Reviewed by A. John Kanellopoulos, MD
Surgeons who may perform a variety of cataract-refractive procedures may recognize corneal crosslinking (CXL) as the gold standard for halting progression in eyes with keratoconus or post-LASIK ectasia, but there are multiple indications for using CXL in a combination regimen, according to A. John Kanellopoulos, MD.
“Looking beyond ectasia stabilization to visual rehabilitation, adding a procedure to CXL can improve visual function to offer patients a normal lifestyle,” said Dr. Kanellopoulos, clinical professor of ophthalmology, NYU Langone Medical Center, New York, and Medical Director, Laservision.gr Institute, Athens, Greece.
“In addition, CXL can be added to LASIK as a biomechanical modulator and used with antibiotics to treat infectious keratitis.”
The Athens Protocol
The Athens Protocol—involving same-day, sequential CXL and topographyguided partial PRK—was developed by Dr. Kanellopoulos and is his preferred combination approach for addressing visual rehabilitation needs in patients being treated with CXL for corneal ectasia.
“CXL can also be combined with intrastromal corneal ring segments, but I abandoned that approach because of variable refractive results and long-term problems with corneal melting and ring extrusion,” he said. “Implanting a phakic IOL after CXL appears to be a safe and effective approach to address high residual myopia and/or anisometropia after stabilization with CXL alone or the Athens Protocol.”
Not all patients are candidates for the Athens Protocol. First, confirm that the patient has progressive keratoconus and not just an epithelial anomaly or worsening corneal edema. In addition, patients whose disease treatment must have failed other options for facilitating visual function, have sufficient residual stroma to allow safe ablation, and understand that unlike with PRK in a conventional refractive surgery patient, the goals of the procedure are not to achieve emmetropia and provide 20/15 or 20/20 uncorrected vision.
A. John Kanellopoulos, MD
E: [email protected]
This article was adapted from Dr. Kanellopoulos’ presentation at the 2018 meeting of the American Academy of Ophthalmology. Dr. Kanellopoulos is a consultant for AJKMD Events, Alcon Laboratories, Allergan, ARC Laser, Avedro, Carl Zeiss Meditec, i-Optics, IPS Surgical, Keramed, Optovue, and Orca.