1. EPITHELIUM-ON CORNEA COLLAGEN CXL FOR KERATOCONUS: INCREASING PATIENT COMFORT WITHOUT SACRIFICING EFFICACY WORLD CORNEA CONGRESS VII SAN DIEGO 2015

2. AUTHORS/DISCLOSURE Michael P Ehrenhaus, MD  New York Cornea Consultants  MD Ojos Sebastian Guzman, MD  MD Ojos Melvin Gutierez, MD  MD Ojos The authors have no financial interests to disclose

3. PURPOSE Epithelium-on cornea collagen cross linking (CXL) is a more comfortable procedure than epithelium-off, but is still quite uncomfortable. The study was done to investigate a way to make the procedure more comfortable for the patients without sacrificing efficacy. Keywords: Crosslinking and Keratoconus

4. METHODS Epithelium-on Collagen Crosslinking was performed using the approved protocol. Additionally, after the initial cases demonstrated more then expected discomfort and pain, a 10mm Chayet LASIK sponge was then used in the majority of cases to protect the conjunctiva and absorb the runoff Paracel and Vibex Xtra. Peripheral BSS wash of the conjunctiva was added to further eliminate chemical conjunctival toxicity during the procedure. Pain/discomfort questionnaire was used after all of the procedures epithelium-on CXL. Prospective case series. Patient ages ranged from 10-40.

5. EPITHELIUM-ON CXL PROTOCOL Apply topical anesthetic to the cornea. Apply a lid speculum using standard clinical techniques. Apply sufficient Paracel TM (Riboflavin 0.25%, HPMC, NaCl, EDTA, Tris, Benzalkonium Chloride) to completely cover the cornea and repeat this procedure every 90 seconds for a total of 4 minutes. Rinse cornea completely with VibeX Xtra TM (Riboflavine 0.1%). Then apply sufficient VibeX Xtra to completely cover the cornea and repeat this procedure every 90 seconds for a total of 6 minutes. Rinse cornea completely with BSS(Balanced Sterile Saline Solution) and Initiate UV treatment using the Avedro System. ~Recommended protocol is pulsed illumination at interval [1,1] using 45mW/cm2 for a surface dose of 7.2J. Rinse cornea completely with BSS. Advise the patient not to rub the eye.

6. PAIN

7. IRRITATION

8. RESULTS Pain was dramatically reduced for the majority of patients with almost 43% with 0-3 scale pain and 77% reporting a score of 6 or less on the pain scale. Irritation (Foreign body sensation) was still a factor, though almost 58% were reporting 6 or less on the irritation scale, and more patients were reporting 0-3 irritation/FBS in the sponge group than those did not have one during the procedure. Additionally, irritation/FBS and pain were resolved by 24 hours after CXL for almost all patients recorded in the study. Vision score (UCVA, BCVA) were stable at the 3 and 6 months visits. Topography/Keratometry was stable at 6 months in those that returned for topography/keratometry testing.

9. CONCLUSIONS Epithelium-on cornea collagen cross linking is a viable and successful treatment modality for stopping the progression of keratoconus. It is a more comfortable procedure than epithelium-off CXL, but is still quite uncomfortable. Using a Chayet sponge and peripheral conjunctival BSS wash can drastically reduce pain scales in almost all epithelium on Crosslinking cases, and potentially can reduce pain in epithelium-off procedures as well. Further data collection and investigation is underway to further compare treatment without the Chayet sponge vs. treatment with the Chayet sponge, and if the use of a soft-contact bandage can have a role in even further reducing the irritation and pain scores.