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Cross-linking: A revolution in progress
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 Matteo Piovella |
The advances of today’s ophthalmology are the result of top-quality scientific research and constant innovation in technology and procedures. The past 2 decades have witnessed a revolution that has allowed us to deliver increasingly better services to our patients.
Cataract surgery has overcome all barriers and represents, for the broad range of indications and high level of results, the benchmark standard for all types of surgery in all branches of medicine.
Refractive surgery, however, is a dream come true. It has allowed us to overcome one of the major and more widespread handicaps related to the imperfect construction of our eyes.
The exciting thing about our profession is that we never stop learning, we never stop inventing and we never stop improving.
Corneal cross-linking is one of our latest new adventures. For several years now, an increasing number have been using this technique to slow down, halt or even improve the progressive deformationof the cornea in keratoconus patients.
Corneal cross-linking, as all innovative and courageous ideas, has sparked controversy that has raised both enthusiasm and skepticism among opinion leaders. The need for a long-term follow-up in the treatment of a disease that progresses in such a variable manner is undeniable, and the word “caution” is frequently heard from both enthusiasts and skeptics.
To date, adverse events or treatment-related complications have been seldom reported. Topographic evidence of corneal flattening was seen in the majority of eyes, and although a temporary decrease in visual acuity is experienced postoperatively, full recovery and stabilization occur within 3 to 6 months after the procedure.
The instruments used are still first generation, and we can reasonably foresee, as the technique becomes more and more established, fast technological advances that will improve customization, safety and efficacy of the treatment.
Visualization during cross-linking is greatly improved by the use of the operating microscope, with X and Y axes movements and micrometric vertical adjustments. During the irradiation phase, accurate focusing is mandatory, following the features of the different UV devices available.
Finally, variations in the technique and in the concentration and composition of the photosensitizing agent that will allow a shorter duration of the treatment are currently under investigation. To date, 1 entire hour is needed. A 50% reduction in time would be a big step forward.
To further improve our results, we should learn from our previous mistakes. The sterilization protocols that have been enforced for other procedures should be extended to these innovative treatments to ensure patient safety. This would reduce the risk of corneal ulcers, which currently seems the most common complication of cross-linking.
Reference:
- Eberwein P, Auw-Hädrich C, Birnbaum F, Maier PC, Reinhard T. Corneal melting after cross-linking and deep lamellar keratoplasty in a keratoconus patient. Klin Monatsbl Augenheilkd. 2008;225(1):96-98.