Visual acuity, topography remain stable in most eyes 10 years after corneal cross-linking
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Key takeaways:
- Visual acuity and topography remained stable in most eyes 10 years after corneal cross-linking.
- Eyes with keratoconus appeared to be more stable than those with corneal ectasia.
Most eyes with keratoconus or corneal ectasia after laser refractive surgery remained stable 10 years after corneal cross-linking, although eyes with keratoconus appeared to be more stable, according to a study in Eye & Contact Lens.
“Long-term data on stability after the cross-linking procedure remains limited,” Steven A. Greenstein, MD, and colleagues at Rutgers New Jersey Medical School, wrote. “The literature on the long-term stability of cross-linking for eyes with corneal ectasia after refractive surgery is even more limited.”
To assess topographic and visual outcomes 10 years after CXL among patients with progressive keratoconus and corneal ectasia following refractive surgery, researchers conducted a cross-sectional cohort study of a single-center, prospective clinical trial.
They examined 19 eyes from 13 patients aged 16 to 49 years at the time of CXL (average age, 33.7 years). Eleven eyes were originally diagnosed with keratoconus and eight with ectasia after laser refractive surgery. Outcomes included uncorrected visual acuity and best spectacle-corrected visual acuity at 1 and 10 years postoperatively, as well as maximum keratometry and thinnest pachymetry. Researchers also used the Belin ABCD progression display to evaluate progression of anterior and posterior curvature and corneal thickness.
According to results, the average maximum keratometry changed from 58.2 ± 12 D at baseline to 55.4 ± 7.7 D at 1 year and 58.3 ± 10.1 D at 10 years. Six eyes had a steepening of maximum keratometry of at least 2 D after 10 years, two with keratoconus and four with ectasia. Further, anterior and posterior curvature progressed in five eyes, one with keratoconus and the remaining with ectasia.
The average thinnest pachymetry changed from 440.6 ± 51.6 m at baseline to 442.5 ± 49.3 m at 1 year and 442.3 ± 54.4 m at 10 years, with corneal thickness progressing in nine eyes, five with keratoconus and four with ectasia.
The average uncorrected visual acuity changed from 0.79 ± 0.42 logMAR at baseline to 0.76 ± 0.49 logMAR at year 1 and 0.86 ± 0.46 logMAR at 10 years, with uncorrected visual acuity worsening by more than two lines in 42.1% of the total cohort, 18.2% with keratoconus and 75% with ectasia at 10 years.
The average BCVA changed from 0.38 ± 0.26 logMAR at baseline to 0.2 ± 0.14 logMAR at 1 year and 0.33 ± 0.34 logMAR at 10 years. BCVA worsened by more than two lines in 13.8% of the total cohort, none with keratoconus and 37% with ectasia at 10 years.
At 10 years, 68.5% of the entire cohort, 81.8% of keratoconus eyes and 50% of eyes with ectasia remained topographically stable after CXL.
“All patients undergoing cross-linking treatment should be counseled about the long-term stability of the procedure and should be advised of the importance for continued regular follow-up examinations after treatment,” Greenstein and colleagues wrote. “In particular, patients with corneal ectasia after laser refractive surgery should be counseled on the possible increased risk of progression after CXL and the need for future cross-linking retreatment.”
Perspective
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Corneal cross-linking is often considered the standard of care for keratoconus and corneal ectasias. CXL is one of the least invasive treatments and helps to preserve best-corrected vision and delay corneal transplantation. Many practitioners refer for CXL either at first diagnosis of keratoconus or with documented progression, which is quite common as keratoconus is by definition a progressive, noninflammatory corneal ectasia.
This study looked at the stability of patients 10 years after the initial CXL trials. Though quite limited in subject number and statistical power, they showed the majority of eyes were stable 10 years after CXL. These findings are encouraging and help to justify referral of all eligible patients for a consultation for CXL. From the patient’s perspective, the likelihood of long-term stability can help justify this costly procedure without immediate visual benefit.
Notably, CXL patients with corneal ectasia after refractive surgery were less stable than those with keratoconus, and progressive thinning after CXL was not necessarily correlated with decreased visual acuity. Further research is necessary, but this study is valuable to help manage expectations after treatment.
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