12/3/2016 I have no financial interests in this subject matter. - PowerPoint PPT Presentation

12/3/2016 � I have no financial interests in this subject matter. Jennifer Rose-Nussbaumer, MD Assistant Professor UCSF/Proctor Foundation � 0.1% topical riboflavin � Exposure to UV-A light at a wavelength of 365nm with irradiance of 3mW/cm 2 � Continue to receive topical riboflavin Q5 min intervals 1

12/3/2016 12 year old boy - � Included 3 RCTs from UK, US and Australia � Failed vision screen at Pediatrician office � 225 adult eyes and randomized to epithelium-off CXL vs control � VA: 20/20 OD 20/60 OS � All studies has issues with masking and incomplete follow-up � Pachy: 497 OD 444 OS � On average, treated eyes had a less steep cornea (~ 2D) and better UCVA (~2 � SLE: lines) OD: Prominent cornea nerves OD; � Adverse effects of CXL included K edema, AC inflammation, recurrent erosions, OS: Mild apical thinning, + vogt striae OS infectious keratitis, sterile K infiltrates � MRx: � No studies reported decreased VA or endothelial damage compared to untreated OD: -1.00 +1.00 x 125 eyes OS: -8.50 + 5.00 x 029 Sykakis et al. Cochrane Database of Systematic Reviews 2015, Issue 3 29 y/o with KCN: � Slightly decreased mean visual acuity: � VA 20/300 � 20/35 DALK � Pachy: 350 microns � 20/32 PKP � SLE: Cone, fleischer ring & � Reduced risk of rejection vogt striae � Reduced endothelial cell loss 2

12/3/2016 � Transepithelial CXL � Accelerated CXL – 30mW/cm 2 for 4-9 minutes � Two possible mechanisms: � Antimicrobial effects of CXL � CXL plus – CXL + refractive surgery � Increased resistance of corneal tissue to enzymatic degradation � PACK-CXL - infectious keratitis � Other potential benefits: � Treat drug resistant or difficult to treat bacteria/fungi � Decrease toxicity � Non-compliance 3

12/3/2016 � Two-arm masked randomized controlled trial with 1:1 randomization to: � Collagen cross-linking & moxifloxacin Primary: Culture positivity after CXL � Moxifloxacin medical therapy alone Secondary: � 3-month BSCVA � Four-arm masked randomized controlled trial with adaptive randomization to: � Infiltrate/scar size � Collagen cross-linking & Natamycin (5%) � Rate of perforation � Collagen cross-linking & Ampho (0.15%) � Astigmatism � Natamycin medical therapy alone (5%) � Ampho medical therapy alone (0.15%) � Corneal thickness � IND-VFQ � CXL has finally been FDA approved in the US for treatment of KCN � UCSF will begin CXL in January 2017 � Call (415) 514-8200 or (415) 514-6853 for patient referrals � Fax (415) 514-6845 � Future directions include shorter less invasive CXL techniques � Potential innovative treatments for refractive surgery and infectious keratitis. 4