Collagen crosslinking with ultraviolet-A and hypoosmolar riboflavin solution in thin corneas

Corneal collagen crosslinking (CXL) with riboflavin and ultraviolet-A light is a method for treating progressive keratectasia. The currently accepted treatment parameters induce collagen crosslinking in the anterior 250 to 350 μm of corneal stroma. To protect the endothelium, CXL inclusion criteria require a minimum corneal thickness of 400 μm after removal of the epithelium. In advanced keratoconus, however, progressive corneal thinning often leads to a remaining stromal thickness of less than 400 μm. We have therefore modified the current treatment protocol by preoperatively swelling thin corneas to a stromal thickness of at least 400 μm using hypoosmolar riboflavin solution. This treatment protocol was performed in a case series of 20 patients, and no complications were observed. Preoperative swelling of the cornea safely broadens the spectrum of CXL indications to thin corneas that would otherwise not be eligible for treatment.