Cross-linking at the Slit Lamp—Why Moving Corneal Cross-linking from the Operating Room to an Office-based Procedure Makes a Difference

Corneal cross-linking (CXL) is a procedure that combines stromal riboflavin saturation and ultraviolet (UV) light to strengthen the cornea. CXL is typically performed in an operating room. The UV-riboflavin photochemical reaction also kills pathogens, and CXL is even used to treat infectious keratitis, raising the question: do you need to perform CXL in a sterile operating room? There is a trend to move small surgical procedures out of the operating room and into minor procedure rooms or the doctor’s office, and CXL is an obvious candidate for this. The benefits of avoiding the operating room in terms of cost and resource use are manifest. However, traditional CXL involves the patient lying supine for 30 minutes, while UV irradiation is applied. For CXL to be performed at, for example, the near-ubiquitous slit lamp in an office setting, several hurdles needed to be cleared, including reducing the time a patient needs to sit at the slit lamp, and understanding whether or not riboflavin settles under gravity when a patient is sat upright during CXL. This article reviews those potential obstacles and how they have been overcome, and the benefits of bringing CXL technology to clinics that do not have easy access to operating rooms for the treatment of corneal ectasia and infectious keratitis, in both developing and developed countries.