UK Keratoconus Self-Help and Support Association

I have just found the following article on Lynn White's website which talks about a modified CXL treatment offered by David Jory.
http://www.lwvc.co.uk/index.php?option= ... &Itemid=99. I look forward to following her blog and seeing how her patient Mark progresses since having the precedure.



Femto-Pocket CXL
Patient Blog Patient Clinical Follow Up

PROCEDURE

This new technique, performed by Mr David Jory, allows the epithelial layer to be kept intact but delivers the Riboflavin solution to the area it is needed. It is therefore an “epi-on” CXL procedure.ornea with a femtosecond laser as w

Riboflavin is injected directly into the pocket and then irradiated with the UV crosslinking machine for 30 minutes, while saline and Riboflavine are applied regularly in the normal way.

By effectively thickening the cornea with a bolus of riboflavin the treatment gets the energy to where it is needed ie the anterior half of the cornea.
Why do this procedure?
Although “Epi off” has a proven track record of effectivity, for some people it can result in several weeks of fluctuating vision as the cornea settles. This “epi on” system means the corneal surface is not affected and the small incisions created by the femtosecond laser heal very quickly. There is consequently less risk of post operative infection and a much quicker healing time and less pain than the “epi-off” procedure. It may also reduce risk of further scarring from already damaged corneas.
What are the long terms benefits/side effects?
As with any new technique, there is not yet the evidence base to say this method has the same effect as normal “epi-off”. However, as the only real argument against “epi-on” CXL is the question of whether the Riboflavin sufficiently passes through the corneal surface barrier, this procedure does address that issue.

I am currently following up patient "Mark" regualry after having this procedure on the left eye and will post his progress on this page. Although this is not scientific evidence of the efficacy of this procedure, it is hoped that it will provide useful information to anyone considering it. He will undergo the same procedure on the right eye in December.hni,

PATIENT MARK
My patient, who I will call "Mark"had been diagnosed with keratoconus 13 years ago when I first saw him on July 6th 2011. He started wearing soft lesnes to correct vision and eventualy moived to rigid types. He had also tried Hybrid lenses but had developed neovascularisation.

When I saw him, he was wearing large diameter RGP lenses (Intra Limbals) which were a poor fit with central bearing touch and signifcant edge lift. He was now struggling to maintain any kind of reasonable wear time.

Visual Acuity in the contact lenses was:
Right Eye: 6/19 (20/63) Left Eye: 6/15 (20/50)

Spectacle Prescription:

Right Eye: -8.00/-1.50 x 10 VA 6/19 (20/63)

Left Eye: -11.00/-4.50 x 120 VA: 6/36 (20/125)

Initial Topgraphy

Keratography Left Eye Topography Left Eye



He was refitted into soft lenses, understanding that time was need for the corneas to return to normal shape. During this time the average visual acuity in both eyes was around 6/15. After a couple of months, he made the decision to have CXL in order to stabilise his condition. Even though he was now 30 and had the condition long enough for it to theorectically stabilise, he felt he could only have "peace of mind" if he knew his corneas were crosslinked.

However, corneal thickness was 392 microns and there was some deep scarring present and thus "epi-off" CXL was thought to have some risk. He also was worried as to whether hos cornea and prescription would keep fluctuating after the procedure, making work difficult. He was therefore interested in having this new procedure and understood that there are no long term studies that provide evidence for its long term efficacy.

Hi All,

Thanks dplees for your highlighting of this procedure.

I would just like to add a few points of interest.

The procedure was pioneered by Kanellopoulis in Greece. In many ways it makes sense, as in Riboflavin is delivered to the exact place where it is needed and the procedure is epi-on, which causes less disruption than epi off. The only reason for going epi off is to endure Riboflavin properly soaks through the cornea. Epi on should also reduce the risk of further scarring in already scarred corneas.

However, it has to be said, that as far as knowing long term effects of this particular variation, the clock has to be set back to zero, as there are no long term follow ups of people undergoing this procedure.

My motive for putting this online is to try and give as much info as possible as to what happens post op and I will hopefully be updating this weekend.

Lynn

Lynn,

Do you have any updates on how your Femto-Pocket patient is doing?

Thanks

dplees

Hi

Yes, I have just updated the clinical progress page.

He had a period of time when the eye became inflamed and showed signs of allergy. After much investigation, we found there was a connection to contact lens solutions and the fact it always happened after travelling in a colleagues car with the heater blowing towards the eye. This has all now resolved.

The follow ups have now been updated to the 28th December. Due to the inflammatory incident, the operation on the other eye has been delayed until the new Year.

What is interesting is that although at one point, the refraction had come down to almost nothing, it has now fluctuated again and gone back up. This sort of thing is entirely normal post CXL and it is important that people do not become over excited at an apparent "improvement" and then be depressed because it goes back up again.

Lynn

Hi Lynn, its been a good read, never knew you had a website, its very informative:thumbsup:

Is there any more updates or progress reports on 'Marks' condition?

Hi Ttuf...

Yes, I saw him this weekend and have now updated the clinical details.

Vision is now settling and refraction has returned to that of a month or so ago.

Lynn

Very good read as always, excellent results so far!!Pretty much identicle outcome to normal c3r surgery, but with slightly quicker healing time and less scarring.

Its interesting about the aerosol/deodorant issue 'Mark' was having. I have found a similar issue with air fresheners, when ever its sprayed in the house my eyes irritate, so i kind of only use/spray them if im heading out or something. Same even in my car!! The magic tree thing hanging down. On hot days when its giving out more smell/fragrance, i have always noticed eyes feel very very irritated, on cooler days when you cant smell it much eyes/CL (RGP) been fine. So people having similar issues, its worth ripping the magic tree off that rear view mirror and launch it through the window (not literally, just bin it)
Also pollen filters fitted in cars are worth changing aswell, if they are blocked/full of dust, that doesnt help much either, if you are doing alot of motorway miles like i do, every little helps to make your journey that little bit better.

Hi Ttuf

You know, I was wondering if there was a little "tree" in his colleagues car, as you will note he also got inflammation when travelling.

The idea of this kind of surgery is to do CXL epi on in cases where the cornea is already very thin or scarred (epi off being too risky) and to really ensure that Riboflavin is where it is meant to be in sufficient concentrations . Where I think it does differ a little bit is that the pooling of Riboflavin within the cornea temporarily causes a power change/fluctuation, as it acts like a liquid lens in the eye.

I sent Mark through the updated toric lens for the left eye and he texted today to say vision is excellent, so fingers crossed on stability now. Thing is, of course, you can't go back and do this all over again with epi off and see if it had been any different. I also think the whole inflammation issue with the deodorant has been a diversion we could have done without

Lynn

Further updates on this procedure:

Mark is still doing well and his prescription and vision is stable and still maintaining better visual acuity than before the operation. He is due for the same op on the better eye in March.

I saw the second patient to have this procedure today. His situation was that he was turned away for normal cross linking in his Right eye due to severity of the keratoconus and reduced corneal thickness. With no other alternative, this eye was deteriorating fast and unable to wear any contact lens successfully. The left eye was passed as OK for normal epi off and he had this procedure done 3 weeks ago.

Two months ago, he underwent femto pocket CXL in the right eye and I saw him for the first time today for a contact lens assessment. He achieved 6/12 with spectacles and a sharp 6/12+ with a normal soft toric lens. This is better than the patient expected.

There is some corneal haze, entirely in line with that expected after CXL.

I am entirely pleased with this result, as is the patient. In fact, the patient was surprised that the right eye was actually better than the left (which is undergoing RGP demoulding as well as CXL effects).

I will try and upload topographies this weekend and the patient has given permission for me to continue with follow up on the website.

So, this procedure is definitely showing promise but obviously, all the caveats I have given about ANY procedure still hold. It is not a procedure that I would recommend if your eye is un-scarred or of reasonable thickness. However, it is definitely of interest if you have been rejected for normal cross linking.

Lynn