Moderator
Marcony R. Santhiago, MD, PhD
Panelists
Jason R. Mayer, MD
Hajirah Saeed
Viewing Papers
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Presenting Author
Weijie V Lin, MD, ABO
Co-Authors
Brandon Ayres MD, Zeba Syed MD, Clark Chang MSc, OD
Purpose
Corneal crosslinking (CXL) reduces keratoconus (KCN) progression, but it has a risk of complications. Large-scale U.S. studies are limited. We present our historical experience at Wills Eye Hospital (WEH).
Methods
We conducted a retrospective review of epi-off CXL performed for progressive KCN, by two practices at WEH between 01/2018 and 09/2023. These were identified by CPT procedure code. The cases with less than 3 months of follow-up were excluded. Demographic characteristics, clinical factors, and complications were analyzed with T-test, Fisher exact test, and regression modelling.
Results
889 patient encounters that received UV-mediated CXL via the KXL system (Glaukos, Burlington, MA) were identified. Complication rates were 67.7% for haze, 3.7% for persistent epithelial defects (PED), and 3.4% for infiltrates. Multivariate analysis demonstrated that: 1) haze was associated with younger age (p<0.013) and="" thinner="" baseline="" pachymetry=""><0.019), and="" 2)="" ped="" was="" associated="" with="" pre-op="" scarring=""><0.001) and="" use="" of="" general="" anesthesia="" (ga)=""><0.001). interestingly,="" no="" infiltrates="" developed="" in="" the="" ga="" cases.="" socioeconomic="" factors="" including="" gender,="" average="" household="" income="" by="" zip="" code,="" and="" self-reported="" race/ethnicity="" were="" not="" associated="" with="" postop="" cxl="">
Conclusion
While CXL complication rates are low, associations exist with various clinical factors, including use of GA, younger age, and pre-op corneal scarring. These findings may guide pre-CXL selection and post-CXL monitoring to further optimize outcomes.
Presenting Author
Ali Nowrouzi, MD, FEBO, FRCS
Purpose
To evaluate and compare postoperative stromal demarcation line depth following standard accelerated localized transepithelial (Epi On) crosslinking in patients with keratoconus versus using a novel method of localized concentrated riboflavin at the level of the cone with supplementary oxygenation.
Methods
A prospective, randomized, longitudinal study was performed on 30 subjects diagnosed with Bilateral progressive Keratoconus. Bilateral keratoconus patients were randomized to either standard transepithelial (Epi On) accelerated crosslinking protocole with the potency of 45 mW/cm2 and energy dose of 7.2J/cm2 0.22% Riboflavin 6 minutes following 0.25% Riboflavin 4 minutes with a total ultraviolet time of 5 minutes 20 seconds pulsed (1,1) or Concentrated Riboflavin at the level of cone was placed by well based on the topographic study and supplementary oxygenation. The demarcation line depth was compared at one month by anterior optical tomography, and the stability of the disease was assessed.
Results
The average postoperative demarcation line depth was more profound in the group of concentrated Riboflavin at the level of the cone placed by well based on the topographic study and supplementary oxygenation at 220.2 �m (standard deviation: 48.63 �m ) compared to the average postoperative demarcation line of the first group 185 �m ( standard deviation 45.63 �m) (p< />
Conclusion
This study focused on reporting the demarcation line depth of patients undergoing an accelerated epi-on CXL protocol performed with localized riboflavin and supplementary oxygenation. Our results suggest that the demarcation line depth is more profound in the localized riboflavin approach with supplementary oxygenation.
Presenting Author
Sibel Zirtiloglu, MD
Co-Authors
Gulzar Ganboyzada MD, Duygu Tuzun Sayin MD
Purpose
To investigate the effect of age on postoperative values in pediatric patients undergoing cross-linking.
Methods
Pediatric patients (18 years and younger) diagnosed with keratoconus who underwent Cross-linking between 2022 and 2024 were retrospectively analyzed. Cross-linking was performed in accelerated mode ((10 mW/cm2, 9 min) epi-off. Patient follow-up was performed with Sirius topography (Sirius; Costruzione Strumenti Oftalmici [CSO], Florence, Italy). Visual acuity, K1, K2, Kmax, thinnest corneal thickness, astigmatism, keratoconus screening values (BCV, Sifi Kvf), coma and spherical aberration values were recorded preoperatively, six months postoperatively and one year postoperatively.
Results
15 eyes of 15 patients were included in the study. The mean age of the patients was 14 ?2. Seven of the patients were female and 8 were male. Preoperative K1, K2, Kmax, Kmax, Slf, kVf, BCV and coma aberrations were positively correlated with age, whereas postoperative values did not change significantly with age (p=0. 04, r=0.5; p=0.04, r=0.50; p=0.01, r=0.60; p=0.50, r=0.50; p=0.01, r=0.60; p=0.01, r=0.60, p=0.02, r=0.60, respectively). In addition, there was no significant correlation between age and thinnest corneal thickness, astigmatism and value.
Conclusion
In pediatric keratoconus, there was an age-related increase in K1, K2, Kmax, Slf, kVf, BCV and coma aberrations when the patients first presented; however, age had no effect on the change in K values, corneal thickness change and aberrations after cross-linking.
Presenting Author
Christoph F. Kranemann, MD
Purpose
To determine whether Customized CXL combined with Customized PRK in Keratoectasia- both centred on the cone - results in greater flattening of the cone and greater refractive effect than traditional CXL with equal or greater stability over time.
Methods
Prospective study of patients with Keratoconus (KC) or Pellucid Marginal Degeneration (PMD) as confirmed by Anterior and posterior corneal topography. Topography, best corrected vision, pachymetry, anterior segment OCT and full eye examination were obtained pre intervention and post intervention at month 1, 6, 12 and years 2-5. After a customized PRK with an optical zone of 5 mm and maximum 60 microns of tissue removal, customized CXL centred on the cone with a central zone of 5 mmm and a secondary zone to 6.5-7 mm 10 J/cm2 for the central and 7 J/cm2 for the outer zone while supplying supplemental oxygen at 2.5 l/min. The CXL system was equipped with an eye tracker.
Results
17 patients completed the 5 years follow up. The UDVA improved to +.1 +/- 0.2 (P<.002) and CDVA to -.10 +/- 0.22 (P<.001). Kmax by -3.2 +/- 1.24 (P< 0.001). Endothelial cell count was unaltered and no serious adverse events occurred.
Conclusion
Customized CXL combined with Customized PRK, and supplemental oxygen and a smaller central treatment zone appears to be worthwhile for further study.
Presenting Author
Maanasa Indaram, MD
Co-Authors
Simon Fung MA, MD, FRCOphth, Neel Pasricha MD, Shreya Menon BSc, Tessnim Ahmad MD
Purpose
Keratoconus (KCN) progresses more rapidly in children and developmentally delayed patients. Timely collagen cross-linking (CXL) is vital to prevent vision loss, though can be challenging in clinic for them. This study reports 3-year outcomes of CXL under general anesthesia for pediatric and developmentally delayed patients at two academic sites.
Methods
KCN patients <18 years="" or="" with="" developmental="" delay="" who="" underwent="" epithelium-off="" cxl="" using="" the="" dresden="" protocol="" under="" general="" anesthesia="" between="" january="" 2018="" and="" march="" 2023="" at="" the="" university="" of="" california="" san="" francisco="" and="" university="" of="" california="" los="" angeles="" were="" retrospectively="" reviewed.="" best="" corrected="" visual="" acuity="" (bcva),="" keratometry="" values="" obtained="" through="" scheimpflug="" corneal="" tomography="" (pentacam;="" oculus:="" arlington,="" wa),="" the="" need="" for="" either="" repeat="" cxl="" or="" corneal="" transplantation,="" and="" any="" post-operative="" complications="" were="" assessed="" at="" the="" 6-month,="" 1-year,="" and="" 3-year="" time="" points.="" statistical="" analysis="" was="" performed="" using="" two-tailed="" welch="" t-test="" and="" fisher�s="" exact="">
Results
Ninety-six eyes of 65 patients were reviewed. Nine patients (13%) had developmental delay. Median age at time of CXL was 14.3 years (range: 9-18 years). Median follow-up duration was 12 months, and 16 patients had at least 3 years of follow up. Mean Snellen BCVA was 20/40 at baseline and 20/30 at the final follow up visit. Mean maximal keratometry (Kmax) was 60.1 diopters at baseline versus 60.1 diopters (p=0.97), 51.9 diopters (p<0.05), and="" 58.2="" (p="0.45)" at="" 6="" months,="" 1="" year,="" and="" 3="" years="" postoperatively="" respectively.="" no="" patients="" required="" repeat="" cxl="" or="" corneal="" transplantation="" by="" their="" final="" follow="" up.="" there="" were="" no="" intraoperative="" or="" postoperative="">
Conclusion
Pediatric patients and those with developmental delay are at risk for rapid keratoconus progression necessitating swift intervention. Our multi-center, intermediate-term outcomes of CXL under general anesthesia are favorable, with patients maintaining stable visual acuities and keratometry measurements at up to 3 years postoperatively.
Presenting Author
Aafreen Bari, MD
Co-Authors
Namrata Sharma MD, Tushar Agarwal MD, Tanuj Dada MD
Purpose
To analyse the risk factors, clinical features, visual outcomes and in-vivo imaging characteristics in cases of keratoconus developing keratitis following accelerated collagen cross linking (CXL).
Methods
A retrospective observational case series at a tertiary eye centre in India evaluating eyes that underwent accelerated CXL from January 2021 to July 2024.
Results
Of 723 eyes undergoing CXL, 13 eyes developed infectious keratitis (1.79%). Majority belonged to upper middle socio-economic class and presented in summer and rainy season. The use of bandage contact lens was common in all cases. The mean duration from onset of symptoms to presentation was 2.7 days. The most common clinical presentation was multifocal stromal infiltrates observed in 85.7% cases. The median area of epithelial defect was 12 sq. mm and average resolution time was 18.4 days. The most common organism that was isolated was CoNS, while others included Staphylococcus aureus, Escherichia coli, Candida sp. and Acanthameba sp. The resistance to moxifloxacin was seen in 3/5 cases.
Conclusion
Infectious keratitis following accelerated CXL is a rare clinical entity. Early presentation, timely management including use of topical steroids are associated with good visual outcomes.
Presenting Author
Stacie Puyleart, MD
Co-Authors
Chad Serels MD, David Hardten MD
Purpose
To report the outcomes of same-day Corneal Tissue Addition Keratoplasty (CTAK) and collagen cross linking in eyes with post-refractive ectasia.
Methods
This retrospective review included all eyes with a history of post-refractive ectasia that underwent same-day Corneal Tissue Addition Keratoplasty (CTAK) and collagen cross linking between March 2022 and September 2024. Main outcome measures included pre- and post-operative uncorrected and corrected visual acuity, manifest refraction, keratometry, pachymetry, higher-order aberration, and indices of corneal irregularity.
Results
Eleven eyes with post-refractive ectasia underwent CTAK with same-day crosslinking and were followed for up to 6 months postoperatively. UDVA improved by at least 2 lines in 66% (4/6) of eyes at 6 months. There was no significant change in CDVA at any time point. Spherical equivalent reduced from -0.93 +/- 1.99 to +0.48 +/- 2.65 (p=0.045) and Kmean decreased from 47.21 +/- 6.76 to 43.47 +/- 7.14 (p<0.001) at="" 6="" months="" postoperatively.="" no="" topographic="" keratoconus="" index="" met="" the="" level="" for="" statistical="" significance.="" eye="" developed="" a="" lasik="" flap="" dehiscence="" at="" the="" time="" of="" tissue="" insertion="" requiring="" suture="" refixation="" and="" eye="" developed="" infectious="">
Conclusion
Same-day CTAK and crosslinking is a promising option for patients with post-refractive ectasia. Complications can arise related to utilizing a lamellar channel in eyes with a prior LASIK flap. However, overall, this is an effective strategy which offers improvements in uncorrected distance visual acuity, mean keratometry, and spherical equivalent.
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