Collagen Cross-Linking

Corneal collagen cross-linking (CXL) at Corneal Associates of New JerseyCorneal Associates of New Jersey is proud to offer corneal collagen cross-linking in New Jersey. The procedure, also known as CXL uses UVA light with riboflavin to strengthen corneal tissue, has shown promising success in stabilizing corneal curvature and thickness, and slowing or halting the progression of keratoconus and post-refractive corneal ectasia. Corneal Associates of NJ is proud to offer this advanced medical treatment to our patients.

See TV Star and Dr. Perl Patient Bill Schindler’s Keratoconus Story HERE

New Technique: Epithelium On CXL, Less Discomfort – Faster Healing

At Corneal Associates of New Jersey, we now perform the collagen cross-linking  procedure in select patients by leaving the epithelium in place as opposed to removal of the surface cells as is commonly done for many patients. The results have been impressive with a significantly faster recovery of vision and minimal post-operative discomfort. This is an improvement in terms of comfort and yet provides the same outstanding results. During your evaluation, Dr. Perl will discuss whether or not epithelium-on or epithelium-off is the best procedure for you.

Collagen Cross-Linking FAQ’s

What is keratoconus?: Keratoconus is an abnormality of the eye in which the normally round, dome-shaped cornea weakens and becomes progressively thinner and irregular in shape. The resulting cone-shaped cornea can cause high levels of astigmatism (irregular curvature) and nearsightedness. Keratoconus has been estimated to occur in 1 out of every 1,000 persons in the general population. It is generally first diagnosed in young people at puberty or in their late teens. It is found in all parts of the United States and the rest of the world. It has no known significant geographic, cultural, or social pattern.

How does keratoconus affect my eyes and my vision?: The cornea is the clear window of the eye and is responsible for refracting, or bending, most of the light coming into the eye. Therefore, abnormalities of the cornea can severely affect the way we see the world, making it difficult to perform simple tasks, such as driving, watching TV, or reading a book. In its earliest stages, keratoconus causes slight blurring and distortion of vision and increased sensitivity to light. These symptoms usually first appear in the late teens and early twenties. Keratoconus may progress for 10-20 years and then slow or stabilize, usually by the age of 40-45. Often keratoconus patients first require glasses, then gas permeable contact lenses, to restore their vision. As the disease progresses, Intacs (intracorneal rings implanted into the outer edge of the cornea) are sometimes used to flatten the steep, bulging cornea. The primary goal of Intacs is to make the eye tolerant of contact lenses once again, and to avoid corneal transplantation. If the condition progresses to a severe level, a corneal transplant may be needed.

What is collagen cross-linking?: Corneal collagen cross-linking (CXL), a procedure first developed in Dresden, Germany in the 1990’s, is a technique used to treat individuals with progressive keratoconus, to strengthen and stabilize the front layers of the cornea. Collagen cross-linking is not a cure for keratoconus. The aim of this treatment, which utilizes Vitamin B2 (riboflavin) and ultraviolet light, is to arrest progression of keratoconus, and thereby prevent further deterioration in vision and the need for corneal transplantation. Glasses or contact lenses will still be needed following the cross-linking treatment (although a change in the prescription may be required). CXL has also been successful in treating patients with corneal ectasia, a steepening of the cornea which occurs as a complication of previous laser refractive surgery. CXL has been used successfully in Europe and other countries for more than 15 years, and is currently undergoing FDA clinical trials in the United States. Although CXL is not yet FDA approved, it is considered a practice of evidence-based medicine decision. Our practice is now able to provide this treatment to our patients using advanced technology for corneal cross-linking.

How does collagen cross-linking work?: Collagen is the structural protein that provides strength and firmness to our corneal tissue. CXL works by forming new cross-links between collagen fibers, which are the natural “anchors” within the cornea. These anchors are responsible for preventing the weakened cornea from bulging out and becoming steep and irregular. The addition of these “cross beams” acts like adding rungs on a ladder to stiffen and strengthen the cornea, allowing it to focus light more efficiently and accurately.

How is collagen cross-linking performed?: The collagen cross-linking treatment is an outpatient procedure performed in the doctor’s office. First, you will be given anesthetic (numbing) eye drops to prevent pain or discomfort. The corneal epithelium, a thin layer of clear, protective “skin” that covers the cornea, is gently removed by the doctor. Next, vitamin B2 (riboflavin) eye drops are instilled in the eye, one drop every 2 minutes for about 30 minutes. Then the doctor will check your eye to make sure that the riboflavin drops have saturated the cornea, so that the treatment will be effective. Next, you will relax in a reclining chair and look up at a soft blue ultraviolet light during the 5-minute treatment. To help prevent you from blinking, an eyelid retainer will be placed between your upper and lower eyelids. The UVA (ultraviolet) light source will then be shined into your eye. The light “activates” the riboflavin, which causes the cross-linking of the collagen fibers. The UVA treatment will last approximately 5 minutes. It generally is not difficult to look at the light because your eyes are numb. A bandage soft contact lens will be placed on your eye immediately after the procedure, and antibiotic and nonsteroidal eye drops are then instilled. The contact lens remains in place for approximately 4-5 days to aid healing and comfort. The lens is clear and has no power. You will receive instructions regarding your post-CXL eye medications.

How effective is cross-linking?: Based on available data, CXL offers a treatment for a disease that currently has no real medical treatment other than surgical insertion of plastic implants (INTACS) or corneal transplantation. Many research studies have shown that cross-linking prevents further vision loss in more than 95% of patients, with more than 70% of patients getting improved vision. As with many conditions, the earlier the condition is treated, the better the results. If cross-linking is performed early, it may be possible to prevent the signs and symptoms of keratoconus in some eyes with “pre-clinical” keratoconus.

How long does cross-linking treatment last?: Based on cross-linking results from more than a decade, the beneficial effects of CXL appear to last for a long time, and there is evidence that this strengthening effect may be permanent. In many studies, most patients respond to a single cross-linking treatment and do not need to have the procedure repeated. For the occasional patient in whom this treatment is not successful, cross-linking can be repeated.

Does the CXL procedure hurt?: No. The actual cross-linking procedure is painless because anesthetic eye drops are used to eliminate any discomfort. It is normal for you to have some discomfort after CXL while the corneal epithelium heals. You may experience light sensitivity, a dry, scratchy sensation in your eye, or feel as if there is an eyelash in your eye.

How safe is CXL?: The doctor will review the benefits, as well as the risks, of corneal cross-linking with you during your consultation. Although CXL is a relatively new procedure, an increasing volume of data from pioneers of the technique appears to support its safety and efficacy. There are no injections, incisions, or stitches required during the CXL treatment. Adverse effects are rare, and may include corneal haze, scarring, infection, delayed healing, or loss of visual acuity.

Can cross-linking prevent the need for a corneal transplant?: Many studies have shown that cross-linking can often prevent the need for a corneal transplant and allow patients to wear contact lenses or glasses more comfortably and safely again.

Can I have cross-linking if I already had a corneal transplant?: Each patient and each patient’s eyes are different. In some cases, cross-linking can be performed after corneal transplantation.

Is cross-linking like LASIK?: No. LASIK reduces or eliminates the patient’s need for glasses or contact lenses by removing, and reshaping, corneal tissue after a thin corneal flap of tissue is created. It is performed on patients with normal, healthy eyes. CXL is a non-invasive treatment using UVA light and vitamin eye drops. The purpose of cross-linking is to prevent further deterioration of vision and potentially to improve vision in patients with abnormal corneas. Patients will typically require a lower eyeglass prescription and can have an easier time being fit with contact lenses.

If cross-linking works for me and stops my vision from getting worse, can I have laser vision correction afterward?: Some patients may be able to have PRK (a type of laser vision correction) to improve their vision after they have healed from the cross-linking procedure. Also, corneal cross-linking treatments can sometimes be combined with Intacs to flatten the cone in the keratoconic eye.

Can cross-linking be performed on anyone with keratoconus?: During your consultation, the doctor will determine if cross-linking might be an appropriate treatment option for you.

To be a candidate, you must:

  • Be 14 years of age or older
  • Have been diagnosed with progressive keratoconus or corneal ectasia
  • Patients who have corneal scarring or whose corneas are too thin or too steep are NOT good candidates for CXL.
  • Patients who are female must not be pregnant or nursing.

Do I have to stop wearing contacts before having CXL?: We recommend that you stay out of contact lenses for 1 or 2 weeks if possible before your consultation to see if you might benefit from cross-linking. Most patients can return to wearing contact lenses 3 to 6 weeks after having the cross-linking procedure.

Will I need new glasses or contacts after CXL?: Because cross-linking often improves vision, some patients find that their old glasses or contacts are too strong. However, because the effects of CXL occur slowly, most patients can wear their old glasses until several months after the procedure when the doctor will prescribe new ones. You may need to be refit for contact lenses.

When will I notice any changes or improvements in my vision?: Visual improvement is a long process. Most patients find that immediately, and for several weeks after CXL, their vision may be slightly worse than it was before treatment. Then patients will start to notice gradual positive effects. Major improvement in vision generally takes 3-6 months.

When can I return to my usual activities after CXL?: The doctor will tell you when you can return to work or resume your normal daily activities. Most patients can usually do so after approximately 3-5 days, but this can vary depending upon your individual circumstances, your vision, and your responsibilities and duties at work.

Does insurance cover the cross-linking treatment?: Insurance generally does not cover the cost of collagen cross-linking.

Is financing available for CXL?: Convenient, affordable financing is available to help our patients get the treatment they need before their keratoconus or other similar condition progresses to the point where they can no longer have cross-linking.

How do I get started?: For more information about collagen cross-linking and how to schedule a consultation, please call Corneal Associates of NJ at 973-439-3937 and ask to speak to our CXL Coordinator, or visit our website at
We will be happy to assist you.