April 2011

14 CXL + ICRS Limited refractive predictability, Haloes and subjective visual complaints, Intrastromal deposits, ICRS migration / extrusion, Infection Saelens IE, et al. Cornea 2011;30:

15 CXL + topo-prk Progressive decrease in myopia and K readings at postoperative 13, 19, 30 and 36 months Krueger & Kanellopoulos JRS 2010;26:S

16 CXL + topo-prk Dahl BJ, Spotts E, Truong JQ. Optometry 2012;83:33-42.

17 CXL + topo-prk Decrease in HOA after CXL + topo-prk... A significant decrease in HOA after CXL only 5 mm pupil total RMS 0.74 μ 0.25 μ Coma like RMS 0.26 μ 0.01 μ Kymionis GD, et al. Open Ophthalmol J. 2011;5:10. Vinciguerra et al. Arch Ophthalmol 2009; 127:

18 CXL + topo-prk Stiffened cross-linked corneal tissue is partly removed by consequential PRK Refractive unpredictability : altered corneal ablation rate on cross-linked stroma Increased possibility of post-prk haze : anterior stroma is repopulated by new keratocytes after 6 months

19 Posterior stromal linear haze Interaction between CXL and photoablation both of which result in keratocyte activation NO full thickness keratocyte repopulation at 12 months after CXL + PRK! Kymionis GD, et al. IOVS 2010;51:

20 The Athens Protocol Topo-PRK + mitomycin-c + CXL Kanellopoulos AJ & Binder PS. JRS 2011;27: Long term effects of mitomycin-c on photoablated cornea after near total apoptosis of keratocytes?

21 New surgical options Avedro technology Microwave-based system for reshaping the cornea Seros medical technology Infrared continous wave laser to shrink anterior stroma Kanellopoulos AJ. Current Surgical Options for Visual Rehabilitation in Keratoconus. Sept 2010, Paris. Eurotimes Supplement April 2011 Followed by transepithelial CXL No published data on long term results yet

22 Triple techniques Topo-PRK + CXL + piol Kanellopoulos AJ & Skouteris VS. JRS 2011;27: ICRS + Toric piol + CXL Güell J. Current Surgical Options for Visual Rehabilitation in Keratoconus. Sept 2010, Paris. Eurotimes Supplement April 2011 ICRS + CXL + topo-ptk PRK Coskunseven E. Current Surgical Options for Visual Rehabilitation in Keratoconus. Sept 2010, Paris. Eurotimes Supplement April 2011 A lot of unknown s.

23 Timing of surgeries 1 CXL st All keratoconus patients < 20 years old should have CXL without documentation of progressive keratoconus Current Surgical Options for Visual Rehabilitation of Keratoconus Eurotimes Suppl April 2011 Fellow eye PK / underlying VKC

24 1 CXL Timing of SVR st Regularization of corneal surface could take up to 1 year and refractive error could be variable during that time of regularization. Koller T et al. Cornea 2009;28:510-5.

25 Timing of surgeries 1 SVR st Effect of CXL on stroma previously treated with excimer laser photoablation / microwave? Homogenous distribution of riboflavin in the stroma with ICRS? Possible prismatic effects of ICRS that would focus UVA on endothelium?

26 Timing of surgeries - simultaneous Mechanical effect of ICRS take time Effect of CXL on stroma treated with excimer laser photoablation or microwave simultaneously? Don t forget : Contact lens tolerance can increase after CXL only

27 Other influences on surgeons?

28 Take home message I would recommend waiting for at least 6 months to see the results before proceeding with the next surgery!

29 Thank you for your kind attention...

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