Treatment of Keratoconus with Corneal Cross-linking – Results and Complications in 2 Years Follow-up

Authors: E. Strmeňová 1,2;  E. Vlková 1;  L. Michalcová 1;  V. Trnková 1;  D. Dvořáková 1;  M. Goutaib 1;  J. Němec 1;  A. Gerinec 2
Authors‘ workplace: Oční klinika LFMU a FN Brno, prednostka prof. MUDr. Eva Vlková, CSc. 1;  Klinika Detskej oftalmológie, DFNsP Bratislava, prednosta prof. MUDr. Anton Gerinec, CSc. 2
Published in: Čes. a slov. Oftal., 71, 2015, No. 3, p. 158-168
Category: Original Article


The objective of the study was to assessment of changes of monitored parameters after CXL. Incidence of complications were assessed in the whole group and in groups of patients divided according to the selected criteria. Evaluated parameters were also relations between them and in time.

The 86 eyes of patients with progressive keratoconus who underwent CXL according to the Dresden protocol in the years 2007-2009 at the Ophthalmic clinic FN Brno Bohunice were included in this study.

There was observed significant increase of BCVA (letters – before CXL 42,30 ± 10,35, 1st year after CXL (1Y) 44,68 ± 10,04, p < 0,01, 2nd year after CXL (2Y) 44,44 ± 10,57, p < 0,01) and SE (-5,95 ± 3,98D, -5,27 ± 3,84D, p < 0,01, -4,94 ± 3,68D, p < 0,01), and decrease of maximum curvature of the cornea (MAX – before CXL 50,39 ± 4,17D, 1Y 49,46 ± 4,13D, p < 0,01, 2Y 49,42 ± 4,14D, p < 0,01). Change of ultrasound CCT, polymegatisms, pleomorfisms and corneal endothelial cell density was not significant.

The value of MAX is the most important parameter in estimating the effect of CXL.

The highest incidence of corneal opacity after CXL was observed in the eyes of patients with III. stage of keratoconus over 40 years old, carrying hard contact lenses and with biomikroskopic symptom of keratoconus on the cornea.

We found that corneal thickness measurement with Orbscan II and the mesurement of IOP with noncontact method is incorrect by patients after CXL.

Corneal cross-linking of the cornea is safe and effective procedure of stopping the progression of keratoconus in 97% of eyes in the period up to 2 years after CXL.

Key words:
keratoconus, corneal cross-linking, riboflavin, UVA irradiation, complications


1. Agrawal, V., B.: Corneal collagen cross-linking with riboflavin and ultraviolet – a light for keratoconus: results in Indian eyes.  Indian J Ophthalmol, 2009 Mar-Apr;57(2): 111–4.

2. Arora, R., Gupta, D., Goyal, J., L. et al.: Results of corneal collagen cross-linking in pediatric patients. J Refract Surg, 2012 Nov; 28(11): 759–62.

3. Asri, D., Touboul, D., Fournié, P. et al.: Corneal collagen crosslinking in progressive keratoconus: multicenter results from the French National Reference Center for Keratoconus. J Cataract Refract Surg, 2011; 37: 2137–2143.

4. Caporossi, A., Mazzotta, C., Baiocchi, S. et al.: Long-term results of riboflavin ultraviolet a corneal collagen cross-linking for keratoconus in Italy: the Siena eye cross study. Am J Ophthalmol, 2010; 149: 585–5935. Caporossi, A., Mazzotta, C., Baiocchi, S. et al.: Age-Related Long-Term Functional Results after Riboflavin UV A Corneal Cross-Linking. J Ophthalmol, 2011; 2011: 608041.

6. Coskunseven, E., Jankov, M., R 2nd, Hafezi, F.: Contralateral eye study of corneal collagen cross-linking with riboflavin and UVA irradiation in patients with keratoconus. J Refract Surg, 2009; 25: 371–376.

7. Eberwein, P., Auw-Hädrich, C., Birnbaum, F. et al.: Corneal melting after cross-linking and deep lamellar keratoplasty in a keratoconus patient. Klin Monbl Augenheilkd, 2008 Jan; 225(1): 96–8.

8. Elksheikh, A., Wang, D., Brown, M. et al.: Assessment of corneal biomechanicla properties and their variation with age. Curr Eye Res, 2007 Jan; 32(1):11.

9. Gokhale, N., S.: Corneal endothelial damage after collagen cross-linking treatment. Cornea 2011 Dec; 30(12): 1495–8.

10. Greenstein, S., A., Fry, K., L., Bhatt, J. et al.: Natural history of corneal haze after collagen crosslinking for keratoconus and corneal ectasia: Scheimpflug and biomicroscopic analysis. J Cataract Refract Surg, 2010 Dec; 36(12): 2105–14.

11. Hersh, P., S., Greenstein, S., A., Fry, K., L.: Corneal collagen crosslinking for keratoconus and corneal ectasia: One-year results. J Cataract Refract Surg, 2011 Jan; 37(1): 149–60.

12. Kankariya, V., P., Kymionis, G., D., Diakonis, V., F. et al.:.

Management of pediatric keratoconus – Evolving role of corneal collagen cross-linking: An update. Indian J Ophthalmol. Aug 2013; 61(8): 435–440.

13. Koller, T., Mrochen, M., Seiler, T.: Complication and failure rates after corneal crosslinking. J Cataract Refract Surg, 2009 Aug; 35(8): 1358–62.

14. Koller, T., Pajic, B., Vinciguerra, P.: Flattening of the cornea after collagen crosslinking for keratoconus. J Cataract Refract Surg, 2011 Aug; 37(8): 1488–92.

15. Koppen, C., Vryghem, J., C., Gobin, L. et al.: Keratitis and corneal scarring after UVA/riboflavin cross-linking for keratoconus. J Refract Surg, 2009 Sep; 25(9): S819–23.

16. Kymionis, G., D., Portaliou, D., M., Bouzoukis, D., I. et al.: Herpetic keratitis with iritis after corneal crosslinking with riboflavin and ultraviolet A for keratoconus. J Cataract Refract Surg, 2007 Nov; 33(11): 1982–4.

17. Mazzotta, C., Balestrazzi, A., Baiocchi, S. et al.: Stromal haze after combined riboflavin-UVA corneal collagen cross-linking in keratoconus: in vivo confocal microscopic evaluation. Clin Experiment Ophthalmol, 2007 Aug; 35(6): 580–2.

18. Meek, K., M., Hayes, S: Corneal cross-lining – a rewiew. Ophthalmic Physiol, Opt 2013, 33, 78–93.

19. O’Brart, D., P., S.: Corneal collagen cross-linking: A review. J Optom,(2014), in press.

20. Pérez-Santonja, J., J., Artola, A., Javaloy, J. et al.: Microbial keratitis after corneal collagen crosslinking. J Cataract Refract Surg, 2009 Jun; 35(6): 1138–40.

21. Pollhammer, M., Cursiefen, C.: Bacterial keratitis early after corneal crosslinking with riboflavin and ultraviolet-A. J Cataract Refract Surg, 2009 Mar; 35(3): 588–9.

22. Raiskup, F., Spoerl, E.: Corneal Crosslinking with Riboflavin and Ultraviolet A. Part II. Clinical Indications and Results. Ocul Surf,  2013 Apr; 11(2): 93–108.

23. Raiskup, F., Hoyer, A., Spoerl, E.: Permanent Corneal Haze After Ribofl avin- UVA-induced Cross-linking in Keratoconus. J Refract Surg, 2009 Sep; 25(9): S824–8.

24. Raiskup, F.: Crosslinking pomocou riboflavínu a UVA žiarenia pri ektatických degeneráciách rohovky. In Rozsíval et al. Trendy soudobé oftalmologie 5, 1. vydanie, Praha, Česká republika: Galen; 2008, pp 62–81.

25. Raiskup, F., Spoerl, E.: Corneal crosslinking with riboflavin and ultraviolet A. I. Principles. Ocul Surf, 2013 Apr;11(2): 65–74.

26. Raiskup-Wolf, F., Hoyer, A., Spoerl, E. et al.: Collagen crosslinking with riboflavin and ultraviolet-A light in keratoconus: long-term results. J Cataract Refract Surg, 2008; 34: 796–801.

27. Rama, P., Di Matteo, F., Matuska, S. et al.: Acanthamoeba keratitis with perforation after corneal crosslinking and bandage contact lens use. J Cataract Refract Surg, 2009 Apr; 35(4): 788–91.

28. Sady, C., Khosrof, S., Nagaraj, R.: Advanced Maillard reaction and crosslinking of corneal collagen in diabetes. Biochem Biophys Res Commun, 1995; 214: 793–7.

29. Seiler, T.,G., Schmidinger, G., Fischinger, I. et al.: Komplikationen der Vernetzung der Hornhaut. Ophthalmologe, 2013, 110(7): 639–644.

30. Sharma, A., Nottage, .J., M., Mirchia, K. et al.: Persistent corneal edema after collagen cross-linking for keratoconus. Am J Ophthalmol, 2012 Dec; 154(6): 922–926.e1.

31. Spoerl, E., Huhle, M., Seiler, T.: Induction of cross.links in cornela tissue. In: Exp Eye Res, 1998, 66, p. 97–103.

32. Vinciguerra, P., Albé, E., Frueh, B., E. et al.: Two-year corneal cross-linking results in patients younger than 18 years with documented progressive keratoconus. Am J Ophthalmol, 2012 Sep; 154(3): 520–6.

33. Vinciguerra, P., Albè, E., Trazza, S. et al.: Refractive, topographic, tomographic, and aberrometric analysis of keratoconic eyes undergoing corneal cross-linking. Ophthalmology, 2009 Mar; 116(3): 369–78.

34. Vlková, E., Loukotová, V., Hlinomazová Z. et al.: The dynamics of corneal topography and pachymetry after riboflavin-UVA corneal collagen crosslinking. In Book of abstract XXVI. Congress of the ESCRS. 2008.

35. Wittig-Silva, C., Chan, E., Islam, F. et al.: A randomized, controlled trial of corneal collagen cross-linking in progressive keratoconus: three-year results. Ophthalmology, 2014 Apr; 121(4): 812–21.

36. Wollensak, G., Spoerl, E., Seiler, T.: Stress–strain measurements of human and porcine corneas after riboflavin ⁄ ultraviolet- A-induced cross-linking. J Cataract Refract Surg, 2003 Sep; 29(9): 1780–5.

37. Wollensak, G., Spoerl, E., Seiler, T.: Riboflavin/Ultraviolet-A-induced collagen crosslinking for the treatment of keratococnus. Am J Ophthalmol, 2003; 135: 620–627.

38. Yuksel, N., Bilgihan, K., Hondur, A., M.: Herpetic keratitis after corneal collagen cross-linking with riboflavin and ultraviolet-A for progressive keratoconus. Int Ophthalmol, 2011 Dec; 31(6): 513–5.

39. Zamora, K., V., Males, J., J.: Polymicrobial Keratitis After a Collagen Cross-Linking Procedure With Postoperative Use of a Contact Lens: A Case Report. Cornea, 2009 May; 28(4): 474-6.

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