Holcomb C3-R®/CXL (Epi-off)

Cornea Collagen Crosslinking with Riboflavin

Stabilize Your Keratoconus and Preserve Your Vision

Ever since keratoconus was first described by Burchard Mauchart in 1748, eye doctors had no means to stop the progression of this disease. When patients would ask their eye doctors, “Is there anything that can stop this from getting worse?” often the answer was, “We do not even know what causes keratoconus.” Some patients were told by their eye doctors the only option was hard contacts and then eventual cornea transplant. Mainly patients just had to suffer as their keratoconus progressed and vision continued to deteriorate.

Since mid-1990’s there has been a surge in research which have led to the evolution of quick, easy, and effective treatments that can save patients from deteriorating eyesight. There are many modern treatments that can treat keratoconus, improve vision and restore lives of people with keratoconus; among these revolutionary treatments is Cornea Collagen Crosslinking with Riboflavin.

Corneal collagen crosslinking with riboflavin (also known as Holcomb C3-R® or CXL) has quickly become recognized by many pioneers in the field that this is the first and only proven method that preserves vision and prevents further loss of eyesight by halting/slowing corneal steepening. Studies show increased corneal strength cornea collagen crosslinking with riboflavin by stress-strain measurements, thermal studies, and enzyme digestion studies. In pig corneas, an increase of up to 71.9% in corneal strength was reported across the entire cornea. The change in donated human corneas was even more dramatic with a 328.9% increase corneal strength. In time, ophthalmic historians will likely consider Cornea collagen crosslinking with riboflavin to be among the revolutionary treatment for this disease.

Two techniques have been available for this treatment. The first technique developed by Gregor Wollensak, MD of Germany, is referred to as “Epi-Off” crosslinking. This technique is considered invasive since the surface skin layer (epithelium) is removed. While initial studies in Germany primarily performed by Gregor Wollensak, MD in the 1990’s only evaluated this “Epi-Off” technique, in recent years “epi-off” technique has been debated as since there are greater risks. The risks with the “epi-off” technique include infection, cornea haze, pain during healing, light sensitivity during healing, and delay of use of contacts for two weeks or more after treatment.

“Epi-off” is a 30 minute procedure and one eye is treated at a time. During the procedure, numbing drops are used to numb the eye, the outer layer of the cornea called ‘epithelium’ is scraped off using surgical instruments and riboflavin in allowed to soak into the cornea. A low-dose of ultraviolet light (UVA) is applied to the cornea for 30 minutes. During that that time, riboflavin is applied to the corneas every 3 minutes. The light reacts with the riboflavin to make the cornea stronger.

Photo documenting riboflavin (yellow) in the cornea with epithelium left in place.

After “Epi-Off” crosslinking patients may experience moderate to severe pain and scratchiness for up to 1 week. Typically the vision can be hazy for 1 to 12 weeks after the procedure. Some patients report mild to moderate light sensitivity for the first month. Since the epithelium is removed a course of antibiotic and steroid eye drops will be used to assist with healing. Depending on each individual healing response patients will use these eye drops from 1-4 weeks after the procedure. Patients can expect to resume daily routine, such as driving and going to work once the epithelium heals, usually 4-10 days. Contact lenses can be resumed 1-12 weeks after the procedure.

Brian S. Boxer Wachler, MD, invented a second, non-invasive technique in 2003 (which was the first technique ever performed in the United States) and is referred to as “Epi-On” crosslinking and goes by the name Holcomb C3-R® (named in honor of Olympic gold medal bobsledder Steve Holcomb). The procedure is considered non-invasive since the surface skin layer (epithelium) is not removed. Multiple studies have shown that riboflavin can penetrate the cornea without removing the epithelium (please see above photo).

“Epi-On” is a painless 30 minute procedure. Both eyes can be treated at the same time if both eyes require treatment. During the procedure, numbing drops are used to numb the eye and a proprietary crosslinking solution is allowed to soak into the cornea. A low-dose of ultraviolet light (UVA) is applied to the cornea for 30 minutes. During that that time, the special crosslining solution will penetrate through the undisturbed epithelium. The light reacts with the crosslinking solution to make the cornea stronger.

After “Epi-On” crosslinking patients may experience some mild “foreign body sensation” and haziness in the vision for the remainder of the day, which is cleared up by the next morning. Pain does not occur with the “epi-on” technique, because the epithelium is left in place undisturbed.  The day after the procedure, patients can expect to resume daily routine, such as driving, going to work, and even re-inserting contacts that very next day.

Cornea Collagen Crosslinking appears to represent one of the most important advances in ophthalmology in the last decade. The laboratory and clinical studies indicate a safe, effective, and elegant treatment for keratoconus.

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