Corneal Cross-linking: Epi-On vs. Epi-Off Current Protocols, Pros, and Cons
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CATARACT & REFRACTIVE SURGERY (CE STARR AND A BRISSETTE, SECTION EDITORS)
Corneal Cross-linking: Epi-On vs. Epi-Off Current Protocols, Pros, and Cons Kenneth A. Beckman 1,2 & Mark S. Milner 3,4 & Jodi I. Luchs 5,6 & Parag A. Majmudar 7
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review To review the current protocols for corneal cross-linking for the treatment of keratoconus, including a comparison of epithelial off (Epi-off) and epithelial on (Epi-on) treatments. Recent Findings After over 15 years of investigation, corneal cross-linking was approved in the USA in 2016. While Epi-off cross-linking is safe and effective, it is also associated with some drawbacks. Therefore, Epi-on is being investigated as a safer alternative. This paper reviews traditional Epi-off cross-linking and the latest Epi-on protocols. Summary While Epi-on protocols are being evaluated and have shown potential for success, most studies have shown Epi-off to be more effective. However, the well-known risks associated with Epi-off treatment may be significantly mitigated with Epi-on treatment. Therefore, if Epi-on proves to be as effective as Epi-off, and gains approval, it may become the preferred procedure. Keywords Cross-linking . Epi-on . Epi-off . Keratoconus . CXL . Ectasia
Introduction Corneal cross-linking (CXL) has rapidly become a first-line treatment for keratoconus throughout the world. CXL employs UV-A light and riboflavin (vitamin B2), a photosensitizer, to increase the tectonic strength and thereby halt progression of ectasia, or “bulging,” of the cornea. These ectatic changes are marked by corneal thinning and an increase in the anterior and/or posterior curvatures of the cornea and often lead to high levels of myopia and irregular astigmatism. The most common manifestation of ectasia is keratoconus, but it may also be seen in pellucid marginal degeneration,
keratoglobus, and after laser vision correction such as LASIK and less commonly PRK. CXL was introduced into routine clinical practice during the past decade [1]. Before that time, the management of keratoconus included spectacle and contact lens correction and intrastromal corneal ring segment (ICRS) implantation [2]. However, these interventions are purely symptomatic and improve visual function without addressing the underlying pathophysiology of keratectasia. Before CXL, the only true treatment for ectasia was lamellar or penetrating keratoplasty, which typically was reserved for advanced cases [3]. The primary purpose of cross-linking is to stabilize or possibly
This article is part of the Topical Collection on Cataract & Refractive Surgery * Kenneth A. Beckman [email protected] Mark S. Milner [email protected] Jodi I. Luchs [email protected] Parag A. Majmudar [email protected]
1
Department of Ophthalmology, The Ohio State University, Columbus, OH, USA
2
Comprehensive EyeCare of Central Ohio, 450 Alkyre Run Dr #100, Westerville, OH 43082, USA
3
Yale University School of Medicine, New Haven, CT, USA
4
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