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What is cross-linking?

Cross-linking (x-linking) is a procedure applied mainly in the treatment of mild keratoconus. Other indications for this procedure are some ocular diseases with progressive decrease in corneal thickness, as well as postoperative corneal shape changes.

The procedure was developed at the Technical University of Dresden, Germany, in the mid 1990’s (Prof. Theo Seiler, Gregore Wollensak, Eberhard Spoerl). However, the safety and efficacy of this method have been verified only recently.

Riboflavin (vitamin B2) drops are administered onto the corneal tissue and it is than exposed to ultraviolet A light (wavelength of 365 nm). This stimulates the formation of new links between collagen fibres, known as cross-links (hence the name of cross-linking). Additional bonds between collagen fibres present in the corneal stroma make the cornea stiffer and more robust (hardened).

The purpose of cross-linking is to turn keratoconus from progressive to non-progressive; nevertheless, in many cases the result is also a partial improvement in patient’s condition.


How is cross-linking carried out?

Typically, cross-linking is performed after a prior removal of the central corneal epithelium. For this purpose, the eye is anaesthetised with drops, and then the epithelium is removed with the use of 18% alcohol solution (as in laser vision correction with the LASEK method). Subsequently, riboflavin (vitamin B2) solution is administered on the cornea every several minutes for the duration of 30 minutes. The next stage is exposure to UVA ultraviolet light (wavelength of 365 nm) for 30 minutes, during which riboflavin drops continue to be administered. When irradiation is complete, a bandage contact lens is put on the cornea, which shouldn’t be removed until a follow-up examination. For several days following the procedure, the patient may experience significant pain, until the ocular surface has been covered with new epithelium.

There is also a newer, but less tested method, in which cross-linking is done without removal of the corneal epithelium. Riboflavin drops are administered onto cornea for much longer in this case, which lasts over 2 hours; whereas the UV irradiation is 30 minutes long. Benefits of this version of the procedure include the possibility to perform it at a more advanced stage of the disease – when the cornea is slightly thinner, as well as quicker healing and lack of postoperative symptoms. The disadvantages are the higher price of the preparation containing riboflavin and the fact that the amount of available study results is considerably smaller.


Preparation for the procedure

About 2 weeks before eligibility decision and the actual procedure, the patient must stop wearing contact lenses, at least in the eye which is going to be treated.

For several days before the treatment, the patient administers antibiotic drops into the eye qualified for cross-linking.

On the day when the patient arrives to undergo the procedure, he or she cannot have a cold or be in the course of inflammatory disease treatment.


After treatment

When cross-linking is performed with removal of corneal epithelium, a bandage contact lens is put on the eye at the end of the procedure. The patient must not remove it or rub their eyes despite feeling pain. In the case of cross-linking performed without removal of corneal epithelium, the dressing on the eye is removed by the doctor during follow-up on the following day.

Until the first ophthalmologic follow-up, the patient must take required medication prescribed by the ophthalmologist who checked his or her eligibility for treatment.

During that time, the patient shouldn’t wear a hard contact lens.

Any questions should be consulted with an ophthalmologist.

The effects will be fully felt several months after the procedure.