Corneal Crosslinking – Is It Helpful for Keratoconus? – Eye Love Cares

corneal cross linking

CXL (corneal crosslinking) is a minimally invasive procedure made to treat progressive keratoconus and occasionally, additional conditions which cause corneal weakening.

The corneal crosslinking procedure stabilizes and strengthens the cornea by developing fresh links between collagen fibers inside the cornea. The two-step treatment applies liquid riboflavin to the eye’s surface instantly followed by a controlled exposure to UV light.

The two kinds of corneal crosslinking include:

  • Epithelium-Off Corneal Crosslinking. In this kind of crosslinking treatment, the thin outer layer of the cornea is taken off to permit the liquid riboflavin to more easily get through the corneal tissue.
  • Epithelium-On Corneal Crosslinking. In this treatment (additionally referred to as transepithelial corneal crosslinking), the protective corneal epithelium is left intact and requires a lengthier riboflavin “loading” time.

Also, CXL may be combined with additional treatments for keratoconus. For instance, combining corneal crosslinking with implanting small, arc-shaped corneal inserts referred to as Intacs has been proven to assist in reshaping and stabilizing the cornea in more advanced keratoconus cases.

At present, the only corneal crosslinking platform that’s approved by the FDA for the treatment of progressive keratoconus within the United States is Avedro’s KXL System, including the company’s signature Photrexa, as well as Photrexa Viscous riboflavin options.


What is CXL for Keratoconus?

As aforementioned, CXL is a fairly non-invasive medical treatment made to stabilize and strengthen the cornea and therefore slow or halt keratoconus progression.

corneal cross linkingIn corneal crosslinking, a riboflavin solution (a kind of vitamin B) is applied to the cornea; then, the eye’s front surface is exposed to a controlled amount of UV (ultraviolet) light. The ultraviolet light activates a process in which the riboflavin develops extra bonds between connective tissue fibers that are made of collagen inside the cornea. Those “cross-linkings” offer extra rigidity and strength to the cornea.

There are two kinds of CXL, depending upon whether the cornea’s exterior layer (epithelium) is left intact or taken off before the application of the riboflavin solution. Within “epi-on” corneal crosslinking, the outer layer is left intact; in “epi-off” corneal crosslinking the epithelium is taken off.

Also, corneal crosslinking is utilized to stabilize the cornea in instances of a rare complication of LASIK surgery referred to as corneal ectasia that generates likewise symptoms and signs as the ones of keratoconus.

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Keratoconus: What is It?

corneal cross linkingKeratoconus is an eye disease that is characterized by a bulging forward of the eye’s front surface due to irregular corneal thinning.

Causes of keratoconus are not completely understood; however, risk factors involve heredity, allergies, and eye rubbing.

Some studies suggest disruption of regular levels of special enzymes and additional substances inside the cornea (which includes compounds that influence inflammatory responses) are related to keratoconus, yet the underlying cause of that disruption isn’t clear.

The reported prevalence of keratoconus widely varies based upon geography as well as methods utilized to diagnose the eye disease. The most cited study of the epidemiology of keratoconus within the U.S. found that keratoconus affects around 54 individuals per 100,000 population (around one in 2,000 individuals).

But recent research in the Netherlands discovered that the estimated prevalence of keratoconus within the general population was 265 instances per 100,000 (one in 377), which is substantially greater than values reported in prior studies.

Generally, keratoconus starts in a person’s teenage years or early 20s. Keratoconus may affect one or both eyes. Within the aforementioned Netherlands research, 60.6% of diagnosed patients were men.

Keratoconus, if left untreated, is progressive: the cornea ultimately becomes abnormally cone-shaped and causes blurred vision which can’t be corrected with traditional contact lenses or eyeglasses. Also, keratoconus may lead to corneal scarring that further reduces visual acuity.

Can Eye Rubbing Lead to Keratoconus?

corneal cross linkingIt isn’t clear whether eye rubbing is a symptom or a cause of keratoconus, or maybe both.

Keratoconus is thought to be at least a partially hereditary disease. Therefore, it might be that eye rubbing is a keratoconus risk factor only among people with genetic factors which might predispose them to the development of the disease.

More common eye rubbing causes are pink eye and eye allergies that cause itchy eyes.

But if you happen to have a family history of keratoconus or if your optometrist says you might have early indications of keratoconus, you definitely should avoid rubbing the eyes. Eye rubbing might increase your risk of the development of keratoconus or make the keratoconus worse.

Even if you do not have any risk factors or indications of keratoconus, it isn’t a good idea to rub the eyes. Eye rubbing may boost your risk of additional eye infections by transferring bacteria and other pathogens from the hands to the eyes.

Plus, aggressive eye rubbing may cause a corneal abrasion and potentially even boost your risk of retinal detachment or glaucoma.


Can I Undergo LASIK if I Have Keratoconus?

corneal cross linkingLASIK and additional laser refractive surgery treatments such as SMILE and PRK correct nearsightedness and additional refractive errors by reshaping your cornea. In the process of reshaping, some corneal tissue is extracted, which makes your cornea thinner.

Because it’s a degenerative corneal disease which causes corneal thinning and leads to irregular and unpredictable changes in the shape of the eye’s front surface, LASIK usually isn’t advised for anyone who has keratoconus.

As a matter of fact, there’s a tiny risk that LASIK may induce a keratoconus-type condition referred to as corneal ectasia if too much tissue is extracted from the cornea of people prone to the condition.

If you have keratoconus and are curious about refractive surgery to correct your nearsightedness or additional refractive errors, step one includes having the cornea closely examined by an optometrist — preferably a keratoconus expert.

The doctor might suggest a CXL treatment to stabilize and strengthen the cornea before you consider refractive surgery. Depending on the result of this treatment, LASIK or some additional kind of refractive surgery to reduce your dependence upon contact lenses or eyeglasses may be possible.

Related: How Much Does LASIK Cost?

If I Have This Condition, Am I Able to Serve in the Military?

People who have keratoconus presently aren’t permitted to serve in the U.S. military.

People who’ve been diagnosed with keratoconus aren’t eligible to serve in the U.S. Armed Forces according to Department of Defense Instruction upon Medical Standards for Appointment, Enlistment, or Induction within the Military Services (DoDI 6130.03, Section 4c).

It appears the prohibition applies even if the keratoconus was successfully managed with corneal insert surgery, CXL, or additional corrective surgery.

If you have already enlisted within the military and it’s diagnosed within your training, you usually won’t be deployed for combat. Plus, a keratoconus diagnosis may result in a medical discharge.

Are you considering enlisting? If you have keratoconus, first ask your recruitment officer for the most recent data on your eligibility to serve, as policies may change.

In January of 2017, the medical device and pharmaceutical organization Avedro issued a press release that announced they were offering their KXL-brand CXL system (which includes the ophthalmic solutions utilized in the treatment) to military hospitals countrywide.

In addition, in November of 2016, Virginia’s Fort Belvoir Hospital became the first military facility within the country to do the FDA-approved CXL treatment and treated service members diagnosed with progressive keratoconus.

Given those latest developments, if you have keratoconus and are thinking about enlisting with the military, talk about your condition with the recruitment officer to receive the most recent information regarding your eligibility to serve.

Does Use of Computers Make it Worse?

corneal cross linkingThere isn’t any clear proof that using computers or using additional digital devices like smart phones, e-readers, and tablets will cause keratoconus to worsen.

But excessive usage of electronic devices that have digital displays sometimes can cause dry eyes. Most folks who have dry eyes usually rub their eyes, and the eye rubbing potentially could cause the keratoconus to progress.

In order to be safe (even if you do not have keratoconus), avoid rubbing the eyes after or during computer use. Plus, take consistent breaks to avoid computer eye strain, as well as use artificial tears if the eyes start feeling dry while spending substantial time in front of the computer screen or utilizing digital devices.

In addition, be aware that though present research hasn’t shown that computer usage makes it worse, a variety of studies have discovered a link between computer use and myopia progression and myopia, especially among kids. Ask your optometrist what can be done to decrease your youngster’s risk of becoming nearsighted (or more nearsighted year upon year).

Top Related Article – Heterochromia: Two Different Colored Eyes

How to Find a Keratoconus Expert

Usually, keratoconus is detected with a regular eye exam.

corneal cross linkingBut efficient keratoconus treatment requires unique equipment, skills, and training. For best results, you ought to locate an eye doctor who specializes in keratoconus.

Surgical keratoconus treatment — including CXL, Intacs, additional corneal implant operations, corneal grafts, and transplants (keratoplasty) — usually have to be performed by an ophthalmologist.

On the other hand, follow-up examinations as well as fitting contact lenses for keratoconus more frequently are done by an OD (optometrist).

Oftentimes, ophthalmologists and optometrists work hand in hand to monitor, diagnose, and treat keratoconus. Generally, an optometrist will conduct the routine examinations and contact lens adjustments and fittings. If the keratoconus continuously progresses and/or contact lens wear becomes a problem (or if the physician feels CXL might be required to stabilize a cornea), the patient usually is referred to an ophthalmologist specializing in keratoconus surgical treatment. This collaborative approach is referred to as co-management of keratoconus.

The majority of eye doctors (both optometrists and ophthalmologists) who conduct regular eye examinations are aware of MD or ODs close to them specializing in keratoconus.

In addition, the National Keratoconus Foundation has a list of ophthalmologists and optometrists specializing in taking care of patients who have keratoconus.

How to Prevent Keratoconus from Getting Worse

If you’ve been diagnosed with keratoconus, the most critical thing to do to keep your condition from getting worse includes following the advice the eye doctor gives you concerning follow-up care and best treatment options.

Depending on the specific keratoconus characteristics, those treatment choices might involve being fitted with scleral contact lenses, going through corneal crosslinking treatment, or both.

It also is extremely vital that you refrain from rubbing the eyes. Eye rubbing has been linked to keratoconus getting worse.

Successful keratoconus management requires lifelong and frequent eye examinations to ensure that your cornea stays stable and visual acuity is maintained.

If you’re uncertain or confused about the advice received from your eye doctor regarding keratoconus management, consider getting a second opinion from an ophthalmologist or optometrist who is a keratoconus specialist.

Keratoconus Treatment: How Much Does It Cost?

corneal cross linkingThe keratoconus treatment cost depends on the kind of treatment(s) required and the severity of the condition.

Because there isn’t any outright cure, disease management may extend for years and add to the cumulative expense of keratoconus.

Fitting contact lenses for this condition is a more customized and complex process than fitting traditional contacts on a regular eye. In addition, doctors specializing in keratoconus have to invest in advanced instrumentation like automated corneal topography machines to manage, monitor, and diagnose the disease.

The materials, fitting, measurements, and exam for keratoconus treatment with contact lenses oftentimes run from $2,000 – $4,000 per eye. But the range may be lower or higher, depending upon the disease’s severity and the kind of contact lenses that are prescribed.

According to industry sources, the price of CXL for keratoconus conducted in the United States usually ranges from $2,500-$4,000 per eye.

The price of Intacs and additional corneal insert or keratoconus corneal implant surgery may go from $1,500-$2,500 per eye.

According to the HHS, corneal transplants for advanced keratoconus conducted in the U.S. cost around $13,000 for an outpatient treatment and almost $28,000 for an in-hospital treatment for people who do not have health insurance.

In the majority of cases, the price of keratoconus surgery and eye exams done in the United States is partially or fully covered by health insurance. The price of contact lenses for keratoconus might or might not be covered by insurance based on the kind of policy you have. Talk to your insurance company for details.


Keratoconus: Is It a Disability?

Keratoconus is a disease of the eyes that might or might not cause loss of visual acuity that’s serious enough to be considered a disability. Keratoconus itself, in other words, isn’t a disability, yet vision loss that is caused by keratoconus might be serious enough to qualify as a disability.

Within the U.S., if an individual’s best-corrected visual acuity inside both eyes is 20/200 or worse — whether caused by keratoconus or another condition — that individual is considered to be legally blind and might be eligible for disability benefits.

Luckily, in the majority of cases, treatments like corneal crosslinking and/or scleral contact lenses may prevent even advanced keratoconus from leading to this level of serious vision loss.

If you have substantial vision loss caused by keratoconus, go to a keratoconus specialist to figure out if one of the new treatment options (or potentially a cornea transplant) may improve your visual acuity and eliminate any possible disability from keratoconus.

Keratoconus: Is It Covered by Insurance?

The keratoconus treatment cost may be several thousand dollars and up. If you need a corneal transplant, the treatment alone may cost anywhere from $13,000 to almost $28,000, depending on the kind of surgery and whether it is done on an outpatient basis or includes a hospital stay.

Additionally, the expenses of contact lenses and eye exams for keratoconus are recurring costs year upon year.

Luckily, most expenses related to keratoconus typically are covered by medical or health insurance. Medical insurance generally covers the majority of the price of CXL or other major keratoconus operation (less copays and deductibles determined by your insurance policy).

The price of eye examinations (or portions thereof) specifically conducted for the monitoring and diagnosis of keratoconus commonly are covered too. The price of contact lenses for keratoconus might or might not be completely covered depending on your policy.

If you do not have medical or health insurance and you are not covered by Medicaid or Medicare, financing companies specializing in medical costs provide plans in which you may pay for expenses related to keratoconus treatment over a period of time at appealing interest rates.

If you’re diagnosed with keratoconus, speak to the eye doctor and insurance provider in order for you to completely understand your obligations and benefits concerning the price of the keratoconus treatment.

Keratoconus: Is It Genetic?

Much still isn’t known about what causes the thinning and weakening of the cornea characteristic of keratoconus.

It appears that keratoconus is partially genetic in origin, yet specific behavioral and environmental factors additionally play a part. These are referred to as epigenetic factors.

A person, in other words, might have genetic factors which place him or her at higher risk for keratoconus; however, the disease might not happen unless specific epigenetic factors are also involved.

The main epigenetic factors related to keratoconus are contact lens trauma, eye rubbing, as well as UV radiation exposure.

Plus, instead of being caused by one gene mutation, scientists think keratoconus is a complicated disease involving the interaction of several epigenetic and genetic factors.

Keratoconus: Is There a Cure?

At present there isn’t any cure for keratoconus. It’s a lifetime eye disease.

However, thankfully, the majority of keratoconus cases may be managed successfully.

For keratoconus of a mild to moderate nature, scleral contact lenses designed of rigid, advanced gas permeable lens materials are typically the most popular treatment. Those lenses are bigger than conventional GP (gas permeable) contacts and therefore may vault over even large spaces of distorted cornea and offer comfortable, clear vision.

For keratoconus of a more advanced nature, a fairly non-invasive treatment referred to as CXL (corneal crosslinking) may stabilize and strengthen an irregularly shaped, thinning cornea.

However, it doesn’t “cure” keratoconus. CXL, in other words, strengthens and might stabilize the cornea, yet it does not return the cornea to regular thickness. Plus, there isn’t any guarantee that keratoconus will not continuously worsen after the treatment.

Also, scleral contact lenses or another kind of contact lens usually still will be required after corneal crosslinking for vision correction.

For serious keratoconus cases, a keratoplasty (corneal transplant) might be necessary.

Successful keratoconus management — which includes post-op care — requires regular eye examinations throughout the affected individual’s lifetime. Also, avoiding eye rubbing is crucial, as this behavior has been related to worsening of keratoconus.

Keratoconus: What Are the Best Contact Lenses?

corneal cross linkingScleral contact lenses generally offer the best fit, visual acuity, and comfort for someone who has keratoconus.

Scleral contacts are bigger in diameter than traditional GP (gas permeable) contact lenses which permits them to vault over fairly big spaces of distorted cornea. This eliminates a lot of the irregular astigmatism and additional refractive errors that are caused by keratoconus.

Plus, when correctly fitted, scleral contacts offer a more stable fit and are less likely to become dislodged from your eye during sports and other activities. (They’ll fit more securely underneath the eyelids because of their bigger size.)

But the best kind of contact lens for keratoconus may vary from one person to another. In some instances, traditional GP contacts might be your best bet — particularly if you have a hard time removing and applying bigger scleral lenses.

Hybrid contact lenses — lenses with a rigid GP central zone surrounded by an exterior zone designed of silicone hydrogel material — are an another great choice for keratoconus of a mild to moderate nature. There even are customized soft contact lenses made for the correction of astigmatism from keratoconus.

Step one in choosing the best contact lenses if you have keratoconus includes scheduling a comprehensive eye examination and contact lens assessment with an eye doctor.

Who Are the Best Candidates for Corneal Crosslinking?

CXL is most effective if it may be done before the cornea becomes too irregular in shape, there’s substantial loss of vision from keratoconus, or additional causes of corneal ectasia abound. Typically, CXL, if applied early, stabilizes or even improves the shape of a cornea and results in better visual acuity as well as an improved capability of wearing contact lenses.

Other possible CXL applications involve the corneal ulcer treatment that is unresponsive to treatment using topical antibiotics. Research also has discovered that corneal crosslinking may be efficient for eradicating various corneal infections.

Some surgeons also have reported reasonable results in the improvement of the stability of the cornea in those who’ve undergone radial keratotomy, an incisional refractive treatment from the 80s and 90s. Crosslinking seems to work better for the ones who are suffering day-to-day vision fluctuations.

Those considering vision correction treatments like LASIK also eventually might be pre-treated using corneal crosslinking to strengthen an eye’s surface prior to going through an excimer laser ablation which reshapes a cornea.

What Can Be Expected After and During CXL?

During the preliminary exams, the eye doctor is going to measure the thickness of the cornea and ensure that you’re an excellent candidate for the treatment. You’ll also have to have a regular eye examination to evaluate your visual acuity and overall eye health. And the doctor is going to conduct cornea mapping (referred to as corneal topography) to figure out the level of the eye condition.

Corneal crosslinking strengthens the bonds inside the stroma of the cornea, the layer from which tissue is extracted with LASIK surgery.

In most cases, the crosslinking treatment takes 60-90 minutes. If you’re getting epithelial-off crosslinking, the surgeon will put you into a reclining position, then extract the epithelial layer from the cornea. Then, riboflavin eye drops are given. After sufficient time passes (depending on the method), the surgeon is going to assess your eye to make sure that your cornea has enough riboflavin present.

The thickness of the cornea is checked, and ultraviolet light is applied for up to 30 minutes.

In some cases, a bandage contact lens is applied. Anti-inflammatory drops and topical antibiotic are prescribed.

With epithelial-on CXL and epithelial-off alike, research has discovered that 99% of patients will stay stable or experience improvement in their corneal shape, very substantial for those who have progressive keratoconus which otherwise may lead to serious loss of vision.

Although corneal crosslinking might cause a bit of initial eye irritation, the eye’s surface and tear film appear to completely recover within a few weeks. Within recent research investigating possible alterations of the surface of the eye and tear film parameters, three months after corneal crosslinking in those who have progressive keratoconus, no adverse effects on the ocular surface and tear functionality (vital for visual quality) were found.

Corneal Crosslinking Cost

The price of corneal crosslinking for progressive keratoconus treatment commonly ranges from $2,500-$4,000 per eye.

Some of that expense might be covered by your insurance policy. Ask the insurance company or eye doctor for help determining what your overall out-of-pocket cost for the treatment will be.


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