Cross Linking

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

What is CXL?

Keratoconus gets worse because the cornea weakens. CXL, also known as C3R, uses ultraviolet light and vitamin B2 (riboflavin) drops to stiffen the cornea. Used together, they cause fibers within the cornea to cross-link – or bond more tightly. This treatment mimics the normal age-related stiffening of the cornea, which is known as natural cross-linking

Which patients benefit from CXL?

The treatment is usually recommended only for patients whose corneal shape scans show that their keratoconus is getting worse. In order to obtain the most accurate scans, we ask that you remove your contact lenses prior to your scan (2 weeks for RGPs, 1 week soft contact lenses).

If you are unable to manage without your lenses, treatment may still be available. In this situation, so long as the cornea is not too thin, treatment may be offered based on your individual estimated risk of disease progression. Age is the most important factor in determining this risk: because of natural cross-linking as you get older, keratoconus usually stops getting worse by the mid-30s, so CXL is not normally required for older patients.

Will I have both eyes treated at the same time?

If you need CXL for both eyes, we can offer you treatment for both eyes at the same time. If you would prefer to delay the second eye treatment, please request this at the clinic appointment prior to your treatment.

What happens during CXL?

CXL is performed as a day-case procedure by a senior ophthalmic nurse. Although the procedure takes 30-45 minutes, there is usually some waiting time before treatment and you will also need to stay for a short while afterwards so we can check that you have everything you need to go home. Please be prepared to spend up to half a day in hospital.

You will be asked to lie flat on the treatment table. Anaesthetic drops are used to numb the surface of your eye before a small clip is placed to keep your eyelids open. The surface skin of your eye (epithelium) is gently brushed clear and riboflavin drops are applied every few minutes for at least 10 minutes. Following this, the ultraviolet light is shone at your eye for eight minutes. A soft ‘bandage’ contact lens is placed on your eye at the end of the procedure.

What happens after CXL?

You will be given eye drops to use after the procedure. The soft ‘bandage’ contact lens will remain in your eye until the surface has healed (about seven days). If the bandage lens falls out during this time, please throw it away – do not attempt to reinsert it.

The anaesthetic drops will wear off later on the day of your procedure, and your eye will be gritty, red and sensitive to light for several days. Everyone’s experience of pain is different, with some patients reporting very little discomfort and others describing the first few days as very painful. Your eyes could 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.

It is normal to experience fluctuating pain within the first two days after surgery. However, if you experience increasing pain three or four days after the procedure this could be indicative of infection and you should visit your eye doctor. Please note that infection is rare, affecting fewer than 1% of patients.

Do I need to take time off work or studies?

Yes. You should allow at least one week off while most of the surface healing occurs, or two weeks if your job involves a lot of computer work, and the treatment is being done on your best eye. You will be putting eye drops in every hour for the first day, and then every four hours for the following days.

Day to day activities such as watching TV or using a computer will not do any damage to your eye, but you might find it more comfortable to rest with your eyes closed early on.

You will be given an appointment the following week to check your eye is healing properly.

What should I do, or not do, after CXL?

It is important to put the eye drops in regularly as prescribed. Wash and shower normally, but try to avoid getting water in your eyes. You may exercise, but should not swim before the surface of your eye has healed.

We will check your vision in the clinic the week after your procedure to confirm if your vision is good enough to drive. It is normally safe to resume contact lens wear once the eye surface skin layer has healed. This typically happens around the end of the second week after your procedure. If you use spectacles, you are advised to see you own local optician no earlier than 1 month after the treatment if you feel your prescription needs updating.

Vision and spectacle tests, along with corneal shape scans will be repeated in the clinic 6 months after CXL.

What are the risks of CXL?

In general, CXL is very safe, but like all operations your eye needs time to heal and problems do occasionally occur. About 3% of patients will lose some vision in the treated eye as a result of haze, scarring, corneal surface shape irregularity or infection. In most cases, this visual loss is potentially reversible with a corneal transplant. Without CXL treatment, at least 20% of all patients with keratoconus will eventually require a corneal transplant. The risk of transplantation for patients with documented disease progression is probably higher.

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