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

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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

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Jennifer Rose-Nussbaumer, MD Assistant Professor UCSF/Proctor Foundation

I have no financial interests in this subject matter.

0.1% topical riboflavin Exposure to UV-A light at a wavelength of 365nm with irradiance of 3mW/cm2 Continue to receive topical riboflavin Q5 min intervals

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Included 3 RCTs from UK, US and Australia 225 adult eyes and randomized to epithelium-off CXL vs control All studies has issues with masking and incomplete follow-up On average, treated eyes had a less steep cornea (~ 2D) and better UCVA (~2

lines)

Adverse effects of CXL included K edema, AC inflammation, recurrent erosions,

infectious keratitis, sterile K infiltrates

No studies reported decreased VA or endothelial damage compared to untreated

eyes

Sykakis et al. Cochrane Database of Systematic Reviews 2015, Issue 3

12 year old boy -

Failed vision screen at Pediatrician office VA: 20/20 OD 20/60 OS Pachy: 497 OD 444 OS SLE: OD: Prominent cornea nerves OD; OS: Mild apical thinning, + vogt striae OS MRx: OD: -1.00 +1.00 x 125 OS: -8.50 + 5.00 x 029

29 y/o with KCN:

VA 20/300 Pachy: 350 microns SLE: Cone, fleischer ring &

vogt striae

Slightly decreased mean visual acuity: 20/35 DALK 20/32 PKP Reduced risk of rejection Reduced endothelial cell loss

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Transepithelial CXL Accelerated CXL – 30mW/cm2 for 4-9 minutes CXL plus – CXL + refractive surgery PACK-CXL - infectious keratitis

Two possible mechanisms:

Antimicrobial effects of CXL Increased resistance of corneal tissue

to enzymatic degradation Other potential benefits:

Treat drug resistant or difficult to treat

bacteria/fungi

Decrease toxicity Non-compliance

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Two-arm masked randomized controlled trial with 1:1 randomization to: Collagen cross-linking & moxifloxacin Moxifloxacin medical therapy alone Four-arm masked randomized controlled trial with adaptive randomization to: Collagen cross-linking & Natamycin (5%) Collagen cross-linking & Ampho (0.15%) Natamycin medical therapy alone (5%) Ampho medical therapy alone (0.15%)

Primary: Culture positivity after CXL Secondary:

3-month BSCVA Infiltrate/scar size Rate of perforation Astigmatism 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.