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Corneal Collagen Cross-Linking

Corneal Cross-Linking (CXL) is a treatment to prevent keratoconus getting worse. It is successful in over 90% of cases. After treatment, spectacles or contact lenses will still be needed. Although vision is often hazy at first, most patients can resume contact lens wear and return to work within 2 weeks. As with all operations there are risks: CXL is safe, but there is a small chance (about 1 in 30) of worse vision afterwards and the eye is sore for 1 week after treatment.

What is CXL?

Keratoconus progresses because the cornea weakens. CXL (also known as C3R) using ultraviolet light and vitamin B2 (riboflavin) drops to stiffen the cornea. Used together they cause fibers within the cornea to bond more tightly (‘cross-links’). This treatment mimics the normal age-related stiffening of the cornea (natural cross-linking).

Which patients benefit from CXL?

The treatment is currently available for patients whose corneal shape scans show that their keratoconus is getting worse. Because of natural cross-linking, keratoconus normally stops getting worse by the mid-thirties and CXL is not normally required for older patients.

What evidence is there that it works?

Collagen cross-linking is the only treatment currently available which appears to stop progression of keratoconus. To date, there have been 3 randomised clinical trials on CXL, and the one with the longest follow-up (3 years) is an Australian study. These trials have shown success in halting keratoconus progression in 97% of treated eyes; with over 45% of eyes also gaining an improvement in corneal shape. Vision is better after treatment than before in about 50% of eyes treated with CXL

What happens during CXL?

CXL is performed as a day-case procedure. Although the procedure takes less than an hour, there is usually some waiting time before treatment and some further time is required for discharge instructions. So be prepared to spend up to half a day at the Day Surgery.

Anaesthetic drops are used to completely numb the surface of the eye before a small clip is placed to keep the eyelids open. The surface skin of the eye (epithelium) is gently brushed clear and riboflavin drops are applied every few minutes for 30 minutes. Following this, the ultraviolet light is shone at the eye for 30 minutes. A soft ‘bandage’ contact lens is placed on the eye at the end of procedure.

What happens after CXL?

You will be given eye drops to use after the procedure. The soft contact lens will remain in your eye until the surface has healed (usually 5 to 7 days). After the anaesthetic drops wear off later that day, the eye will be gritty, red and sensitive to light for several days afterwards. Everyone’s experience of pain is different, with some patients reporting very little discomfort and others describing the first few days as very uncomfortable. The eyes may be light sensitive and many patients find sunglasses helpful. Your vision will be quite blurred at first, but will clear gradually over the first few weeks.

What are the risks of CXL?

In general, CXL is very safe, but like all operations, the body needs time to heal and problems do occasionally occur. It is very important that you take your eye drops as prescribed to minimise any risk of infection or corneal haze after the procedure.

Without CXL treatment, at least 20% of all patients with keratoconus will eventually require a corneal transplant.

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Dr Dana Robaei - Sydney Ophthalmologist

Dr Dana Robaei

Ophthalmic Surgeon MBBS(Hons) BSc(med) MPH PhD FRANZCO

Dr Dana Robaei is a consultant ophthalmic surgeon, with fellowship training in Cataract Surgery and Corneal Transplantation from Moorfields Eye Hospital, and Medical Retina from Sydney Eye Hospital.

She has extensively published in the national and international ophthalmic literature, and presented at international ophthalmology conferences.

She specialises in Cataract Surgery, Pterygium Surgery, Macular Degeneration and all aspects of comprehensive ophthalmology.

Dr Robaei is committed to clinical and surgical excellence, with the aim of providing the highest possible standard of care based on the latest available evidence, in combination with effective communication to patients and their referrers.

Professional Qualifications

  • Graduated from UNSW with Honours, Bachelor of Medicine, Bachelor of Surgery
  • Master of Public Health, UNSW
  • PhD in medicine (Visual impairment in Australian School Children)
  • Advances specialty training in ophthalmology and ophthalmic surgery at Sydney Eye Hospital
  • Subspecialty fellowship training in cataract surgery and corneal transplantation at Moorfields Eye Hospital, London UK
  • Clinical Senior Lecturer in ophthalmology, University of Sydney
  • Consultant Ophthalmologist, Westmead Hospital
  • Director of Forest Eye Surgery, Frenchs Forest