All of us Vs Keratoconus

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TOPIC: bluesfan's x-linking


Status: Offline
Posts: 18
Date: Sun Oct 28 8:03 PM, 2007
RE: bluesfan's x-linking


I don,t wanna be boring with a lot of links. I got all the presentations from this course from Dr Mazzota who visited us some months ago. And I know all the literature and i´ve read it. I was not questioning about the use of B2 or UV; it was a way of saying that some people is now questioning if there are other ways to crosslink the cornea and exploring other possibilities. Sorry if i did not express myself well; i´m not english speaking.

Thank you for your link. And i am very optimistic about the progression done in xlinking. Hope we can avoid many corneal grafts in the future. But we need more time to make conclusions. If you want to use this data, we have done around 20 % less corneal grafts this year 2007 than in 2006 due a increase in intrastromal ring implants and xlinking. For me there are good news.

Good night

-- Edited by Juanito at 21:55, 2007-10-28


Veteran Member

Status: Offline
Posts: 38
Date: Sun Oct 28 11:19 PM, 2007

Dear Doctor Juanito,

Thank you very much for your pieces of information ! It's really very precious to benefit from the opinion of some physicians on this forum !

I had some questions to ask you :

1°) Has it been reported some C3R failures in ohptalmologists congresses where C3R is evocated ? Is an eventual failure more frequent in the method with a removal of epithelium or not ? The case of mrs elaine osborn'son was not very clear because a first post indicated that KC had progressed and a second post indicated that finally Prof Kohlaas found that KC had not progressed.

2°) What is your opinion about the strenghtening effect of C3R ? The profesor who treated me was a litlle doubtful because CRF values given by ORA were not significantly changed after C3R but he thought that perhaphs this was because ORA is not a very sharp machine, particularly in keratoconus corneas.

Recently, in Medline, they added this article which seems to be in favour of a strong effect of strenghening ? What is your point of view ?

[Enzymatic evidence of the depth dependence of stiffening on riboflavin/UVA treated corneas.][Article in German]

Schilde T, Kohlhaas M, Spoerl E, Pillunat LE.
Universitäts-Augenklinik Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland,

PURPOSE: It has been shown that the treatment of keratoconus with riboflavin/ultraviolet A (UVA) causes significant stiffening of the cornea due to cross-linking. The aim of this study was to evaluate how deep the mechanical stabilization after collagen cross-linking could be shown biochemically. METHOD: Ten out of 20 enucleated porcine eyes were treated with riboflavin as a photosensitizer and UVA (370 nm, 3 mW/cm(2), 30 min). The other 10 eyes served as controls. With a Microkeratom device, two flaps with a thickness of 200 microm and a diameter of 8 mm were cut off from each eye and put in a collagenase solution (NaCl plus collagenase A, 1:1). The surfaces of the flaps were measured digitally every day to characterize the dissolving behavior. RESULTS: The resistance (regarding corneal collagen against enzymatic digestion) of the treated superficial flaps was considerably higher (p=0.001) compared to those that were cut secondarily and to the control flaps. But even the flaps from deeper layers showed a significant increase in resistance (p=0.02) compared with the untreated flaps. The half-life of the surfaces of the treated superficial flaps was 220 h; of those cut secondarily, it was 80 h. Both untreated flaps had a half-life of 50 h. CONCLUSIONS: The biochemical study showed that the treatment of the cornea with riboflavin/UVA leads to significant collagen cross-linking not only in the anterior slice of 200 microm but also in the following 200 microm. This locally limited cross-linking effect may be explained by the absorption behavior for UVA of the riboflavin-treated cornea; 65% of UVA irradiation is absorbed in the first 200 microm and only 25-30% in the next 200 microm. Therefore, deeper-lying structures and especially the endothelium are not affected.

Dear Doctor, I hope you will not be too much disturbed by all these questions. Thank you very much for being one ot the doctors who try to improve treatments for keratoconus.



Senior Member

Status: Offline
Posts: 124
Date: Mon Oct 29 12:09 AM, 2007


Are you reading my posts or you just reply and say what you want to say?

To begin with,the initials CE means Center Europe nowadays.This comes from a University book called Total Quality Management.

Also,you are saying about the concetration of the riboflabin you are using that is the same with the IROC center.For a minute i will agree with you.So,if it is the same why dont you use the german medio cross riboflabin solution???Why my friend?Why do you use this riscrolin you are saying from Italy?What is the purpose of that?If its the same then use the german.I am telling you that with a very kind way.

Secondly,have you studied and taken your degree in Italy?I would love to hear where you have studied.You named Ferrari but you forgot to mention Michael Shumacher.Xmm,i think he is German and he was the one behind the wheel all this years.biggrin.gif

You said that crosslinking it depends for each person and each cornea.ITS THE FIRST TIME I HEAR that.I know from all doctors i have read and visited that crosslinking is achieved to all people and the keratoconus disease has halt/stop/freezed and to many cases the cornea has flatten more with reduction of K VALUES.Tell us.Do you believe in crosslinking or you believe more to corneal transplants?I still havent get it.Also you said that kc it entirely ends at the age of 50 years old?I am suprised because i know other.As the age of 35 or close 40.

The FDA approval you want to discuss is a big issue and as for being a European member i can speak for my continent.What happens overthere is something that they got to resolve it by themselves.I think that i have made you searching all the google machine and thats very nice because you are learning something.aww.gif

You mentioned if i understood well that the CBM machine for crosslinking made in Italy has the CE mark,and that from the IROC center(German and Swiss Doctors) didnt at that time has the CE mark.So the Italian machine had first the CE mark.

Are you insane?The Germans and Theo Seiler invented it and made all the experiments and performed the treatments to persons throughout the world and they waited for the italians to come and have first the CE mark?Is there any logic to that?

Its at least a pitty when you are reffering to corneal transplants(atigmatism success you claim) you have made first to people.Instead of becoming an enthusiastic fan of crosslinking which the German have results 6 yearssmile.gif you are saying ^Oh,lets wait and see^.Yes lets wait and start praying and maybe,i say maybe the kc will stop.I am going to lose my mind with that opinions i read but i can not stop you from telling them.You are exposed to the people in here.

I have a question and please reply with honest.Are you performing laser surgery such as Lasik and Prk?I am really curious.ashamed.gif

I can not comment the Xlinking-PRK treatment.You need to have the knoweldge background to discuss this innovative treatment.Its like explaining to a child from kindergarden.I can not do that.Its unfair.

The third collagen crosslinking and doctors such as Dr Theo Seiler have a whole section named collagen cross linking and laser surgery.Maybe you should call him and tell him that is experimental.Tell him that thing ^Oh lets wait and see^ as you like this expression.

I do not have any problem or hate Italy.You are from Spain right?So why you copy pasting all their work?Is it your work?You are a spanish doctor not an Italian.Its very simple.All i want to hear is why you are using other riboflabin solutions like riscrolin and other machine.And dont say that cheap excuse of the CE mark.I have explained you before.The Germans invented and the Italians got first the approval?It smells to me like Italia

If you are ready for an honest reply please do so.The first picture of bluesfan eye is underxlinked.I didnt speak for progression of kc.But the first picture is underxlinked.I dont know if time will be at his side if he is still underxlinked.

Good night and Good luck.

nothing else matters

Phase Two

Status: Offline
Posts: 484
Date: Mon Oct 29 10:57 AM, 2007

I wanted to just let this topic run and not get involved as to me the reader of this topic can decide on it. Most people just want to know the facts, we are getting to the detail so thats good... but can we be more cordial please.

It can be fustrating using text to explain, so I sometimes just write points to make it easier... covering each point concisely with out using too many words. This way words don't run in to each other and it is more cordial.

Please PM each other and try to reach some middle ground. You guys are great people, great friends who have not met yet I feel. I remember a time there was nothing like this or no-one, ain't this great we can do this? Let's be friendly, Please!

It is in giving will receive ...its in pardoning others are pardoned

-- Edited by QuintriX at 17:13, 2007-10-29



Status: Offline
Posts: 67
Date: Mon Oct 29 12:08 PM, 2007

Absolutely fascinating thread - nothing better than a good old debate! I feel you're both arrivng at the same points and making a lot out of the inconsequential - who cares what CE stands for? What the FDA approve etc?

You both want to prevent KC progression and have 2 differing viewpoints. One of you has had great succes with experimental techniques so is obviously an advocate of such, the other works within professional confines and thus must often stick to the rules and evidence - an unfortunate circumstance which bains our existence as optometrists as well - see the NICE vs Leucentis/Avastin debate.

Keep well all


We all love Leeds!


Status: Offline
Posts: 20
Date: Mon Oct 29 3:23 PM, 2007

Hello Everyone,

I have been trying to respond to this thread days ago but haven’t been able to due to problems with my internet connection. When I logged in today I couldn’t believe how things have developed on this thread while I was away! I was extremely overwhelmed that I really don’t know where to start!!! Without exaggeration I have been seriously upset all day today over this as I somehow feel responsible for this because afterall I started this thread…

I hope everyone will hear me out though and read what I have to say:

1st of all:
I would like to make it very clear that when I decided to share my story here, I didn’t mean for this to turn into a debate or argument as to which doctor is right or wrong, nor to point fingers at anyone or accuse anyone of anything, this never was my intention, honestly.

Like many of you, I simply came here for knowledge sharing, feedback and support. I also wanted to share my story as candidly and as fairly as I can, and to the best of my ability and within the limitations of my knowledge as a patient (I don’t claim to be an expert). Just like all the other members who shared their stories did. I apologize if I fell short of that or if I ever sounded too critical, it was definitely not what I intended, I only meant to report the day-by-day developments and what I was being told.

I respect each doctor’s professional opinion and judgement. I am sure different doctors have their own reasons and convictions. It is up to the patient at the end of the day to look at these opinions in the most objective way possible and decide what makes the most sense and which opinion is the most trustworthy.

I have absolute respect and highest regard for Dr Juan Alvarez de Toledo as a person and doctor, and for his professionalism and his judgement. I believe I have mentioned this clearly from early on in this thread. I mean that earnestly as I continue to trust his judgement. In fact I wanted to mention that in response to Joseph’s post a few days ago.

There is nothing wrong with getting another medical opinion especially when the purpose is to gather more information and learn more about various treatment options for a condition that is not so common or often not understood well enough as Keratoconus. A 2nd opinion doesn’t mean a doctor’s competence is being questioned. In fact if it wasn’t for 2nd and 3rd opinions I would not have known about the Barraquer Centre or Dr Alvarez de Toledo. Prior to that, I saw 3 doctors some of whom gave me very little hope and spoke against crosslinking so strongly that I couldn’t help but wonder. Luckily I found a doctor who really knew what she was saying and guided me in the right direction to where I got my crosslinking under reliable hands. I know that confident and professional doctors understand and appreciate the importance of 2nd opinions.

Finally, I am just a member on this site, so I don’t have any moderator privileges, but nevertheless I feel this site is what we make of it and we should all feel a sense of responsibility as if we are moderators so that we can continue to benefit. Let us all remember that this is a forum to share knowledge and experience and support and also to discuss issues related to Keratoconus. I am absolutely sure that everyone here has good intentions. So, and without mentioning any names, let’s discuss issues calmly, rationally and reasonably and please, please, PLEASE avoid the hostility.

I apologize for yet another long post, but I hope my message came through. My apologies again if I ever was unclear and if anyone was offended.

-- Edited by bluesfan at 16:27, 2007-10-29



Status: Offline
Posts: 437
Date: Mon Oct 29 10:00 PM, 2007

hi everybody,
i think it is an issue of where to discuss general issues...We have a topic "x_linking". So theoretically all general questions, doubts, thechnical issues, should be put there...When we discuss a particular treatment case, we can evoke generalities and technical details to explain some phenomena. But such things like CE etc should be held in the topic dedicated to the procedure itself...An intervention of a doctor is ALWAYS welcome. But since they are heavy-weights wrt to us, it is better, I believe if they write in general section. I may be mistaken.



Status: Offline
Posts: 18
Date: Mon Oct 29 10:17 PM, 2007

Hi bluesfan:

Thank you for your post. I totally agree with you in all your comments. I would have done the same as you.

In answer to Action 444:

1) First of all we have to define failure. In my opinion, failure is when keratoconus continues progressing after the treatment. The main goal, as you know, is to stop its progression. Other things are complications: haze, scarring, decrease in Visual Acuity, endothelial damage ( one case has been described to my knowledge), acute lamellar keratitis ( only when C3R is performed in a post-LASIK ectasia patient; a paper about that is gonna be published soon in the Journal of Cataract and Refractive Surgery soon and i´ve been one of the reviewers of it), infections, UV toxicity to the limbal epithelial stem cells, lens or retina ( not described yet and i think they would never happen)

I will continue performing C3R removing the epithelium. Dr Pinelli describes the effect is the same without epithelium removal, but i,ll follow the initial protocol until more studies come to us. We are trying to measure the percentage of UV light filter by a sheet of isolated epithelium in our lab studies. I cannot inform you about the results yet.

2) Regarding the strenghtening effect, all the lab studies published describe its increase in animal models. We also have developed a lab experiment in which human eyes from the eyebank that were not suitable for transplantation were crosslinked in a very controlled way ( keeping its intraocular pressure constant during all the experiment with a special pump used in vitreoretinal surgery) and we performed ORA measurements. There was a two fold increase in CRF an CH ( corneal hysteresis) values, but we have not been able to see any statistically significant increase in our C3R patients, as your doctor told you. And no paper has been published yet. ORA is not a perfect machine, but is the only one we have now to measure some biomechanical properties of the cornea. Dr Dupps is developing what he calls a corneal elastometry with a device invented by him which measures wave surface propagation. here is one link:

[url= [/url]

Hope it helps

About a question made to me about my experience in LASIK and PRK, I started doing LASIK and PRK in Oct 1995, and i have treated with these procedures more than 15000 eyes. Now we are using LASIK new technologies like the femtosecond laser to perform cutting in corneal transplants. You can precisely cut the graft and the patient with a laser with the precision of 2 or 3 microns, doing mushroom cuts, lamellar cuts, etc... It is just in its early period of developing, but patients are doing extremely well regarding wound healing and vision recovery.

Thank you for your patience in reading long posts.
Good night.

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