1. Doug Wallin OD Keith Rasmussen OD

2. Cornea Crosslinking When and when not? Doug Wallin, OD Keith Rasmussen, OD

3. Evolution of KCN: Ectasia to Hydrops

4. Press Release

5. Crosslinking procedure

6. Corneal epithelial debridement like PRK

7. Crosslinking procedure Corneal epithelial debridement like PRK Riboflavin (vitamin B2) applied to cornea

8. Crosslinking procedure Corneal epithelial debridement like PRK Riboflavin (vitamin B2) applied to cornea Ultraviolet light (365nm) applied to cornea

9. Crosslinking procedure Corneal epithelial debridement like PRK Riboflavin (vitamin B2) applied to cornea Ultraviolet light (365nm) applied to cornea BCL is placed and follow up care similar to PRK

10. Making cross-links

12. Case 1 33 yo Hispanic male Wears soft contacts well OD sent in to rule-out KC No eye rubbing

13. Case 1 Glasses 5 yrs old -1.75-1.25x046 20/20-3 -1.75-1.75x124 20/30 MRx -1.75-1.25x045 20/20 -0.50-6.00x130 20/20-2

16. Case 2 57 yowf PKP OD Toric CL OD BCVA 20/25- OS -12.25-6.00x087 BCVA 20/400 Can’t get a good fit with scleral contact

17. OD post-PKP

18. OS Keratoconus

20. CXL—long term results Collagen crosslinking with riboflavin and ultraviolet-A light in keratoconus: Long-term results Frederik Raiskup Wolf, MD, Anne Hoyer, MD, Eberhard Sproel, PhD, Lutz E. Pillunat, MD Methods Four hundred eighty eyes of 272 patients with progressive keratoconus were included in this long-term retrospective study. The maximum follow-up was 6 years. At the first and all follow-up examinations, refraction, best corrected visual acuity (BCVA), corneal topography, corneal thickness, and intraocular pressure were recorded. Results The analysis included 241 eyes with a minimum follow-up of 6 months. The steepening decreased significantly by 2.68 diopters (D) in the first year, 2.21 D in the second year, and 4.84 D in the third year. The BCVA improved significantly (≥1 line) in 53% of 142 eyes in the first year, 57% of 66 eyes in the second year, and 58% of 33 eyes in the first year or remained stable (no lines lost) in 20%, 24%, and 29%, respectively. Two patients had continuous progression of keratoconus and had repeat crosslinking procedures. Conclusions Despite the low number of patients with a follow-up longer than 3 years, results indicate long-term stabilization and improvement after collagen crosslinking. Thus, collagen crosslinking is an effective therapeutical option for progressive keratoconus.

21. CXL—long term results Am J Ophthalmol.Am J Ophthalmol. 2015 Dec;160(6):1154-63. doi: 10.1016/j.ajo.2015.08.023. Epub 2015 Aug 22. Corneal Cross-linking to Halt the Progression of Keratoconus and Corneal Ectasia: Seven-Year Follow-up. O'Brart DP O'Brart DP 1, Patel P 2, Lascaratos G 2, Wagh VK 2, Tam C 2, Lee J 2, O'Brart NA 3Patel PLascaratos GWagh VKTam CLee JO'Brart NA METHODS: Thirty-six patients (36 eyes) who underwent epithelium-off CXL at a University Hospital (Guy's and St Thomas' National Health Service Foundation Trust) 6-8 years previously were examined. The main outcome measures were refractive error, visual acuity, corneal topographic keratometry, ultrasonic pachymetry, and topography-derived corneal wavefront. RESULTS: At 7 years compared to preoperative values, mean spherical equivalent refractive error (SEQ) increased by +0.78 diopter (D) (P <.005) and mean simulated topographic keratometry (SimK) and mean maximum keratometry (Kmax) reduced by -0.74 D (P <.0001) and -0.91 D (P <.0001), respectively. Uncorrected distance acuity (UCDA) (P <.0005) and corrected distance acuity (CDVA) (P <.0001) had improved and root mean square (RMS) (P <.0005), coma (P <.0005), and secondary astigmatism (P <.005) lessened. At 7 years compared to 1 year, CDVA improved (P <.05); mean SimK (P <.0005) and mean Kmax (P <.005) reduced by -0.45 D and -0.56 D, respectively; and RMS (P <.0005) and coma (P <.0005) decreased. At 7 years compared to 5 years, CDVA improved (P <.05) and trefoil reduced (P <.05). No treated eyes progressed. In 29 initially untreated fellow eyes mean SimK increased by +0.54 D (P <.02), mean Kmax by +0.87 D (P <.05), and refractive astigmatism increased (P <.0005). CONCLUSIONS: Following corneal cross-linking, improvements in topographic and wavefront parameters evident at 1 year were seen to continue to improve at 5 years and were maintained at 7 years. No treated eyes progressed over the 7-year follow- up period.

22. CXL results Improvement met the definition of success (i.e. a difference between treatment groups of ≥ 1D in the mean change in K max from baseline) at Months 3, 6, and 12 n=2183

23. Get to them early Educate patients on expectations CXL stabilizes progression of KC Take home

24. Graft failure 10 year post-op 25 year post-op 20 year post-op 11 % 51%83% Kelly, T., Williams, K., & Coster, D. (2011, June). Corneal Transplantation for Keratoconus. Archives of Ophthalmology, 129(6), 691-697.

27. Refractive stability

28. CrosslinkToo late…

29. Thank you