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Corneal Collagen Cross Linking

Corneal collagen cross linking (CXL) is a relatively recent advance in ophthalmology, which has been shown to strengthen the biomechanical properties of the pathologically thinning (ectasia) of the cornea. Since its first reported use some 15 years ago, it has revolutionised treatment of keratoconus, pellucid marginal degeneration and post-refractive surgery ectasia by offering a treatment for corneal ectatic conditions, which previously may have required corneal transplant. This timely book, c0-edited by renowned Irish ophthalmologist Mr Arthur Cummings, describes the state of play of CXL treatment and acts as a reference text for the current and evolving practice of CXL.

There are over 50 international contributors to this edition who give their invaluable personal experience of CXL while also discussing the current evidence-based practice. The book is laid out in nine chapters and while sometimes dense with text, summary boxes at the end of large sections can be easily referenced to recap on pertinent points.

In the early chapters of this book, the nature of corneal ectatic diseases, in particular keratoconus, is detailed along with evolving methods for diagnosis. Clinical signs present in established and late disease, previously relied on for diagnosis, are clearly illustrated with patient images. Recent advances in technology developed for refractive surgery are described, which integrate multiple parameters to diagnose and grade severity of corneal disease before the onset of overt clinical signs. Examples of data output from these corneal scans are illustrated with useful and descriptive examples, which allow the reader to confidently diagnose corneal ectasias in their clinical practice.

The principles of CXL are reviewed while discussing the evolution of optimising treatment. The various treatment modalities and the evidence-base for each is discussed, while also importantly including the limitations of each technique. The rationale and outcomes of newer accelerated treatment options are reported in an unbiased way as well as combination of CXL with refractive surgery procedures.

Clinical cases with corneal photographs paired with imaging data effectively discusses the more challenging and controversial opinions in CXL such as paediatric cases, retreatment and early intervention prior to visual symptoms.

A comprehensive review of clinical CXL results as well as basic science models of the disease is included in an unbiased manner. The authors frequently refer to practical outcomes for patients from their own experiences also. The intra-operative, post-operative and long-term follow-up of patients is described, as well as giving a detailed look at clinical parameters affecting outcome. As most complications of CXL are related to epithelial problems post-procedure, the evidence for newer epithelium-on versus epithelium-off techniques is discussed. Newer techniques entering the clinical arena such as inophoresis is also included in detail.

An entire chapter is dedicated to CXL in children as the benefit in preventing progression requiring corneal grafting is greatest in children. Response may not be as predictable as it is for adults, with results from some paediatric trials showing potential for improvement superior to the stabilisation effect seen in adults. This chapter also gives practical steps for CXL in children, which is extremely useful given that CXL in the paediatric age group is currently not done frequently. Specific challenges in this age group are discussed including parameters for progression of keratoconus.

The final chapter discusses the future of CXL. This chapter sets out what is required to further optimise the CXL procedure. Newer advances such as accelerated techniques to make the procedure shorter and leaving the epithelium intact for patient comfort are included. The remainder of this chapter discusses the additive role of CXL being investigated in treatment of corneal infections, corneal oedema and concurrent with refractive procedures.

The uptake in CXL procedures has increased exponentially in the last number of years, despite the fact that evidence for long-term corneal stability post-procedure is relatively lacking. This point is openly referenced throughout the book with many of the studies cited being retrospective studies rather than prospective. However, that being said, this book summarises the available literature well – sometimes in tabulated formula describing study size and duration so the reader can make up their own mind as to the value of each study.

Writing a book on CXL is difficult in an era when this new treatment is rapidly evolving. This book is beneficial as a reference manual for any ophthalmology unit, which undertakes CXL-ing procedures. It would also be beneficial to opticians, ophthalmic nurses and technicians interested in CXL and treatment of corneal diseases. This book accurately describes the CXL procedure in its completeness as our knowledge stands, while including putative roles currently under investigation and in early clinical practice for the future.

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