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BLOG: Cross-link early and often
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The remarkable evolution of keratoconus treatment in the past 10 years has brought many advances, including scleral contact lenses, collagen cross-linking, renewed interest in intracorneal ring segments and even conductive keratoplasty to permanently and locally flatten steep areas of the cornea. Of all these, cross-linking is the most broadly applicable and impactful because it permanently stops the forward progression of this disease in the overwhelming majority of patients. Through experience, there are three truths we have discovered about cross-linking:
1. Cross-link early. Waiting for a young patient with signs of keratoconus to demonstrate “progression” often does a disservice, allowing progressive irregular astigmatism to affect the eye permanently. While no one wants to treat a patient before there is clear evidence of this disease, there is little reason to wait once the diagnosis is firmly made. The best way to treat irregular astigmatism is never to have it threaten vision.
2. Older patients benefit, too. Sequential topographic exams show that many patients well over age 40, and indeed into their 70s, have progression of keratoconus. In many cases, it makes perfect sense to cross-link before cataract surgery to improve the optical shape and improve the likelihood of visual success with surgery. While the cost and delays involved in cross-linking cataract patients are a barrier, it’s a worthwhile consideration for many of these patients.
3. Cross-linking facilitates improved vision. While the cross-linking procedure itself is mainly intended to stabilize disease and only improves vision meaningfully in about 50% of patients, cross-linking can be paired with other procedures such as Intacs (Addition Technology) and CK, which can improve corneal shape and meaningfully improve vision. Naturally, PRK is also possible and is gaining widespread use around the world, although it seems best performed after the cross-linked eye has healed for some time.
Those of us with significant experience in keratoconus treatment have come to trust cross-linking as a safe, effective procedure. As a platform for other shape-altering procedures, it now enables us to halt and reverse a disease that just a few years ago was a leading indication for corneal transplants. Indeed, every patient with keratoconus deserves to know about cross-linking and the benefits it can deliver.
Disclosure: Hovanesian reports no relevant financial disclosures.