Corneal Collagen Cross-Linking
Sonali Talsania, MD
Collagen cross-linking (CXL) was first described in 2003 for the treatment of progressive keratoconus in adults and received FDA approval in 2016 for treatment of patients over 14 years of age with progressive keratoconus. CXL uses reactive oxygen species generated when riboflavin 5′-phosphate is activated by ultraviolet A (UVA) light to create covalent bonds between collagen fibrils in the corneal stroma, thereby crosslinking them to strengthen the cornea.1 The goal of CXL is to achieve disease stabilization; improvement in visual acuity has been described but is not the primary goal. CXL is performed in patients younger than 14 years of age, but is not covered by most insurance plans as it is not currently FDA approved for this age group.
PREOPERATIVE CONSIDERATIONS
Patients who demonstrate progressive keratoconus are candidates for CXL (see below for adult guidelines from CXL studies; currently, there are no strict guidelines for patients ≤14 years old). The age of the patient should be considered when assessing a patient’s fitness for CXL. Children with keratoconus progress more quickly and may be considered for CXL at the time of their diagnosis. Many still opt to monitor closely given the risks of CXL and lack of insurance coverage for the procedure.2,3 Adults can be monitored for progression every 3 months and considered for CXL if meeting criteria for progression as listed below.
Preoperative testing:
Tomography (Pentacam most commonly used) to diagnose keratoconus and monitor for progression (Fig. 18.1).
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