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Should PACK-CXL be used as a first-line procedure for or in addition to antimicrobial treatment?
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PACK-CXL would bypass problems of antibiotic resistance
In 2014 we published in the British Journal of Ophthalmology one of the first papers on PACK-CXL. We reported on a series of patients who did not respond to full medical therapy. After CXL, bacterial infections resolved very well. What we were dealing with and could effectively defeat with CXL were most likely antibiotic-resistant bacteria.
Despite growing alarm, antibiotics are overprescribed worldwide. Overuse and misuse are leading to increasing resistance, and many of the common bacteria have become hard to fight with the antibiotics we have today. Not many new antibiotics are in the market nowadays. The last big thing was moxifloxacin. Whatever the reason, financial or scientific, behind this halt of research, we are now disarmed against bacteria
Cross-linking has shown to help in patients who are resistant to antimicrobial therapy. It is a safe method that causes no collateral damage, and I would recommend it as first-line treatment. There are not many published papers supporting this yet, but I am part of an undergoing trial that might prove that PACK-CXL is safe and effective and can be used straight away, together with if not before medications.
PACK-CXL might be a true sight saver, particularly in areas where access to therapy is not very good and due to logistic, economic and cultural reasons it is very difficult to have patients take antibiotic drops regularly and visit the doctor every day.
- Reference:
- Shetty R, et al. Br J Ophthalmol. 2014;doi:10.1136/bjophthalmol-2014-304944.
Rohit Shetty, MD, PhD, is vice chairman and chief of cornea and refractive surgery, Narayana Nethralaya Eye Hospital, Bangalore, India. Disclosure: Shetty reports no relevant financial disclosures.
There is not enough evidence, and complications should be a concern
PACK-CXL is a promising technique, but not enough data have yet been produced to support its use as a first-line procedure. I would still suggest to use antibiotics as first-line, and maybe consider cross-linking in selected, special cases.
Although cross-linking seems to be a safe procedure, we should not forget that there are potential complications involved. Cases of severe corneal melting after cross-linking have been reported, and concerns about this possibility should be even greater when dealing with corneas that are weakened by an infection.
All in all, I think antibiotics are still the method of choice. However, antibiotic resistance is a fast-growing problem, and this might lead cross-linking to become the standard procedure in a not too distant future. Where I see a role for PACK-CXL even now is in underdeveloped countries where there is no access to antibiotics.
Martin Dirisamer, MD, PhD, is in the Ophthalmology Department, University of Munich, Germany. Disclosure: Dirisamer reports no relevant financial disclosures.