Corneal Collagen Cross-Linking with Riboflavin

Corneal collage cross-linking with ribovlavin (CXL) is an innovation used to treat patients with the corneal abnormality called keratoconus or progressive corneal ectasia. The treatment strengthens the cornea with riboflavin (vitamin B2) and ultraviolet-A (UVA) causing a cross-linking reaction in the middle layer of the cornea, which ultimately makes the collagen in the cornea stronger.

What is keratoconus?
Keratoconus is a non-inflammatory abnormality of the cornea, which caused by changes in the structure of the cornea. It causes the cornea to thin and bulge outward in a cone shape or drooping. However, this condition can impair vision.
Keratoconus can be treated in several ways, include:
  1. Glasses can be worn in the early stages of the disease, when the cornea has not consequentially changed.
  2. Contact lenses can be used when astigmatism is too severe for glasses.
  3. Corneal transplant if the condition worsens.
Currently, there is a search for treatment options that stop the changing of the cornea, Thus, limiting the need for corneal transplant, including:
  1. Intrastromal corneal ring segment implantation (ICRS). This involves an insertion of a ring into the cornea to reduce its curvature.
  2. Corneal collagen cross-linking with riboflavin (CXL). This involves the use of riboflavin and ultraviolet-A (UVA) light to strengthen the cornea.
The purpose/benefit of corneal collagen cross linking (CXL) is to strengthen the cornea and slow down or stop it from bending more than it has. This can help maintain vision or even improve it. The condition will not be worsen to the point that a corneal transplant will be needed.
  1. Stop wearing contact lenses accordingly to the doctor’s treatment plan.
  2. Do not wear make-up, line your eyes, wear perfume, use any oil or gel in your hair, or wear false eyelashes.
  3. Wash your face and shampoo your hair the day before or the morning of the procedure.
  4. Do not wear any accessories or valuables to the hospital.
  5. Bring a family member or friend to help you after the procedure (for the case that does not require a hospital stay).
  1. Come to the hospital at the scheduled date and time as issued by the Eye Center.
  2. You will have to lie on your back during the procedure.
  3. Anesthetic eye drops will be administered before the procedure.
  4. During the procedure you will be conscious the whole time, but a drape will be placed on your face and your body, which can make you slightly uncomfortable.
  5. Carefully follow all of the doctor’s instructions during the procedure.
  6. After the procedure, the ophthalmologist will place the bandage contact lens or cover your eyes with eye pads or eye shields.
  1. On the first day after the procedure, get plenty of rest and especially rest your eyes as much as possible.
  2. On the first day after the procedure, keep the eyes covered to prevent rubbing and protect them from impact.
  3. Avoid getting water in the eyes. Use a washcloth soaked in water and wrung out to wipe your face and get your hair washed at the salon for the first week after the procedure.
  4. Do not wear make-up or powder, line your eyes, or use face cream, as instructed by the doctor.
  5. Wash your eyes before and after administering eye drops.
  6. Start using eye drops and taking medication (if any) as instructed by the doctor.
  7. If you experience pain, please take pain medication as prescribed by the doctor.
  8. Keep all scheduled follow-up appointments.
  1. After the procedure you will need to wear prescribed contact lenses. If they fall out, do not put them back.
  2. Your eyes may be sensitive to light and may be red. You may feel some pain or feel like there is a foreign substance in your eye. Vision may be slightly blurry on and off, in the first week after the procedure. All of these symptoms will improve within two to three weeks.
  3. It is recommended that you wear sunglasses when you are outside and use plastic eye shields when you sleep during the first 2 weeks after the procedure.
Just like any other medical procedure, there are possible risks and complications. These depend on the severity of the condition before the procedure and your self-care after the procedure as well as how well you followed the instructions that were that were given by your ophthalmologist. Possible side effects include:
  • Irritation, burning, tearing, inability to open eyes, pain in the first few days after the procedure—all of these symptoms will slowly improve during the first week after the procedure.
  • There is a small chance that you will have some fogginess temporarily after the procedure when eyes are magnified, but this does not usually interfere with your vision. Wear sunglasses when you are outside and use eye drops as prescribed by the doctor to prevent this symptom.
  • Corneal infection is rare. The doctor will ensure cleanliness during the procedure, but afterwards it will be your responsibility to use antibiotic eye drops as instructed. Do not let water get in your eye and do not let your fingers or the eye drop bottle touch your eye.
  • The bulging or drooping of the cornea may worsen, but this is even less likely that in patients who do not receive treatment. It is important to care for allergies and alleviate any eye itching and rubbing to prevent disease progression. Some patients may require a repeat of the corneal collagen cross-linking (CXL).
Before the Procedure
  • You should be staying in Thailand for at least one week during the treatment period.
  • It is recommended you stay in a hotel close to the hospital for convenience in traveling to the hospital.
After the Procedure
  • A family member should accompany you for the procedure as your eyes will be covered after the procedure.
  • A follow-up appointment will be made the next day. If you have no adverse effects from the procedure you will be able to return home. Your doctor will make the final determination.
  • Keep all follow-up appointments, usually scheduled one month, three months, and six months after the procedure. If you are unable to keep these appointments, please see an ophthalmologist closer to you.
The procedure is considered successful if it strengthens the cornea, reduces the bulging, and maintains a vision. The success of the procedure will depend on the severity of the condition.
What if the procedure is not performed?
In some patients, the cornea will continue to bulge, worsening blurriness, and corneal transplant may be eventually required to restore vision.
Keratoconus is an abnormality of the cornea that occurs due to the changes within the structure of the cornea. It is not painful and there is no inflammation or infection involved, but it can compromise vision. Normally vision can be restored through the treatment options mentioned above.

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