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PACK-CXL: Corneal Cross-Linking for Infectious Keratitis

Infectious keratitis is a serious condition that can lead to rapid corneal damage and vision loss if not treated promptly. It is typically caused by bacteria, fungi, or parasites that invade the cornea. Standard treatment involves antimicrobial eye drops, but some infections are resistant to medication or progress despite intensive therapy.
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PACK-CXL—short for Photoactivated Chromophore for Keratitis – Corneal Cross-Linking—is an additional treatment option used at the ELZA Institute in selected cases. It involves applying riboflavin (vitamin B2) to the cornea and then activating it with ultraviolet (UV-A) light. This process produces reactive oxygen species (ROS), which can inactivate a wide range of pathogens and strengthen the corneal structure.

How PACK-CXL Works

PACK-CXL uses the same basic principles as cross-linking for keratoconus, but with a different purpose: instead of treating corneal shape, it helps to manage infection and stabilize the corneal tissue.

  • Riboflavin acts as a photosensitizer, absorbing UV-A light and triggering chemical reactions that generate ROS.
  • ROS have antimicrobial properties, damaging the DNA and cell membranes of invading organisms.
  • Cross-linking also increases the cornea’s resistance to enzymatic degradation, which may help limit tissue damage during infection.

This approach is used as a supplement to, not a replacement for, conventional medical therapy. It may be considered when an infection is not responding adequately to medication, or when the cornea is at risk of further structural weakening.

When PACK-CXL May Be Considered

At the ELZA Institute, PACK-CXL may be considered in selected cases of infectious keratitis, particularly when:

  • There is poor response to antimicrobial treatment
  • The infection is progressing despite appropriate care
  • There is corneal thinning or risk of perforation
  • Standard therapies need additional support

Each case is carefully assessed to determine whether PACK-CXL is appropriate, and the procedure is only performed if the treating ophthalmologist considers it medically justified.

Before PACK-CXL
After PACK-CXL

What to Expect During the Procedure

  • The surface of the eye is prepared with anesthetic drops.
  • Riboflavin solution is applied to the cornea.
  • A controlled dose of UV-A light is applied for a specific duration.
  • The eye is then protected with a bandage contact lens, and antimicrobial therapy continues.

The procedure is typically well tolerated. As with any intervention, there are risks and benefits that will be discussed in detail with each patient beforehand.

1 Intercalation with DNA = stops replication

2 Oxidative stress

3 Increased resistance to digestion

Research and Clinical Development at ELZA

The ELZA Institute has played a leading role in both the clinical development and scientific investigation of PACK-CXL. Research conducted by ELZA’s team has helped clarify how riboflavin and UV light interact to inactivate pathogens and reinforce the corneal structure. This has informed the development of PACK-CXL protocols used internationally, with ongoing studies exploring optimization for different types of microbial keratitis.

Landmark-pack-cxl-phase-3-trial-published-inline-image.png

Conclusion

PACK-CXL is an evolving technique with potential benefits in carefully selected cases of infectious keratitis. It is offered at the ELZA Institute as part of a personalized, evidence-informed approach to managing complex corneal infections. Treatment decisions are based on clinical need, current guidelines, and ongoing assessment.

PACK-CXL videos

PACK-CXL Posts

Categories: |
Ophthalmologie Nachrichten covers ELZA Slit Lamp CXL method
Ophthalmologie Nachrichten recently featured an article from the ELZA Institute, highlighting advancements in corneal cross-linking (CXL). This new approach allows the procedure to be conducted at the slit lamp, significantly reducing costs and extending access to advanced eye care in underserved regions. The innovative method is especially effective for treating keratoconus and infectious keratitis. By optimizing UV exposure times, ELZA’s researchers have made CXL more efficient and accessible, democratizing high-quality ophthalmic treatments globally.

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The Antibacterial Efficacy of High-Fluence PACK Cross-Linking Can Be Accelerated
Categories: |
The Antibacterial Efficacy of High-Fluence PACK Cross-Linking Can Be Accelerated
The article by Lu et al. reports an in vitro study, conducted to determine whether high-fluence PACK-CXL can be accelerated while still maintaining its antibacterial efficacy. The study found that high-fluence PACK-CXL did indeed decrease the bacterial concentration of several clinically significant bacterial strains, including S. aureus, P. aeruginosa, and S. epidermidis. These strains are commonly implicated in bacterial keratitis and contact lens-associated keratitis. Furthermore, the authors found that higher total fluence PACK-CXL protocols led to a corresponding increase in bacterial killing ratio (BKR).

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