Corneal Cross-Linking, or CXL, is a treatment designed to strengthen the cornea — the clear front surface of your eye. It is primarily used to stop the worsening of conditions like keratoconus, where the cornea becomes weak and changes shape, leading to blurry vision.
CXL works by rapidly creating new connections, called cross-links, between collagen fibers inside the cornea. These extra links strengthen and stabilize the cornea, helping to prevent further thinning or bulging.
In keratoconus, the cornea has fewer natural cross-links than normal. This results in a weaker cornea, and this causes the cornea to become thinner and start bulging outward, which progressively distorts vision as the disease advances. Without treatment, this can lead to severe vision problems and may require a corneal transplant.
CXL is currently the only treatment that can slow or stop the progression of keratoconus and similar corneal disorders. By strengthening the cornea early, CXL can help preserve your vision and reduce the need for more invasive surgeries.
The CXL procedure involves three main steps:
To allow the treatment to work, the thin protective layer on your cornea, called the epithelium, is usually gently removed. This helps a vitamin called riboflavin soak into the cornea.
Riboflavin drops are applied to the cornea for about 10-30 minutes to fully saturate the tissue.
The cornea is then exposed to a special ultraviolet-A (UVA) light for about 10-30 minutes. This activates the riboflavin, triggering a natural chemical reaction that forms new cross-links in the cornea.
Eye drops are used to numb your eye, so the treatment is mostly comfortable.
You will be seated either lying down or at a slit lamp, depending on the technique used.
The entire process takes around 45 minutes to one hour, again depending on the technique used.
The epithelium is removed for better riboflavin absorption. This method has been proven to be very effective.
The epithelium stays in place, making the procedure less painful and speeding recovery. However, it may be slightly less effective in some cases.
Using higher-intensity UV light for a shorter time reduces the overall treatment duration.
Special techniques are used to safely treat thin and ultra-thin corneas that do not meet the standard thickness requirements.
A newer method performed with the patient sitting upright at the slit lamp, which increases accessibility and reduces the need for operating room facilities.
CXL was developed in the 1990s as a groundbreaking treatment to strengthen the cornea and halt progressive thinning conditions such as keratoconus.
The initial research was led by Professor Theo Seiler in Dresden, Germany. He and his team investigated methods to reinforce weakened corneas by inducing additional molecular bonds – called cross-links – between collagen fibers using ultraviolet (UV) light combined with the vitamin riboflavin.
In 1999, Professor Seiler relocated to Zurich, Switzerland, where he was joined by (then) Dr. Farhad Hafezi. Together, they conducted some of the earliest clinical studies on CXL at the ELZA Institute and affiliated centers, developing the protocols that formed the foundation of modern CXL treatment. Zurich became an international center for clinical innovation in corneal cross-linking.
During these formative years, the treatment was known by various terms, including corneal collagen cross-linking (CCL) and X-Linking. In 2006, at an international congress held in Zurich, experts reached consensus on the term “corneal cross-linking” (CXL), which has since become the global standard.
Thanks to their early work and ongoing innovations from the ELZA Institute team, CXL today is established worldwide as the gold standard treatment to halt keratoconus progression and improve patient outcomes.
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