CXL Unbound

Sometimes, the sheer scale of an unmet need can surprise you. For many years, keratoconus was thought of as a rare disease: in 1986, a paper reported that 1 in 2000 people in Olmstead County, Minnesota, had keratoconus. And that figure stuck for at least 30 years. But modern diagnostics revealed a different story. Keratoconus rates are higher – and vary by continent and climate. And that’s why efforts like the K-MAP global keratoconus prevalence study are so important; accurate data reveals the true unmet need.

Can we improve how we treat keratoconus? It’s worth recognizing the work of Brillouin biomechanics researchers, such as J. Bradley Randleman and Giuliano Scarcelli, who are leading the way with accurate in vivo clinical assessments of corneal biomechanics. Their work dovetails perfectly with the efforts of others, such as Cosimo Mazzotta, who are trying to develop new “epi-on” CXL approaches that we hope someday will be as effective at stiffening the cornea as the current gold-standard: “epi-off” CXL. Education is vital too; I’d like to show appreciation for the dedication and leadership in training surgeons to perform best-practice CXL: José Álvaro Gomez, Nikica Gabrić, Adrian Lukenda, Qinmei Wang, Shihao Chen, Khaled Ayesh, Bojan Pajic, Gerd Geerling, Reza Dana, Oliver Findl, Heinrich Gerding, Mohammed Shafik Shaheen, Mouhcine El Bakkali, Anssi Poussu, Kamoun Heykel, Mahfoudi El Hadi, and Rohit Shetty.

But this all for nothing, if people aren’t screened, identified, and able to access treatment. The biggest barrier? CXL is performed in an operating room. Certainly, operating rooms have the advantage of being sterile, but they are also costly and typically found only in primary care centers. What happens if you live in a rural area of a developing country and suffer progressive keratoconus but either cannot reach the hospital or cannot afford treatment?

We know that CXL renders the cornea sterile – so why perform the procedure in the OR? Why not treat at the humble slit lamp – found in every ophthalmologist’s office? Now that a slit lamp cross-linking device is available, CXL can be performed almost anywhere, reducing the cost of treatment for patients. I view this as democratization of CXL.

CXL might yet be surpassed. A better basic understanding of the cornea – from the level of the gene upwards – could reveal new therapeutic avenues and better fulfil our patients’ unmet needs. But, in the meantime, knowing we’re able to do more – for less – means a lot.