https://www.reviewofophthalmology.

com/article/when-corneal-crosslinking-goes-bad

Delayed Re-epithelialization

In cases of epithelium-off cross-linking, which many surgeons currently use due to its
effectiveness, one of the chief complications to be wary of is a delay in re-
epithelialization, since this leaves the cornea open to other problems.
“The most common complication I’ve had is delayed re-epithelialization, occurring in
2 to 5 percent of cases,” says Singapore surgeon Jerry Tan. “The delay can go as long
as two weeks. To avoid it, you have to get the epithelium to heal quickly. For this I use
autologous serum and a bandage contact lens. I also keep the eye as moist as
possible postop, which means lots of artificial tears.”

Miami surgeon William Trattler says he’s noticed risk factors for delayed healing. “They
include very steep corneas, as well as patients with steep corneas in whom you place a
bandage contact lens,” he says. “What can occur is the bandage lens can rub the apex
of the cornea and prevent the epithelium from healing. In such cases, remove the
contact lens and consider using a ProKera [corneal bandage device].”

Corneal Haze

As in many postop situations, complications can be interrelated, and this appears to be the
case with corneal haze and re-epithelialization. “Haze is also related to a delay in epithelial
recovery,” says Jorge Alio, MD, of Alicante, Spain. “Most of the cases I’ve seen with this
complication are patients in whom the epithelium takes time to recover. This extra time
increases the wound healing and this wound healing results in a haze that can take many
months to resolve.”
Surgeons say managing corneal haze after cross-linking is similar to dealing with post-
PRK haze. “Treat it with a topical steroid such as FML or loteprednol, one drop four or
six times per day until the recovery is evident,” says Dr. Alio. “Then, decrease the dose
with time. The patient should also wear sunglasses whenever he’s outside, especially if
he lives in a sunny region, because haze increases with sun exposure”

Corneal scarring, which occurred in 2.8 percent of epi-off cross-linking patients in one
prospective study, can be a result of dense haze.1 “If a scar is more peripheral, the
patient can still have good vision,” says Dr. Luchs. “If the scar is causing some irregular
astigmatism, which keratoconus patients have already, the patient may see well as
long as the opacity isn’t in the center of vision. He can often get good vision with the
use of a rigid contact lens or a scleral lens. However, if a scar is dense and large
enough, and interferes with the line of sight, the surgeon’s only recourse may be a
corneal transplant.”
Inflammation
Surgeons say opening up the epithelium also leaves the eye vulnerable to sterile
inflammatory infiltrates as well as the rare case of infection.
Corneal cross-linking can trigger a reactivation of herpes simplex virus, and some
surgeons consider a history of HSV a contraindication to cross-linking
Endothelial Issues