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your solution in corneal cross-linking

Indications

- Progressive keratoconus - Iatrogenic ectasia (e.g. after LASIK) - Pellucid marginal degeneration - Recurrent keratoconus after corneal graft - Peripheral melting diseases

Contraindications

- Corneal thickness <400 µm in swollen state (without epithelium) - Epithelial healing disorders (e.g. MDF) - Nuclear rheumatic disorders - Herpes keratitis (UV can activate herpes) - Pregnancy

Necessary Equipment

- UV-X 2000 illumination system - Innocross-R 0.1%/dextran 20% solution 2ml - Innocross-R hypotonic riboflavin 0.1 % solution 2ml - BSS, sterile physiological balanced salt solution - Protection ring - Operating table and instrument table - Slit lamp with blue light - Pachymeter - Bladed speculum - Hockey knife - Topical anaesthetics (i.e. oxybuprocaine, tetracaine) - LASIK sponges - Merocel™ sponges or similar - Gauze (for fluid collection) - Adhesive tape - Bandage contact lens - Postoperative medication (like after PRK: antibiotics, steroids)

Prior to Treatment

- Mandatory: remove rigid contact lenses two weeks prior to surgery - Discontinue vitamin C treatment one week prior to surgery

Cross-Linking Procedure UV-X 2000

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your solution in corneal cross-linking

Treatment Prior to first treatment on any working day check radiation output with power meter.

1. Drop topical anaesthetics (e.g. oxybuprocaine, tetracaine). 2. Clean eye with Eye-CleanTM or similar solution. 3. Insert lid speculum. 4. Pachymetry with epithelium, central or thinnest point 5. Partially remove the corneal epithelium (8 – 9 mm diameter). (Riboflavin molecule

is too large to penetrate intact epithelium, thus epithelial removal is essential for effective diffusion of riboflavin).

6. Begin dropping riboflavin/dextran solution: 1 drop every 2 minutes for 30 minutes (= 15 drops).

7. After 30 minutes check at slit lamp with blue light whether anterior chamber is slightly yellow. If yes, go to next step. If not, continue to drop riboflavin/dextran solution until anterior chamber is yellow.

8. Check corneal thickness again. If under 400 µm without epithelium, use hypotonic riboflavin 0.1% solution to swell cornea. 2 drops every 10 – 15 seconds until corneal thickness is at least 400 µm.

9. Cover and protect the limbal stem cells by use of a protection ring. Only clear cornea should be irradiated!

10. UV-illumination treatment: position patient under UV-X illumination device (lying position is preferred). Turn on UV-X and focus according to the UV-X2000 user manual (distance between beam aperture and eye ~ 45 mm). Center the beam to the cornea’s thinnest point.

11. Administer BSS every two minutes to keep the cornea moist and one drop of Riboflavin solution after 5 minutes illumination time.

Remember: Riboflavin solution has 2 functions: - initiating cross linking effect when radiated with UV - protecting endothelium, lens and macula by absorbing UV-light

12. After 10 minutes of UV-illumination switch off UV-X device. 13. Apply antibiotic ointment on the cornea and then cover cornea with a bandage

contact lens 14. Give post-op medication similar to post-PRK: pain killers, steroids, antibiotics.