Corneal cross-linking and epithelial management: four pearls for success

Dr Preeya Gupta, ophthalmologist at Triangle Eye Consultants, shares her four pearls for corneal collagen cross-linking.

Dr Gupta recommends that ophthalmologists manage patient expectations, monitor epithelial cells and warn about infectious keratitis. Because every patient is different, it is crucial that patients understand that their healing process may not look like another patient’s. Ophthalmologists may find clinical and interpersonal success when they see patients frequently postoperatively, according to Dr Gupta, because they can monitor how the epithelium is healing and counsel patients at the same time.

Video transcript

Well today I talked about corneal collagen cross-linking, which is a very important procedure in managing our patients with keratoconus. It has really been a sight-saving procedure to help halt the progression of keratoconus, which can be an extremely blinding condition.

The do's and don'ts: So we're talking about the FDA-approved protocol, which is the epithelial-off protocol.

I think my four pearls here are related to first and foremost setting expectations for our patients. Sometimes they think of cross-linking as a refractive procedure, which it can have refractive changes as part of it, but I like my patients to really think of cross-linking as a medical procedure that's really aimed at halting the progression of their disease.

I also think it's really important that patients understand that their vision can change for up to a year after this procedure. We certainly see patients that have reduction in their prescription, flattening of their cornea, and while I hope that for everyone, everyone comes out a little bit different.

Epithelial management is very important with cross-linking. Some of the potential complications of cross-linking include haze formation and infectious keratitis. So I think it's very important for clinicians to see their patients frequently postoperatively. And in those cases where perhaps the epithelium is not healing as quickly as we want, we know that these are abnormal corneas, often very steep corneas, which can make epithelial healing a difficult process for some patients. So we want to see them more often; we want to be aggressive about treating their epithelium.

I have a low threshold to actually remove the soft contact lens and place a cryopreserved amniotic membrane to accelerate the healing. I try to remove preservatives from the ocular surface, and then sometimes even lower the steroid dose initially to aid with epithelial healing.

Last but not least, infectious keratitis is something to consider. This is of course a dreaded complication of really any surgery. And so I have my patients stay on an antibiotic drop until re-epithelialization occurs, and I have a very low threshold to culture and you know, see my patient more frequently so that we can identify any infectious keratitis quickly and treat it.

Note: This transcript has been lightly edited for clarity.