26 EyeWorld Asia-Pacific | March 2025 REFRACTIVE SURGERY Crosslinking to stop the progression of keratoconus and post-surgical ectasia has undergone an evolution both in the U.S., where it was first approved in 2016, and outside the U.S., where it has been in use significantly longer. With new techniques in (or having recently completed) Phase 3 clinical trials to potentially move crosslinking to the next stage in the U.S., EyeWorld spoke with specialists to take a look back at where keratoconus monitoring and treatment was, where it is now, and what could be coming in the future. Then: Transplants Prior to crosslinking becoming available in the U.S., there was no treatment for keratoconus patients until they needed corneal transplants. “Documenting progression was important back then but for different reasons. Back in the day, there was nothing in the U.S. approved to stop progression,” said Kenneth Beckman, MD. “There were things to give you better vision in the moment, such as intrastromal cornea rings. Prior to crosslinking, patients basically lived with glasses and contacts until they needed a transplant. For as long as you could keep them functioning in a contact, you didn’t do the transplant. That was the previous strategy.” The tools to diagnose and monitor were not as sophisticated as they are now. Dr. Beckman said all that was available was topography (which was not as good as today’s technology), clinical signs (such as thinning or the Munson’s sign), or significant refractive changes. Roy Rubinfeld, MD, said keratoconus management was “pretty primitive” back then. “You would hope they wouldn’t get worse, and hope is not a medical plan,” he said. by Liz Hillman, Editorial Co-Director Crosslinking: Then, Now, And Next Up Now: Epithelium Off In 2016, the FDA approved the Avedro crosslinking system—a combination of riboflavin loading on the cornea from which the epithelium had been removed followed by continuous UV light exposure for 30 minutes—for treatment of documented progressive keratoconus. Glaukos acquired Avedro in 2019. iLink—Photrexa Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) and Photrexa (riboflavin 5’-phosphate ophthalmic solution) for use with the KXL System—remains the only FDA-approved crosslinking system in the U.S. Since this became available, alongside significantly improved diagnostics, many changes have occurred in keratoconus management. New corneal imaging systems (topography and tomography), Dr. Beckman Severe keratoconus with scarring. Source: Kenneth Beckman, MD This is a patient undergoing crosslinking with the Glaukos UV light technology. The riboflavin in the cornea fluoresces with the UV light treatment. Source: William Trattler, MD
RkJQdWJsaXNoZXIy Njk2NTg0