Patients with keratoconus exhibit a biomechanically weakened cornea which loses its proper shape and thereby loses its refractive power. It is usually progressive, beginning with poor visual acuity and eventually necessitating corneal transplant. The cause is likely multifactorial, but involves the weakening of the collagen structure of the corneal stroma, resulting in characteristic thinning and conical distortion. Collagen cross-linking is the first treatment to demonstrate efficacy in halting the progression of the disease. UVA radiation is used to activate riboflavin and photochemically induce cross-linking reactions among collagen and proteoglycans within the stroma, thereby stiffening and strengthening the tissue, and preventing further loss of shape. The current standard treatment, which gained FDA approval less than one year ago, has proven to be efficacious, but has been modified very little since pioneering experiments. Optimization aims to maximize clinical effect while maintaining safety and reducing total treatment time. Major procedural modifications involve increasing light intensity over a reduced exposure duration, and varying the method of delivering riboflavin to the stroma. Theoretical modeling, informed by and scaled to experimental results, has the potential to predict clinical effect as a function of treatment parameters, enabling tailoring of individual treatments to the specific needs of each patient.

Background: Collagen cross-linking of the sclera is a promising approach to strengthen scleral rigidity and thus to inhibit eye growth in progressive myopia. Additionally, cross-linking might inhibit degrading processes in idiopathic melting or in ocular inflammatory diseases of the sclera. Different cross-linking treatments were tested to increase resistance to enzymatic degradation of the rabbit sclera. Methods: Scleral patches from rabbit eyes were cross-linked using paraformaldehyde, glutaraldehyde or riboflavin combined with UV-A-light or with blue light. The patches were incubated with collagenase I (MMP1) for various durations up to 24 h to elucidate differences in scleral resistance to enzymatic degradation. Degraded protein components in the supernatant were detected and quantified using measurements of Fluoraldehyde o-Phthaldialdehyde (OPA) fluorescence . Results: All cross-linking methods reduced the enzymatic degradation of rabbit scleral tissue by MMP1. Incubation with glutaraldehyde (1%) and paraformaldehyde (4%) caused nearly a complete inhibition of enzymatic degradation (down to 7% ± 2.8 of digested protein compared to control). Cross-linking with riboflavin/UV-A-light reduced the degradation by MMP1 to 62% ± 12.7 after 24 h. Cross-linking with riboflavin/blue light reduced the degradation by MMP1 to 77% ± 13.5 after 24 h. No significant differences could be detected comparing different light intensities, light exposure times or riboflavin concentrations. Conclusions: The application of all cross-linking methods increased the resistance of rabbit scleral tissue to MMP1-degradation. Especially, gentle cross-linking with riboflavin and UV-A or blue light might be a clinical approach in future.