EyeWorld India March 2014 Issue

44 EWAP CORNEA March 2014 Cornea well soaked by riboflavin solution during CXL procedure with UV-X 2000 device Source: Frederik Raiskup, MD Postoperative management of corneal crosslinking patients by Frederik Raiskup, MD, PhD, FEBO An essential component of the success of the procedure T he success of any surgical intervention depends as much on postoperative care and management as it does on the surgical procedure itself. This undoubtedly also holds true for corneal crosslinking. At our hospital, we have been performing corneal crosslinking with the IROC illumination system (IROC Innocross, Zug, Switzerland) since the development of the first prototype and continue to use the latest UV-X 2000 crosslinking device. Through my experience with this system, I have come to understand that careful management of ocular surface health after surgery is essential for the successful and rapid visual rehabilitation of the patient and to minimize complications. Patient counseling is also equally important to prepare the patient for the potential side effects of the procedure and ensure that he/she is receptive to the postoperative management protocol and any interventions that may be necessary in case of side effects and eventual complications. The essentials of postoperative management The focus of postoperative management after corneal crosslinking is to restore a healthy ocular surface as quickly as possible. There are three main aspects to post-crosslinking patient management: 1) hastening re- continued on page 46 epithelialization, 2) preventing infection, and 3) reducing pain. The first of these, re-epithelialization, is the most important. The current crosslinking standard protocol requires de-epithelialization of the cornea before the administration of riboflavin solution. This is done in order to ensure that a sufficient amount of riboflavin enters the stroma. Therefore, it is important to restore this protective barrier of the ocular surface as quickly as possible after surgery. This not only helps to improve the patient’s comfort and visual acuity more rapidly after surgery, but it also reduces the risk of infection. The epithelial layer serves to protect the cornea from micro-organisms and other environmental factors that could damage the stroma. Even small lesions in the epithelium can increase the risk of infection or melting, the consequences of which can be serious. There have been reports in the literature of microbial keratitis and stromal melting leading to the development of deep stromal scars and loss of visual acuity postoperatively, or in the worst cases, corneal perforation necessitating a corneal graft. Therefore, controlling infection after crosslinking is a priority. Pain management is also an important aspect of postoperative management that ensures patient’s comfort. De-epithelialization of the cornea, a densely innervated and hence very sensitive tissue, causes some amount of pain. However, proper counselling of patients about the level of pain that can be expected after surgery and the use of common analgesics is an effective strategy to control pain. Postoperative management protocol We use a standard protocol in our department for the postoperative management of all corneal crosslinking patients. Soon after surgery, all patients receive a soft contact lens. The function of this lens is two-fold. First, it supports epithelialization, and second, it reduces pain. We