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Crosslinking without Epithelium Removal?

The prior section in this website explained the cause of corneal weakening in keratoconus. Until recently, there was no method to change the integrity and strength of the cornea itself for keratoconus patients.

A non--surgical treatment C3-R^® (corneal collagen cross-linking riboflavin) treatment can strengthen the weak corneal structure in keratoconus. (see Presentation and Research Articles link) This method works by increasing collagen cross-linking, which are the natural "anchors" within the cornea. These anchors are responsible for preventing the cornea from bulging out and becoming steep and irregular (which is the cause of keratoconus).

The figures above show the parallel corneal layers (white) and the collagen cross-linking (red) which are increased after C3-R® treatment.

During the 30-minute, in-office treatment, custom-made riboflavin eyedrops are applied to the cornea, which are then activated by a special light. This is the process that has been shown in laboratory and clinical studies to increase the amount of collagen cross-linking in the cornea and strengthen the cornea. In published studies, such treatments were proven safe and effective in patients.

Dr. Brian invented the non-surgical C3-R^® procedure that does not remove (scrape off) the surface epithelium known as "epi on" crosslinking. This approach saves patients from significant discomfort (often pain) and increased blurred vision during the first week that would otherwise occur with removal of the epithelium (it requires about a week for the epithelium to heal back once it is scraped off). 

The risk of the "epi-on" crosslinking procedure is mild irritation for a couple of days. 

The risks of the "epi-off" (removal of epithelium) crosslinking procedure include:      1) corneal infection and ulceration, 2) corneal haze, 3) delayed epithelial healing, 4) blurred vision, 5) delay in corneal nerve regeneration.  We prefer epi-on crosslinking because the above side effects of epi-off crosslinking have not occured with epi-on crosslinking.

The retreatment rate is about 1% with either epi-on and epi-off techniques.

The below photo shows riboflavin solution (yellow) penetrated through the intact epithelium and into the cornea which is how C3-R® can be done without scraping off the epithelium.  Removing the epithelium creates a painful recovery and significantly increases risk of infection and corneal haze and scarring.

Our studies and studies of other eye doctors in outside countries have shown patient results are not signficantly different with crosslinking with removal of epithelium and leaving epithelium undisturbed in its place.  Therefore, it is not necessary in our opinion based on the data to scrape off the epithelium for crosslinking.  Additionally, the epi-on technique appears to have less risk since the epithelium is not scraped off.

Eye physician’s in Germany performed the initial studies of collagen crosslinking to strengthen the cornea. They reported results of treatments done as long ago as 1998, so there is a good track record for this procedure. Links to these research publications can be found to the left side of this page. It is important to note in these studies that the proper dosages of the components are a very important part of the treatment. When used properly, there were no negative effects.

C3-R^® treatments can also be combined with Intacs^® to flatten the keratoconus cone even more than with Intacs alone. In these cases, C3-R^® treatments can stabilize keratoconus from getting worse as well as help the Intacs^® reverse part of the keratoconus steepening that had already occurred up to the time of the treatment.

The figure above demonstrates almost 10 diopters of corneal flattening in one patient before (left) after this combined treatment (right).

RIGHT EYE
LEFT EYE
Natural progression of keratoconus in a patient’s eyes over 1.5 years. Notice the dramatic lower cone steepening (red) and increased astigmatism over this short period of time.  C3-R® can halt this progression and prevent these progressive distortions in vision. Note: not all keratoconus progresses this rapidly.

This above case of progression occurred in a young woman, but could have been avoided. After consultation with us, she saw another eye doctor in Los Angeles who was misinformed and advised her not to have C3-R. The result: significant vision loss from delay of treatment for over 1 year. She came back for C3-R which stopped the progression and further vision loss.

Dr. Brian is credited as the first doctor in North America to use C3-R^® treatments for keratoconus as well as being the first doctor in the world to combine this treatment with Intacs^®. He has been performing C3-R^® for nearly 5 years - the longest of any physician in North America.  Dr. Brian has the longest experience in collagen crosslinking in North America (including Canada).  Would you trust your precious eyes to someone who just learned how to do the procedure?

In another study in patients who had RK (radial keratotomy), C3-R^® appeared to stabilize progressive farsightedness (hyperopia) changes and reduced visual fluctuations during the day.

Patients come to us from all over the United States and often from other countries.  Please click below to listen to patients share in their own words how the process was for them and the ways their lives have been changed.

Keratoconus is the thinning and bulging of the cornea. Treatments include Intacs^®, C3-R^®, cornea collagen cross linking, and if keratoconus progresses to a serious level, cornea transplantation. Dr Brian Boxer Wachler is a specialist in keratoconus evaluation and treatment.