AAO 2024: Risk factors for complications of epithelium-off cross-linking

In her presentation at the 2024 American Academy of Ophthalmology meeting held October 18 to 21 in Chicago, Weijie Violet Lin, MD, highlighted the outcomes from a study on risk factors for complications of epithelium-off cross-linking that she performed while a completing a cornea fellowship at Wills Eye Hospital in Philadelphia, Pennsylvania.

The study involved a historical chart review of cross-linking records dating back to January 2018. The findings were encouraging, revealing post-cross-linking complications occurring in only 3% to 4% of cases. Key risk factors identified included preoperative corneal scarring and the use of general anesthesia, both significantly linked to persistent epithelial defects. Lin emphasized the importance of early identification and management of complications through strict postoperative monitoring, particularly for patients exhibiting these risk factors, to improve long-term outcomes.

Lin, who is now assistant professor of ophthalmology at Weill Cornell Medicine in New York, New York, shares some of the key takeaways with Ophthalmology Times.

Video Transcript:

Editor’s note: The below transcript has been lightly edited for clarity.

Weijie Violet Lin, MD:

Hello, my name is Violet Lin, and I’m presenting at AAO on a study that I performed at Wills Eye Hospital on risk factors for complications of epithelium-off cross-linking. This was done using a historical chart review of all the cross-linking records that were built at Wills Eye Hospital starting in January 2018. Overall, we found that post-cross-linking complications were fairly low, which is encouraging, about 3% to 4% for persistent epithelial defect and the development of corneal infiltrates. In our multivariate analysis we found that preoperative corneal scarring and the use of general anesthesia was significantly associated with the development of persistent epithelial defects, and that thinner preop pachymetry and younger age was significantly associated with the development of corneal haze afterwards. Luckily, no socioeconomic or clinical demographic factors were associated with the development of any cross-linking complications. We hope that this study will have findings that can benefit post-cross-linking monitoring to reduce the incidence of these kinds of complications.

In our study and other studies as well, the existence of allergy conditions such as...asthma, seasonal allergies even are associated with the development of complications, as well as certain systemic medical conditions that may make it harder for the patient to stay still or predispose them to more eye rubbing.

How do the different techniques of corneal cross-linking (eg, epithelium-off vs epithelium-on) impact the risk of complications?

In our study, we only looked at epithelium-off cross-linking. Our hope is that maybe further research into epi-on cross-linking would be beneficial and then in certain patients, either because of developmental or behavioral issues they may need to be done under general anesthesia, but with care is what we’re finding.

How can early identification and management of complications improve long-term patient outcomes?

Early identification is really critical, and that can only be done by doing strict postoperative monitoring on a strict regimen. We think specifically for those patients that have the factors that we found in our study that were significant, such as the use of general anesthesia, the presence of a thinner pachymetry, or preop corneal scarring, those patients might need to be followed a little bit more closely within especially the first one- to two-week time window, in order to be able to catch these sorts of things early on and to treat infections, inflammation as they come up.