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Cross Linking Surgery: Risks, Benefits, and What to Expect

keratoconus eye needing cornea cross linking surgery

Did you know that a simple procedure can strengthen your cornea and potentially halt the progression of certain eye diseases? For individuals suffering from conditions like keratoconus or corneal ectasia, the shape of their cornea becomes distorted, leading to blurred or distorted vision that can significantly impact daily life.

Enter corneal cross linking surgery, a minimally invasive procedure designed to stabilize the cornea and prevent further deterioration. This treatment involves the use of ultraviolet (UV) light and riboflavin (vitamin B2) eye drops to create covalent bonds between the collagen fibers in the cornea, thereby strengthening and stabilizing it.

In this article, we will explore what cross linking surgery is, who might benefit from it, and what to expect before, during, and after the procedure. We will also delve into the costs associated with this treatment and the financing options that may be available.

So, if you are struggling with a thin cornea or progressive keratoconus, read on to discover how corneal cross linking could potentially be a sight-saving option for you.

What is Cross Linking Surgery?

Video explaining keratoconus and corneal cross-linking surgery

Cross linking surgery (CXL), medically known as corneal collagen cross linking, is a revolutionary treatment designed to strengthen the cornea, the clear front surface of the eye. This procedure is primarily used to treat conditions like keratoconus and corneal ectasia, where the cornea weakens and progressively thins, leading to a distorted, cone-like shape.

The Procedure

The corneal cross linking procedure is relatively straightforward. It involves applying riboflavin drops (vitamin B2) to the corneal surface and then activating them with ultraviolet light.

This process creates covalent bonds between the collagen molecules in the corneal stroma, the middle layer of the cornea. These new bonds help to stabilize and strengthen the corneal tissue, reducing the progression of diseases like keratoconus and corneal ectasia.

Types of Cross Linking

There are two primary types of corneal collagen cross linking:

  1. Epithelium-off (Epi-off) CXL: This method (Dresden protocol) involves the removal of the epithelial layer (the outermost layer of the cornea) before the application of riboflavin drops. This allows for deeper penetration of the riboflavin into the corneal tissue.
  2. Epithelium-on (Epi-on) CXL: Also known as transepithelial cross linking, this method leaves the corneal epithelium intact during the procedure. It is considered a minimally invasive procedure as it avoids the need for epithelial removal, thereby reducing post-operative discomfort and risk of infection.
  3. Accelerated Corneal Cross Linking: Accelerated corneal cross-linking is a modern variation of the traditional cross-linking procedure that uses a higher intensity of ultraviolet light for a shorter duration of time. This technique aims to stabilize the cornea and halt the progression of keratoconus or other corneal ectatic disorders in a quicker and potentially more comfortable manner for the patient.
  4. Combined Collagen Cross Linking: CXL Plus, is a procedure that pairs the standard corneal cross-linking treatment with other refractive surgeries, such as PRK (Photorefractive Keratectomy) or Intacs. This approach aims to not only stabilize the cornea and halt the progression of keratoconus or other corneal ectatic disorders, but also to improve the corneal shape and visual acuity in a single treatment session.

Who is a Good Candidate?

Patients with progressive keratoconus, post-LASIK ectasia, or pellucid marginal degeneration—conditions that lead to a thinning and bulging of the cornea—are often considered good candidates for this procedure.

Keratoconus – cornea is bulging forward with a cone shape

Corneal cross linking can be used to treat progressive:

The goal is to halt the progression of these conditions and avoid a corneal transplant.

Who is NOT a Good Candidate?

The procedure typically requires a minimum corneal thickness of about 400 um.

Factors that may indicate a person is not a good candidate for corneal cross-linking (CXL):

  • Cornea thickness less than 400 um
  • Severe corneal scarring or opacities
  • Active corneal infections
  • History of herpetic ocular infection
  • Severe dry eye
  • Neurotrophic keratitis
  • Pregnancy or nursing
  • Certain systemic health conditions (e.g., severe collagen vascular diseases or autoimmune disorders)

Risks and Considerations

Like any surgical procedure, corneal cross linking carries some risks. Potential complications may include corneal haze, corneal scarring, and corneal infections.

It is essential to have a detailed discussion with your eye doctor about the risks and benefits before proceeding with the treatment.

The Importance of Early Intervention

For patients experiencing blurred or distorted vision due to a thinning cornea, early intervention is key. Cross linking surgery can be a sight-saving procedure, but its effectiveness is greatest when performed before the cornea has become severely scarred or excessively thin.

In essence, corneal collagen cross linking is a groundbreaking procedure that offers hope to those with conditions that threaten their vision.

By strengthening the collagen fibrils within the cornea, this treatment aims to halt the progression of corneal thinning disorders and preserve the patient’s natural, healthy cornea for as long as possible.

The goal of early intervention is to avoid the need for a partial or full thickness cornea transplant.

The Procedure and Recovery of Corneal Cross Linking

The Detailed Procedure

This video shows a live view and explanation of the procedure

The corneal cross linking procedure is an outpatient procedure that typically takes about 60 to 90 minutes. Here is a step-by-step breakdown:

  1. Preparation: The eye is numbed with eye drops, and the corneal epithelium, the outer layer of the cornea, is gently removed. This is known as epithelial disruption.
  2. Riboflavin Application: Riboflavin drops are applied to the corneal surface. This vitamin B2 solution is crucial as it interacts with the ultraviolet light in the next step.
  3. UV Light Exposure: The cornea is then exposed to UV light. This activates the riboflavin and leads to the formation of covalent bonds between collagen molecules in the corneal stroma.
  4. Post-Procedure Care: After the procedure, a bandage contact lens is placed on the eye to aid the healing process and minimize discomfort.

Recovery and Post-Operative Care

After corneal cross linking surgery, patients may experience eye discomfort and blurred vision for a few days. It is essential to follow the post-operative care plan closely:

  1. Eye Drops: Antibiotic and anti-inflammatory eye drops are prescribed to prevent corneal infections and reduce inflammation.
  2. Avoid Rubbing: It’s crucial not to rub the eyes during the initial healing phase to prevent further epithelial disruption.
  3. Follow-Up Appointments: Regular follow-up appointments with the eye doctor are vital to monitor the corneal healing process and ensure that the corneal shape is stabilizing as desired.

Potential Side Effects and Risks

While corneal cross linking is generally safe and effective, there are potential risks, including:

  • Corneal Haze: A temporary cloudiness in the cornea that usually resolves over time.
  • Severe Pain: Some patients may experience significant discomfort after the procedure, but this is generally well-managed with medications and is temporary.
  • Corneal Scarring: In rare cases, the procedure can lead to severe corneal scarring, affecting vision.
  • Infection
  • Treatment failure (up to 10% of patients)

Patients are advised to contact their doctor immediately if they experience severe pain or sudden vision loss during recovery.

Cost and Financing

The corneal cross linking cost can vary, but it is generally between $2,500 and $4,000 per eye in the United States. Insurance coverage for this procedure is increasing but is not universal. Patients should consult with their insurance company and explore financing options if necessary.

The Long-Term Outlook

For many patients, especially those with progressive keratoconus or post-LASIK ectasia, corneal collagen crosslinking offers a chance to stabilize their vision and avoid a corneal transplant.

The goal is to strengthen the corneal collagen and halt the progression of these corneal thinning disorders, preserving the patient’s natural, healthy cornea for as long as possible.

Evaluating the Success and Considering the Alternatives

Measuring the Success of Corneal Cross Linking

The primary goal of corneal cross linking surgery is to halt the progression of corneal ectasia conditions like keratoconus and post-LASIK ectasia. Success is often measured by a stabilization or improvement in the corneal shape and corneal thickness, as well as halted progression of vision loss.

Patients often report a significant reduction in blurred or distorted vision after the procedure. Regular follow-up appointments are essential, where doctors use tools to measure the corneal thickness and assess the corneal shape.

A successful cross linking treatment will show that the cornea has become more stable and that the collagen fibers have strengthened, reducing the risk of further deterioration.

Alternatives to Corneal Cross Linking

For patients with very thin corneas, severe corneal scarring, or those who are not good candidates for corneal cross linking, alternative treatments may be considered:

  • Corneal Transplant: For patients with advanced keratoconus or significant scarring, a corneal transplant may be the best option.
  • Intacs: These are small, semi-circular rings inserted into the cornea to flatten the corneal shape, used to treat keratoconus without removing corneal tissue.
  • Topography-Guided Conductive Keratoplasty (CK): This procedure uses radiofrequency energy to reshape the cornea without removing tissue, an option for those with pellucid marginal degeneration.

The Cost Factor: Is It Worth It?

The corneal cross linking cost can be a significant factor for patients considering this treatment. In the United States, the cost generally ranges between $2,500 and $4,000 per eye.

While this may seem steep, it is important to consider the cost in the context of the potential for stabilized vision and the avoidance of more invasive procedures, such as a corneal transplant. For many, this procedure is a valuable investment in their future vision and quality of life.

It is a beacon of hope for those who suffer from conditions like keratoconus, offering a chance to live a life with improved and stable vision.

Adjusting to New Vision

After corneal cross linking, patients often notice a significant improvement in their blurred or distorted vision. However, it may take several months for the vision to stabilize completely. A hard contact lens or a change in prescription glasses may be necessary to achieve the best corrected vision.


  • How painful is cross-linking surgery?

    Cross-linking surgery is generally not considered to be painful, as numbing eye drops are used to anesthetize the eye before the procedure begins. During the surgery, patients might feel pressure or a slight discomfort, but pain is typically minimal.

    After the procedure, patients may experience some discomfort or a gritty sensation in the eye. Any post-operative pain can usually be managed effectively with prescribed medications and typically subsides within a few days as the eye begins to heal.

  • Is cross-linking worth it?

    For many patients, especially those with progressive keratoconus or corneal ectasia, corneal cross-linking is often considered to be worth it. The procedure aims to halt the progression of these conditions, thereby preventing further vision loss and potentially eliminating the need for a corneal transplant.

    It is a proactive step that can stabilize the cornea and maintain the patient’s current level of vision. However, the decision should be made in consultation with a knowledgeable eye care professional who can assess the risks and benefits based on the patient’s specific condition and needs.

  • What is the success rate of cross-linking surgery?

    Corneal cross-linking has a high success rate in halting the progression of keratoconus and corneal ectasia. Studies have shown that the procedure is effective in more than 90% of cases.

    It is important to note that while cross-linking is effective in stabilizing the cornea and preventing further deterioration, it is not designed to completely reverse the damage caused by these conditions. Success is typically measured by the stabilization of the cornea and the prevention of further vision loss.

  • What is the best age for corneal cross-linking?

    There is no strict age limit for corneal cross-linking, but it is most commonly performed on patients in their teens to mid-40s. The key factor is the progression of keratoconus or corneal ectasia. The procedure is most beneficial when performed at a stage where the disease is progressing, and significant vision loss has not yet occurred.

    Early intervention is generally preferred, as it can help to preserve vision and stabilize the cornea before significant distortion occurs. It is essential to consult with a healthcare professional who can evaluate the patient’s condition and determine the best course of action based on various factors, including age, corneal thickness, and disease progression.


Corneal cross linking is a revolutionary surgical procedure designed to halt the progression of corneal ectasia conditions, such as keratoconus and post-LASIK ectasia.

By strengthening the corneal collagen with UV treatment and riboflavin drops, this minimally invasive procedure aims to preserve the patient’s natural, healthy cornea and maintain clearer vision for a longer period of time.

The corneal cross linking cost can be a significant factor for patients considering this treatment. While the upfront cost may seem steep, it is a potentially sight-saving procedure that can prevent the need for a more invasive cornea transplant.

Patients considering corneal cross linking should be aware of the potential risks and benefits. With proper screening methods, the procedure has a high success rate. But it is essential to have realistic expectations and to follow post-operative care instructions meticulously.

In the fight against progressive keratoconus and other corneal ectasia conditions, corneal cross linking stands as a beacon of hope. It offers a chance for patients to halt the progression of these conditions and to live a life with improved and stable vision.

For those suffering from conditions that thin and distort the cornea, corneal cross linking is more than a procedure; it is a path to clearer, more stable vision and a brighter, more focused future.