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CXL adoption involves planning, training, professional rewards


Treatment slows or halts the progression of keratoconus, corneal ectasia

Corneal collagen crosslinking can be done as an in-office procedure. One clinician describes the process and the logistics.

Reviewed by Kathryn M. Hatch, MD

Office implementation of corneal collagen crosslinking (CXL) requires space and a full staff effort, but it does not compromise practice efficiency and is worthwhile due to its benefits of preserving vision in patients, said Kathryn M. Hatch, MD.

Dr. Hatch has been involved with CXL since 2011 as a clinical trial investigator and has been performing it in her practice since its commercial launch in 2016. She is director, Refractive Surgery Service, Massachusetts Eye and Ear, assistant professor of ophthalmology, Harvard Medical School, Boston.

“CXL is the only treatment available that is able to slow or halt the progression of keratoconus, and corneal ectasia following refractive surgery,” she said.


CXL is performed in a clean room and can be done as an in-office procedure, but the practice needs to have a room available where the patient can undergo the riboflavin loading procedure (riboflavin 5’-phosphate in 20% dextran ophthalmic solution, Photrexa Viscous; riboflavin 5’-phosphate ophthalmic solution, Photrexa T; both from Avedro), and the light treatment (KXL System, Avedro).

Dr. Hatch emphasized the need for an educated support staff to assist with patient scheduling, counseling, care, and reimbursement. She advised designating one staffer as a “CXL champion” to serve as the administrative expert and handle scheduling. The staff member can talk to patients preoperatively, reviewing the steps, and obtaining informed consent.

Dr. Hatch suggested having at least two technicians who are trained to administer the riboflavin, comfortable staying with the patient during the light treatment, and able to review the details about postoperative care.

“I explain to patients that I am in charge of their care, but that they will see me during key steps of their procedure,” she said. “It is important to provide that information because some patients expect that the ophthalmologist will be with them throughout.”

On the day of the procedure, patients are given oral lorazepam when they arrive, about 40 minutes prior to surgery.

RELATED: When to consider corneal cross-linking treatmentAfter epithelial preparation and instillation of the riboflavin solution is completed, Dr. Hatch checks that the loading is adequate, measures the pachymetry, and begins the light treatment. After the irradiation is done, she returns to see the patient, answer any questions, and discharges the patient.

Postoperative management

The follow-up schedule for patients who have undergone CXL includes a return visit at 1 day and about a week after the procedure. Thereafter, patients are seen at 4 to 6 weeks post-CXL, after 3 to 4 months, and after 6 to 9 months. Younger patients, however, are seen more regularly in the first years because they are at high risk for keratoconus progression. Dr. Hatch added that collaboration is needed with diagnosing providers, who can refer patients for CXL and set postop expectations.


Insurance coverage for CXL has come a long way since 2016. As of April 2019, the procedure was covered by six national and 59 regional health plans, which encompass more than 95% of commercial lives. In 29 states, CXL is covered by eight or more plans.

With the availability of the Avedro Reimbursement Custom Hub (ARCH) patient assistance program, cost should not be a barrier to any patient getting treated with CXL. Offices enrolled in ARCH can call a hotline for help with predetermination and appeals processes, and they have access to field-based reimbursement specialists.

If an insurance claim is denied, ARCH will continue to appeal the claim for up to 6 months, and if coverage is still denied, the office receives a credit from Avedro for the riboflavin. Through its indigent program, ARCH also covers the cost of the riboflavin treatment for patients who have Medicaid.

RELATED: Securing reimbursement for CXL


Kathryn M. Hatch, MD
E: kathryn_hatch@meei.harvard.edu
Dr. Hatch is a consultant to Avedro.

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