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Evolving cross-linking techniques treating wider range of keratoconus patients
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Corneal cross-linking, or CXL, is enjoying its 10th anniversary of broad clinical use since the pioneering work of Seiler and Mrochen. In most parts of the world, CXL is approved, available and standard of care for treating the patient with keratoconus. In the U.S., CXL is still not approved by the U.S. Food and Drug Administration, but many of us are hoping this will change in 2015 if Avedro is successful in achieving approval for the so-called standard epithelium-off Dresden protocol.
The world consensus is that CXL is the treatment of choice for mild to moderate keratoconus with documented progression. Still controversial, but gaining many advocates worldwide, is the position that every patient with even the earliest findings of keratoconus should be offered CXL.
In our practice at Minnesota Eye Consultants with four cornea-trained specialists, we have participated in CXL clinical trials for nearly 8 years, starting with the classical Dresden protocol in studies sponsored by Peschke and Topcon and evolving to an investigator-sponsored clinical trial using a proprietary epithelium-on protocol with CXLUSA for just over 2 years.
With the epithelium-on technique, we have been impressed enough with the safety and efficacy to now recommend the procedure to any patient over the age of 10 years with definite topographic changes consistent with keratoconus. We do not believe it is necessary to wait for documented progression but instead offer this alternative to all patients with documented keratoconus. A few patients still elect to be carefully monitored for progression before being treated, and we always offer this alternative, but most select treatment at even the earliest stages of keratoconus. If any of us had a child or close relative diagnosed with keratoconus, we would all treat immediately.
The goal, of course, is to prevent progression of keratoconus. In some patients, we achieve some corneal flattening and improved topography, but this cannot be predicted or relied upon. When caught early, with only topographic changes, most patients with keratoconus still correct to 20/25 or better with spectacles or a soft contact lens. All of us who treat keratoconus patients on a regular basis would love to arrest the disease at that stage. I personally always recommend bilateral treatment in these early-stage patients, even when there are minimal findings in the least affected eye.
Our current treatment protocol using an epithelium-on approach allows bilateral treatment and has low risk with rapid visual recovery. Those patients who progress despite therapy can be re-treated. There will be some treatment failures, and if progression is documented after three repeated epithelium-on CXL, I would offer the patient an epithelium-off treatment, which can generate a more significant CXL response. To date, I have not yet experienced this situation.
Click here to read the publication exclusive, Lindstrom's Perspective, published in Ocular Surgery News U.S. Edition, February 10, 2015.